# Targeted Antibiotics Lead to Prolonged Improvement in IBS Symptoms



## Jeffrey Roberts

http://www.newswise.com/articles/view/524321/?sc=rsmnNewswise â€" Researchers at Cedars-Sinai Medical Center have found that a nonabsorbable antibiotic â€" one that stays in the gut â€" can be an effective long-term treatment for irritable bowel syndrome (IBS), a disease affecting more than 20 percent of Americans.The study, which appears in the October 17 issue of the Annals of Internal Medicine, http://www.annals.org/cgi/content/abstract/145/8/557 , is the first to demonstrate benefits from antibiotic use even after the course of treatment has ended, supporting previously published research that identified small intestine bacterial overgrowth as a cause of the disease.The randomized, double-blind, placebo-controlled study involved 87 participants, all of whom met specific multinational guidelines for diagnosis of IBS. They received 400 mg of the antibiotic rifaximin three times a day for 10 days or a placebo. Participants completed an extensive symptom questionnaire at the start of the study and then weekly for 10 weeks following treatment. The questionnaire measured the severity of nine symptoms (abdominal pain, diarrhea, constipation, bloating, urgency, incomplete evacuation, mucus, sense of incomplete evacuation, and gas). Patients were also asked to provide a percent global improvement from 0 to 100 percent in their overall IBS symptoms.Researchers found that the rifaximin not only led to significant improvement in global IBS symptoms during the 10 days it was administered, but also that the benefit continued for the 10 weeks of follow up when no antibiotic was given, showing sustained benefit. â€œThe fact that the benefit of the targeted antibiotic continued even after it was stopped provides evidence that the antibiotic was acting on a source of the problem: excess bacteria in the gut,â€ said Mark Pimentel, M.D., director of the GI Motility Program at Cedars-Sinai and the studyâ€™s principal investigator. â€œThis finding offers a new treatment approach â€" and a new hope â€" for people with IBS.â€Irritable Bowel Syndrome is one of the top 10 most frequently diagnosed conditions by U.S. physicians. It is an intestinal disorder that causes abdominal pain, cramping, bloating and diarrhea and/or constipation and is a long-term condition that usually begins in early adult life. Episodes may be mild or severe and may be exacerbated by stress. IBS is more common in women than in men.â€œWhile this study being released today demonstrates that the non-absorbed antibiotic rifaximin has great promise in the clinical improvement of IBS, more research is needed,â€ said Pimentel. â€œNext steps include multi-center studies to further assess short- and long-term benefits of this drug. Tests comparing rifaximin to other types of antibiotics that have been used to treat the disease should also be conducted.â€Because the cause of IBS has been elusive, treatments for the disease have historically focused on reducing its symptoms â€" diarrhea and constipation â€" by giving medications that either slow or speed up the digestive process. In The American Journal of Gastroenterology (Dec. 2000), Pimentel linked bloating, the most common symptom of IBS, to bacterial fermentation by giving lactulose breath tests to participants. The test, which monitors the level of hydrogen and methane (the gases emitted by fermented bacteria) on the breath, showed evidence that small intestine bacteria overgrowth may be a causative factor in IBS.Participants in the current Annals study also took the breath tests, which showed similarly increased levels of hydrogen and methane.Rifaximin, an antibiotic that is FDA-approved for travelersâ€™ diarrhea in this country, is made by Salix Pharmaceuticals, Inc. Funding for the study was also provided by Salix. The discovery related to the use of rifaximin for IBS was made at Cedars-Sinai by Pimentel. Cedars-Sinai holds patent rights to this discovery and has licensed rights to the invention to Salix.Other authors from Cedars-Sinai include Sandy Park, James Mirocha, and Yuthana Kong. Sunanda V. Kane from the University of Chicago also participated in the study.One of only seven hospitals in California whose nurses have been honored with the prestigious Magnet designation, Cedars-Sinai Medical Center is one of the largest nonprofit academic medical centers in the Western United States. For 19 consecutive years, it has been named Los Angelesâ€™ most preferred hospital for all health needs in an independent survey of area residents. Cedars-Sinai is internationally renowned for its diagnostic and treatment capabilities and its broad spectrum of programs and services, as well as breakthroughs in biomedical research and superlative medical education. It ranks among the top 10 non-university hospitals in the nation for its research activities and its human research protection program is fully accredited by the Association for the Accreditation of Human Research Protection Programs, Inc. (AAHRPP). Additional information is available at http://www.cedars-sinai.edu.--------------------------------------------------------------------------------Â© 2006 Newswise. All Rights Reserved.


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## Jeffrey Roberts

Hi All---I thought this might be of interest to those of you interested in Dr. Pimentel's Work. This is his most current study that was just published today by The American College of Physicians. I wish more people took part in the study( 87 ) but its still impressiveIf you'd like to check out, Heres the link: http://www.annals.org/current.shtml[Originally posted by David LA ]


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## jjohnson

That's interesting. Personally I've been pretty skeptical of this whole SIBO thing for quite some time. Not that I'm qualified to judge the science in any way, but you would think that if this were an effective therapy, then we would have more positive responses from people on these forums. With other treatments that have shown statistical significance (e.g. Lotronex, Zelnorm, hynotherapy), there are actually a fair number of people here who have benefited and I'm just not seeing that with any of the SIBO-related therapies.


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## eric

On the first page it says"No major differences in abdominal pain, diarrhea, or constipation were observed between the groups."On the abstarct it says"Conclusions: Rifaximin improves IBS symptoms for up to 10 weeks after the discontinuation of therapy."Although I am sure it says more in the full text.Looks like bloating got better, but not pain, d or c. Not sure how much it matters also that they used the rome 1 criteria, instead of Rome II or III?also noticed further down in the table of contents an Editorial from Dr DRossman on the sttudy."Editorials Treatment for Bacterial Overgrowth in the Irritable Bowel SyndromeDouglas A. DrossmanIn this issue, Pimentel and colleagues evaluated the efficacy of a newer broad-spectrum nonabsorbable antibiotic, rifaximin, for the irritable bowel syndrome (IBS), measuring clinical response for up to 10 weeks after treatment. They concluded that rifaximin treatment for 10 days showed greater global improvement than placebo. Demonstrating sustained benefit from a short course of an antibiotic in unselected patients with IBS is certainly novel and important. However, several methodologic concerns stand in the way of drawing firm conclusions from the study."


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## 13968

Hi Jeff,First of all, my most sincere thank-you for starting this website . I have SIBO and it's the 3rd day I'm on Xifaxan. I feel some improvement, so I hope this will work. In some thread in this site I found a reference to Dr. Pimentel Book, "A new IBS Solution" which I already got from Amazon. I'm avidly reading it, as everything Iâ€™ve read so far, makes a lot of sense to me; despite I donâ€™t suffer from IBS. Well thatâ€™s what my Dr said, as IBS seems to be an umbrella term for all what Gastroenterologists cannot figure out.Do you happen to know, what to do if Xifaxan doesnâ€™t work for me?


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## eric

Jeff, do you have access to Dr Drossmans comments on this?This still puzzles me"Over a 10-week follow-up period, the rifaximin recipients reported global improvements in overall symptoms and less bloating more frequently than the placebo recipients. No major differences in abdominal pain, diarrhea, or constipation were observed between the groups."So one group took the med and the other the placebo and there were no changes in pain d or c seen between the two groups.Yet, " recipients reported global improvements in overall symptoms and less bloating more frequently than the placebo recipients"Yet they reported global improvements and reported less bloating then the placebo.SUMMARIES FOR PATIENTSCan Antibiotics Improve the Symptoms of the Irritable Bowel Syndrome? http://www.annals.org/cgi/content/full/145/8/I-24


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## Jeffrey Roberts

Antibiotic May Aid Irritable BowelOct 16, 2006--------------------------------------------------------------------------------(WebMD) Ten days' treatment with the antibiotic Xifaxan reduces symptoms of irritable bowel syndrome (IBS), a small clinical trial suggests.IBS is a condition of the intestinal tract that causes symptoms of bloating, gas, abdominal cramping, diarrhea, and constipation.Xifaxan, now approved for the treatment of travelers' diarrhea, kills bacteria living in the gut. Experts disagree over the cause of IBS. Some suspect the root cause to be overgrowth of gut bacteria.One of these experts is Mark Pimentel, MD, director of the gastrointestinal motility program at Cedars-Sinai Medical Center in Los Angeles. In prior studies, Pimentel used breath tests to show that about 80% of IBS patients may have serious bacterial fermentation going on in their gut.This led him to wonder what would happen if he used a powerful antibiotic to shift the balance between overgrowth of these theoretically harmful bacteria and normal bacteria living in the gut.So Pimentel and colleagues gave a 10-day course of Xifaxan or inactive placebo to 87 IBS patients. Seventy-two patients finished the study. As is common in IBS studies, those who got placebo felt a bit better. Those who got Xifaxan reported even more improvement -- especially less bloating."Xifaxan was superior to placebo for control of IBS," Pimentel tells WebMD. "It suggests we are finally tackling a sustainable cause of IBS. If it is bacteria, we have changed the environment so that IBS is better on a semipermanent basis."The study, funded by Xifaxan maker Salix Pharmaceuticals, appears in the Oct. 17 issue of Annals of Internal Medicine. Pimentel is a consultant to Salix and has received speaking fees from the company. Cedars-Sinai Medical Center has a licensing agreement with Salix.Change of IBS Treatment?Is Xifaxan a new treatment for IBS? Not yet. A larger study, looking at IBS patients treated by their own doctors with Xifaxan, is already underway. Until those results are known, Xifaxan is not an officially approved treatment for IBS.But Pimentel says he's treated "thousands" of IBS patients with Xifaxan -- and he says now the word is getting out."The gem here is you have a sustained effect in IBS. The larger, longer studies will show how well this works," he says. "We've reported these results at professional meetings, and it has changed the way IBS is treated. Sixty percent of gastroenterologists in the country are starting to do it this way."Pimentel says the average patient needs re-treatment every two or three months, but that response varies greatly from patient to patient.Controversy Over IBS TreatmentNot all experts are convinced that bacterial overgrowth is a root cause of IBS, or that antibiotics are the best treatment. One of these experts is Douglas A. Drossman, MD, co-director of the University of North Carolina Center for Functional GI and Motility Disorders, Chapel Hill.In an editorial accompanying the Pimentel study, Drossman notes that IBS is a complex disorder that springs from the complex interplay of an oversensitive gut and the brain.Breath tests, he says, aren't reliable for diagnosing bacterial overgrowth. And Pimentel's study, he says, does not prove that treating bacterial overgrowth helps.Drossman is not impressed by Pimentel's finding that IBS patients reported an average 36.4% improvement in the 10 weeks after treatment with Xifaxan, while those given placebo treatment reported an average 21% improvement."Only bloating improved, and abdominal pain, diarrhea, and constipation did not improve," Drossman notes. "The benefit of using antibiotics is not fully proven and must be balanced with potential risks in terms of side effects, high costs -- a 10-day course of Xifaxan is $250 -- and a breath test, if ordered, costs an additional $304, and the need for recurrent treatment."Pimentel says new studies now coming out will support the bacterial-overgrwth theory of IBS. He does, however, say people with IBS have "movement disorders of the small bowel." He is hoping that a drug to promote movement in the small bowel will improve outcomes for IBS patients treated with antibiotics.--------------------------------------------------------------------------------SOURCES: Pimentel, M. Annals of Internal Medicine, Oct. 17, 2006; vol 145: pp 557-563. Drossman, D.A. Annals of Internal Medicine, Oct. 17, 2006; vol 145: pp 626-628. Mark Pimentel, MD, director, gastrointestinal motility program, Cedars-Sinai Medical Center, Los Angeles.By Daniel DeNoonReviewed by Louise ChangCopyright 2006, WebMD Inc. All rights reserved.


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## Kathleen M.

I've been looking at the full text of the article.While the differences between improvement was significantly different between placebo and the antibiotic, the overall percentage of people who saw improvement was still pretty low. The average % improvement for people on the antibiotics over the 10 week evaluation period was 36.4% and placebo was 21%. The Standard deviations are pretty large as well, but it seems the study was large enough these numbers were statistically significant, but there could be a lot of overlap between the two treatment groups. It would be a lot more encouraging if you saw a higher average improvement (like 1/2 or more of the patients rather than about 1/3rd), especially because while 21% improvement is not uncommon for placebo treatment you can see placebo improvement numbers up into the over 30% range with IBS, although those are usually in studies where you are continually taking something, not taking something for 10 days than stopping.That may be why we get a lot of people here who have been on antibiotics and not seen improvement. There may be some people that it works for (and if it works for you, great, always good to have something that works for anyone), but when it only works for 1/3 or so of IBSers it isn't quite the miracle breakthrough some people may hope this is based on some this research tends to get presented in the lay press. Most articles will mention that it is better than placebo. It is rare in the lay press to find them mention what percentage of people it helps. They are looking for the good story more than accuracy a lot of the time. Significantly different from placebo doesn't always mean that it helped the majority of those that took the treatment.So far I think these are patients selected for IBS without evaluating them for SIBO, which would be the way most of the IBSers here who have tried antibiotics end up on them. It seems fairly rare that people get screened for SIBO before they try antibiotics.What is encouraging is that for those that the treatment worked for the results seem to last for quite awhile which is good for the people that it does end up working for.It would be nice to see a larger study (more like a Phase III clinical trial than a Phase II trial in size). Whether they can get that funded or not is hard to tell. One advantage of a very large trial is you might be able to get a sense of what makes the 1/3rd that get better different from the 2/3rds that do not. If we knew how to target a treatment like this to the few that it is most likely to work for we'd avoid giving a lot of people expensive medications that are more likely to not work than work.K.


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## Moises

Not to be too pedantic but there appears to be two major issues here. First, does SIBO provide a good explanation of IBS? Second, is Xifaxan a good means of eliminating SIBO?One might answer the first question in the affirmative and the second question in the negative. All the evidence I have seen for Xifaxan is rather weak. As Kathleen points out, 36% percent improved in the experimental group versus 21% in the placebo group does not provide good evidence for answering the second question in the affirmative.What is stunning, however, is his claim in his book that he gets a positive response in 85% of experimental subjects when he gives them Vivonex Plus. And I believe his published studies show improvement in 80-81% who take Vivonex Plus.Yes, Vivonex Plus for 2-3 weeks is more inconvenient than popping 2 Xifaxan 3 times a day. But IBS is even more inconvenient. If you could bring about improvement in 80% of subjects, that would be something to shout from the rooftops. Why would Pimentel make Xifaxan the centerpiece of his program and the essential core of his book?All the science appears to point towards Vivonex and away from Xifaxan.


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## 17908

As I mentioned in another post, I'm betting that Pimental made Xifaxan the first course of action because Vivonex is too hard for most people to stick with. I bet he'd like to tell people to try Xifaxan right off the bat, but I bet the success rate would drop because of people not having the mentality needed for two weeks of nothing but Vivonex. I know most people with IBS think they could do it, but I bet it is harder than we think.I'd like to talk to somebody that has tried the Vivonex for at least two weeks.I'm personally having some decent success with Xifaxan. I'm going to go on and to a 10 day course of Xifaxan and neomycin to see if I can up my improvement to 90% or better. I hope I don't have to try the Vivonex, but I'll let you know if I do.


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## 15108

please let me know how your condition goes and the cost of the medication ur currently under(Xifaxan).thank you,vincent.


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## 17908

vincent leeI'll keep you updated. I've done 10 days of Xifaxan (1200 mg per day), and it cost about $220 for that many days. My symptoms improved about 50% to 70%, so I'm going to do 10 more days of Xifaxan AND neomycin.I'll keep you updated.


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## 23392

npearce, if you're in the U.S., news story just came out tonight: Meijer's is giving away generic antibiotics [must be walk-in, with doctor's prescription] for FREE. NO prescription cost. Might include neomycin [not the other one]. Disclaimer: not at ALL affiliated with Meijer's!


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## overitnow

If we have 20% of North Americans with IBS and 1/3 (+/-) were treatable with antibiotics, that would seem like a tremendous number to me. (I mean, the daily dose of aspirin for heart disease only works for the same percentage; but think about the number who take that without any assurance at all that they are in the lucky group. At least with this, you know if you get better or not.)Mark


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## Janet Robinson

Wow I took that drug the first week I was bad , suffered from every side effect there was, but the second week I was 90 per cent better..Now I am on probotics and see even a better improvement. When I had the breath test norm is 12 I came out a 18..I hope the antib doesn't wear off, I thought the probotic was doing the trick hope I am right.


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## David LA

That's great news Janet! I think the combination of Rifaximin and then lots of Probiotics is a winner!


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## 14397

Does this all mean that this new drug Xifan is going to be the answer? Is this something we can go to the GI and get prescribed? What are all of your thoughts about this being something that will help all of "us" who suffer from D,cramps,bloating! I'm so sick of having this, I took 5 immodium went to dinner and then the movies last night and in the middle of te movies I had to run out to the bathroom and barely made it and had cramps all night after! I hope this could be a good solution!


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## 22144

I just saw my doc and took my first dose today. I hope I get some relief.He ordered me to consume mass amounts of yogurt after doing the course.Also, I believe we shouldn't just group people as "IBS" anymore. There should be people with JUST diarrhea in one group. Those with constipation in another. Those with cramps in another. Those with...IBS is a huge catchall for a variety of symptoms. I think these results could be promising for different sub-sub-types of IBS.


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## Nanobug

> quote:That's great news Janet! I think the combination of Rifaximin and then lots of Probiotics is a winner!


I'm doing exactly the same:http://ibsgroup.org/groupee/forums/a/tpc/f...322/m/859107762


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## 22144

Day 2 - no side effects except extreme thirst from the antibiotics. I'm rather impressed. I'm actually feeling OK.


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## Jannybitt

Angst;I'm glad you're doing well so far! Keep us updated often, ok?


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## eric

sage1989 "Does Bacterial Overgrowth Play a Role in IBS?Bacterial Overgrowth & IBS: Too Soon To Tellhttp://ibsgroup.org/groupee/forums/a/tpc/f...261/m/554106962Its not at all clear yet to researchers that sibo causes IBS or is comorbid condition. Some center find only ten percent of their IBS patients have sibo and some others 40 percent and cedars 80 some percent, but cedars used lactolose breath testing, and there is a problem with that in testing for sibo. Other centers have not reproduced Cedars studies. This is a area of great controversary in IBS research right now and a lot of work on it neds to be done still and has not been done yet.There is a great deal of enthusiasm, especially from patinets that this might be the answer for IBS, but its important to read up on it all at this stage in the research. There are other abnormalities in IBS.


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## eric

With all IBS research this should still be kept in mindVisceral Sensations and Brain-Gut MechanismsBy: Emeran A. Mayer, M.D., Professor of Medicine, Physiology and Psychiatry; Director, Center for Neurovisceral Sciences & Women's Health, David Geffen School of Medicine at UCLAhttp://www.aboutibs.org/Publications/VisceralSensations.html


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## 22144

Today I woke up without nausea. Could be a coincidence, or the massive amount of phenergan I took last night.Only a little gas, little to no bloating.It could all be a coincidence? I can't wait until I can start eating yogurt again. My doc said not to eat any until I ran the course of antibiotics... then to load up on yogurt afterward.Every symptom seems to be way less intense.


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## Rick (never give up)

Hi eric,If I understood the article right, the idea is that we IBSers have a higher visceral sensitivity that makes us perceive what normal individuals don't perceive.My only question is why then do some people talking Rifaximin, Neomicin, etc, stop being sensitive while on the antibiotic therapy?. Although I know that after the antibiotic course, symptoms usually return, still while on them these people seem to feel normal, meaning that they are not hyper-sensitive.This reasoning bugs my brain.


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## Moises

> quote:Originally posted by Rick (never give up):Hi eric,If I understood the article right, the idea is that we IBSers have a higher visceral sensitivity that makes us perceive what normal individuals don't perceive.My only question is why then do some people talking Rifaximin, Neomicin, etc, stop being sensitive while on the antibiotic therapy?. Although I know that after the antibiotic course, symptoms usually return, still while on them these people seem to feel normal, meaning that they are not hyper-sensitive.This reasoning bugs my brain.


The problem is that science proceeds by making general laws and each of us occupies a particular situation.I feel frustrated too when I read such articles because they don't appear to address my particular situation. When my symptoms flare up my abdomen measurably distends and I burp 1,000 times in a day. The burps are not an internal (visceral) sensation; they are objectively measurable events.I understand that empirical data shows that people with IBS, when tested, report more discomfort than non-IBSers, to the same stimuli. So the evidence does support the higher visceral sensitivity hypothesis.What is so enticing to me about Pimentel is that he can explain my primary symptom--gas in my gut--without saying either (a) I don't really have a gas problem, I just perceive normal amounts of gas to be a problem but if my perceptions were not distorted, I would be fine; or (







I do have a gas problem but it is a problem that I have created by swallowing too much air and if I would stop swallowing air, I would be fine.I must admit I found the article fascinating and thank Eric for bringing it to our attention. I find the argument about evolution, made in the article, quite compelling. I agree with the claim that it is not evolutionarily adaptive for us to be conscious of stimuli, unless those stimuli prompt us to engage in an adaptive behavioral response. But Mayer does concede in the article that some gut information is useful to the consciousness. He states that it is useful to be conscious of fullness of stomach so that we can stop eating and it is useful to be conscious of rectal gas so we can expel it. I would hypothesize that my (personal) problem is not visceral hypersensitivity but visceral dysfunction. It is good that my afferent visceral nerves are sending signals to my consciousness because the same system that tells me I have cramps is the system that tells me to stop eating and to expel gas. So, a byproduct of having afferent visceral nerves (which are adaptive for weight control) is feeling cramps, which, Mayer hypothesizes, are maladaptive, because (prior to the advent of modern medicine) no behavioral response can diminish them. But this seems to be a weak argument. Many of us get food poisoning and recover. It was adaptive to feel gut pain because it changes our behavior--next time we are offered maggot-infested meat we decline. So visceral pain is, in many instances, adaptive.


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## eric

Rick"If I understood the article right, the idea is that we IBSers have a higher visceral sensitivity that makes us perceive what normal individuals don't perceive."CorrectTwo parts to it though"Visceral hypersensitivity: Enhanced perception, or over-responsiveness within the gut -- even to normal events.""My only question is why then do some people talking Rifaximin, Neomicin, etc, stop being sensitive while on the antibiotic therapy?."It is not known if they get some improvement from the antibiotics effect on bloating itself, gas bubbles in the gi tract put pressure on the cells in the colon which are then activated and in IBS because the nerves are overly sensitive to all stimuli, less gas means less pain. However the last study with the Rifaximin showed a slight improvement in bloating, but not really pain or d or c. Which I personally find interesting. It wasn't really a huge effect.If pain improved in all subject even 50 percent that would be a good thing, but it didn't.So"stop being sensitive while on the antibiotic therapy?" It doesn't really seem to be totally the case and part of what everyone is working on. It is important to remeber this is relatively new research and need to be incorporated with all IBS research. Partly also it maybe enthusiasm and wanting to be better could even play a role or over rating symptom improvements and some people getting better that have sibo and IBS or if SIBO is a subgroup in IBS or if sibo contributes to the actual cause of IBS, but that is a ways away in research still.I believe also the press has overly hyped this. Part of this might be if a person has just sibo or IBS or both, but not every IBSers has sibo and this is part of what everyone is working on, what is the association. That is not clear yet to anyone."Although I know that after the antibiotic course, symptoms usually return"from what I have read I am not sure there is a "cure" for sibo or if its just manageable like IBS, long term studies need to be done.As far as I can tell until the underlying motility disorder is "fixed" it may still return. You have to also keep in mind there is a high placebo rate in IBS and I have not seen that talked about yet in regards to sibo and IBS. Its still important though. One reason why its important to see how patinets are doing a couple months after treatment and 6 months after ect.. Thats not to rain on anyones parade either just a caution. also IBS is associated with a lot of other conditions and non gi symptoms and its already understood there are subgroups of the condition with different abnormalities involved.One is serotonin though because that is the neurotransmitter for sensations and pain and there is a lot of evidence its involved, but there is also a lot of evidence its involved in the altered motility of IBS, so sibo also needs to explain those observations.FYIThe lining of the bowel has cells that are pressure sensitive, so when the bowel is stretched it releases chemicals that can cause pain. "The cardinal symptoms of IBS are abdominal pain and altered intestinal activity - diarrhea or constipation. These are probably related to what is called visceral hypersensitivity; this means the nerve receptors in the intestines are super-sensitive, and fire off signals more readily than those in unaffected people.Visceral hypersensitivity can be demonstrated by inflating a balloon that's inserted in the rectum, and measuring the pressure that produces pain. The pain threshold is lowered in 60% of IBS patients. Interestingly, if the patient is led to anticipate pain, by a stepwise increase in balloon pressure, the pain threshold decreases; on the other hand, if the balloon pressure is randomly altered, there is no lowering of the pain threshold. This indicates that the brain can, indeed, play a part in the symptoms of IBS. And during the anticipation of, as well as actual, distension of the rectum in IBS patients, brain radiographs show increased blood flow in some parts of the brain.Patients with IBS may complain of diarrhea, constipation, or neither of these symptoms. The motility of the colon is clearly an important feature of the condition. Visceral hypersensitivity means the colon will react to a greater extent to stimuli that would produce no obvious effect in unaffected people. A worsening of symptoms after eating, for instance, might be an exaggerated response to the 'gastro-colic reflex', in which a full stomach releases a substance called cholecystokinin-1 that causes contractions of colon musculature.IBS sufferers are sometimes intolerant of certain foods, such as wheat products or milk. An irritant effect can lead, because of visceral hypersensitivity, to poor digestion, excessive gas, bloating, and intestinal 'hurry'.Visceral hypersensitivity implies increased nerve cell signals traveling from the intestines up to the brain (afferent signals), and increased signals going in the opposite direction (efferent signals). These signals are transmitted with the aid of a chemical called serotonin, or 5HT (short for 5-hydroxytryptamine).There are several reasons for believing that 5HT plays a central role in the way IBS symptoms are caused. First, in inflammatory intestinal conditions, such as food poisoning, enteritis, and colitis, the number of special cells that produce 5HT in the intestine wall are greatly increased, and there is increased intestinal motility and hurry. Second, a drug that antagonizes one type of 5HT receptors on the cells (alosetron) is effective in diarrhea-predominant ISB. And third, another drug that antagonizes another type of 5HT receptors (tegaserod) is effective in constipation-predominant IBS.Two other factors are important in how IBS occurs. Stress can make it worse. Acute stress situations are not likely to be a problem; chronic, unrelieved stress, such as separation or bereavement, are more likely triggers."http://www.healthandage.com/Home/gid2=2071There has been a lot more research done since some things have been written.also "History of Functional Disorders"MOTILITYIn healthy subjects, stress can increase motility in the esophagus, stomach, small and large intestine and colon. Abnormal motility can generate a variety of GI symptoms includingvomiting, diarrhea, constipation, acute abdominal pain, and fecal incontinence. Functional GI patients have even greater increased motility in response to stressors in comparison to normal subjects. *While abnormal motility plays a vital role in understanding many of the functional GI disorders and their symptoms, it is not sufficient to explain reports of chronic or recurrent abdominal pain.*VISCERAL HYPERSENSITIVITYVisceral hypersensitivity helps to account for disorders associated with chronic or recurrent pain, which are not well correlated with changes in gastrointestinal motility, and in some cases, where motility disturbances do not exist. Patients suffering from visceral hypersensitivity have a lowerpain threshold with balloon distension of the bowel or have increased sensitivity to even normal intestinal function. Additionally, there may be an increased or unusual area of somatic referral of visceral pain. Recently it has been concluded that visceral hypersensitivity may be induced in response to rectal or colonic distension in normal subjects, and to a greater degree, in persons with IBS. Therefore, it is possible that the pain of functional GI disorders may relate to sensitization resulting from chronic abnormal motor hyperactivity, GI infection, or trauma/injury to the viscera.5BRAIN-GUT AXISThe concept of brain-gut interactions brings together observations relating to motility andvisceral hypersensitivity and their modulation by psychosocial factors. By integrating intestinal and CNS central nervous system activity, the brain-gut axis explains the symptoms relating to functional GI disorders. In other words, senses such as vision and smell, as well as enteroceptiveinformation (i.e. emotion and thought) have the capability to affect gastrointestinal sensation,motility, secretion, and inflammation. Conversely, viscerotopic effects reciprocally affect central pain perception, mood, and behavior. For example, spontaneously induced contractions of the colon in rats leads to activation of the locus coeruleus in the pons, an area closely connected to pain and emotional centers in the brain. Jointly, the increased arousal or anxiety is associatedwith a decrease in the frequency of MMC activity of the small bowel possibly mediated by stress hormones in the brain. Based on these observations, it is no longer rational to try to discriminate whether physiological or psychological factors produce pain or other bowel symptoms. Instead, the Functional GI disorders are understood in terms of dysregulation of brain-gut function, andthe task is to determine to what degree each is remediable. Therefore, a treatment approachconsistent with the concept of brain-gut dysfunction may focus on the neuropeptides andreceptors that are present in both enteric and central nervous systems."http://ibsgroup.org/groupee/forums/a/tpc/f...710974#19710974Two very important cells in IBS are EC cells enterochromaffin cells which store the majority of serotonin in the gut and mast cells. Both connected to everything above.


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## 22144

Update: I've been doing really well lately.I haven't needed to take librax or phenergan. My stomach doesn't gurgle at all anymore. It doesn't make noises unless I'm hungry. I only have minor amounts of gas, too.I ATE MEXICAN SUCCESSFULLY.(yeah, I like to tempt fate.)


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## cynthia

angst, Sounds like you're doing really well with antibiotic therapy. I assume, although I can't find where you say for sure, that you're taking rifaximin. What's the dose you're taking? What are you eating (other than the mexican)? And lastly, what were your symptoms prior to the antibiotic? Your results thus far are quite promising. Cynthia


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## 22144

cynthia:Yes, I was given rifaximin/Xifaxan. I was put on 3 a day for 3 days. I usually eat a whole bunch of things. Chicken is the only meat that I tolerate well, so I eat a lot of chicken dishes. A lot of chicken curries.I was diagnosed IBS-A (mainly D though), nausea, cramps, gas, bloating...


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## Nanobug

> quote:I was put on 3 a day for 3 days


That seems "not enough". I took 6 a day for 10 days...


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## 22144

Yeah I don't feel like it was enough. IBS again.







Perhaps we were barking up the right tree though...I'm also going through a breakup. Too many spurious relationships.


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## 14416

The clinical trial I saw is doing a 14 day trial with the antibiotic therapy; maybe you need to go on it for longer.If it worked for a while, I think it's a good sign, don't you? I thought I even read that you might need to be retreated every so often, too.


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## Nanobug

> quote:Yeah I don't feel like it was enough. IBS again


Some brave people in the SIBO forum have done, and some still are doing, the Vivonex thing. Might be worth a try if you don't want to go the antibiotic route again.


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## 22144

Going to wait until after finals...


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