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March 2019 -
Volume 17, Issue 2

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From the Editor

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Editorial

Dr. Abdulrazak Abyad
DOI: 10.5742/MEWFM.2019.93623

Original Contribution

Self-monitoring of Blood Glucose Among Type-2 Diabetic Patients: An Analytical Cross-Sectional Study
[pdf]
Ahmed S. Alzahrani, Rishi K. Bharti, Hassan M. Al-musa, Shweta Chaudhary
DOI: 10.5742/MEWFM.2019.93624

White coat hypertension may actually be an acute phase reactant in the body
[pdf]
Mehmet Rami Helvaci, Orhan Ayyildiz, Orhan Ekrem Muftuoglu, Mehmet Gundogdu, Abdulrazak Abyad, Lesley Pocock
DOI: 10.5742/MEWFM.2019.93625

Case Report

An Unusual Persistent Mullerian Duct Syndrome in a child in Abha city: A Case Report
[pdf]
Youssef Ali Mohamad Alqahtani, Abdulrazak Tamim Abdulrazak, Hessa Gilban, Rasha Mirdad, Ashwaq Y. Asiri, Rishi Kumar Bharti, Shweta Chaudhary
DOI: 10.5742/MEWFM.2019.93628

Population and Community Studies

Prevalence of abdominal obesity and its associated comorbid condition in adult Yemeni people of Sana’a City
[pdf]
Mohammed Ahmed Bamashmos
DOI: 10.5742/MEWFM.2019.93626

Smoking may even cause irritable bowel syndrome
[pdf]
Mehmet Rami Helvaci, Guner Dede, Yasin Yildirim, Semih Salaz, Abdulrazak Abyad, Lesley Pocock
DOI: 10.5742/MEWFM.2019.93629

Systematic literature review on early onset dementia
[pdf]
Wendy Eskine
DOI: 10.5742/MEWFM.2019.93627



Middle East Quality Improvement Program
(MEQUIP QI&CPD)

Chief Editor -
Abdulrazak Abyad MD, MPH, MBA, AGSF, AFCHSE

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Publisher -
Lesley Pocock
medi+WORLD International
AUSTRALIA
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: lesleypocock@mediworld.com.au
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March 2019 - Volume 17, Issue 3

Smoking may even cause irritable bowel syndrome

Mehmet Rami Helvaci (1)
Guner Dede
(2)
Yasin Yildirim
(2)
Semih Salaz
(2)
Abdulrazak Abyad
(3)
Lesley Pocock
(4)

(1) Specialist of Internal Medicine, MD
(2) General practitioner, MD
(3) Middle-East Academy for Medicine of Aging, MD
(4) medi-WORLD International

Corresponding author:
Mehmet Rami Helvaci, MD
07400, ALANYA, Turkey
Phone: 00-90-506-4708759

Email:
mramihelvaci@hotmail.com

Abstract


Background: Smoking induced chronic vascular endothelial inflammation may even cause irritable bowel syndrome (IBS).

Method: IBS is diagnosed according to Rome II criteria in the absence of red flag symptoms.

Results: The study included 647 patients with IBS and 340 control cases. Mean age of the IBS patients was 41.4 years. Interestingly, 64.2% of the IBS patients were female. Prevalence of smoking was higher in the IBS cases (36.4% versus 20.5%, p<0.001). Similarly, prevalence of antidepressants use was higher in the IBS patients (48.0% versus 15.5%, p<0.001). Additionally, prevalence of urolithiasis was also higher in the IBS group (23.3% versus 9.4%, p<0.001). Mean body mass index values were similar in the IBS and control groups (27.5 versus 27.7 kg/m2, p>0.05, respectively). Prevalence of white coat hypertension was also similar in them (29.3% versus 31.4%, p>0.05, respectively). Although prevalence of hypertension and diabetes mellitus and mean values of total cholesterol, triglycerides, low density lipoproteins, and high density lipoproteins were all similar in them, mean value of fasting plasma glucose (FPG) was significantly higher in the IBS group (110.1 versus 105.6 mg/dL, p= 0.013).

Conclusion: IBS may be a low-grade inflammatory process being initiated with infection, inflammation, psychological disturbances-like stresses, and eventually terminates with dysfunctions of gastrointestinal and genitourinary tracts and other systems of the body. Although there may be several possible causes of IBS, smoking induced chronic vascular endothelial inflammation may even cause IBS. The higher FPG in the IBS patients should be researched with further studies.

Key words: Smoking, irritable bowel syndrome, metabolic syndrome, fasting plasma glucose


INTRODUCTION

One of most frequent applications to Internal Medicine Polyclinics are due to recurrent upper abdominal discomfort (1). Although gastroesophageal reflux disease, esophagitis, duodenal or gastric ulcers, erosive gastritis or duodenitis, celiac disease, chronic pancreatitis, and malignancies are found among possible causes, irritable bowel syndrome (IBS) may be one of the most frequently diagnosed diseases, clinically. Flatulence, periods of diarrhea or constipation, repeated toilet visits due to urgent evacuation or early filling sensation, excessive straining, feeling of incomplete evacuation, frequency, urgency, reduced feeling of well-being, and eventually disturbed social life are often reported by the IBS patients. Although many patients relate onset of symptoms to intake of food, and often incriminate specific food items, a meaningful dietary role is doubtful in the IBS. According to literature, 10-20% of the general population have IBS, and it is more common among females with unknown causes (2). Psychological factors seem to precede onset or exacerbation of gut symptoms, and many potentially psychiatric disorders including anxiety, depression, or sleep disorders frequently coexist with the IBS (3). For example, thresholds for sensations of initial filling, evacuation, urgent evacuation, and utmost tolerance recorded via a rectal balloon significantly decreased by focusing the examiners' attention on gastrointestinal stimuli by reading pictures of gastrointestinal malignancies in the IBS cases (4). So although IBS is described as a physical instead of a psychological disorder according to Rome II guidelines, psychological factors may be crucial for triggering of the physical changes in the body. IBS is actually defined as a brain-gut dysfunction according to the Rome II criteria, and it may have more complex mechanisms affecting various systems of the body with a low-grade inflammatory state (5). For example, IBS may even terminate with chronic gastritis, urolithiasis, and hemorrhoid in a significant proportion of patients (6-8). Similarly, some authors studied the role of inflammation via colonic biopsies in 77 patients with IBS (9). Although 38 patients had normal histology, 31 patients demonstrated microscopic inflammation and eight patients fulfilled criteria for lymphocytic colitis. However, immunohistology revealed increased intraepithelial lymphocytes as well as increased CD3 and CD25 positive cells in lamina propria of the group with "normal" histology. These features were more evident in the microscopic inflammation group who additionally revealed increased neutrophils, mast cells, and natural killer cells. All of these immunopathological abnormalities were the most evident in the lymphocytic colitis group who also demonstrated HLA-DR staining in the crypts and increased CD8 positive cells in the lamina propria (9). A direct link between the immunologic activation and IBS symptoms was provided by work of some other authors (10). They demonstrated not only an increased incidence of mast cell degranulation in the colon but also a direct correlation between proximity of mast cells to neuronal elements and pain severity in the IBS (10). In addition to these findings, there is some evidence for extension of the inflammatory process behind the mucosa. Some authors addressed this issue in 10 patients with severe IBS by examining full-thickness jejunal biopsies obtained via laparoscopy (11). They detected a low-grade infiltration of lymphocytes in myenteric plexus of nine patients, four of whom had an associated increase in intraepithelial lymphocytes and six demonstrated evidence of neuronal degeneration. Nine patients had hypertrophy of longitudinal muscles and seven had abnormalities in number and size of interstitial cells of Cajal. The finding of intraepithelial lymphocytosis was consistent with some other reports in the colon (9) and duodenum (12). On the other hand, smoking is a well-known cause of chronic vascular endothelial inflammation all over the body. We tried to understand whether or not smoking induced chronic vascular endothelial inflammation all over the body is found among one of the possible causes of the IBS.

MATERIALS AND METHODS

The study was performed in the Internal Medicine Polyclinic of the Dumlupinar University between August 2005 and March 2007. Consecutive patients with upper abdominal discomfort were taken into the study. Their medical histories including smoking habit, hypertension (HT), diabetes mellitus (DM), and already used medications including antidepressants at least for a period of six months were learned. A routine check up procedure including fasting plasma glucose (FPG), triglycerides, low density lipoproteins (LDL), high density lipoproteins (HDL), erythrocyte sedimentation rate, C-reactive protein, albumin, thyroid function tests, creatinine, urinalysis, hepatic function tests, markers of hepatitis A virus, hepatitis B virus, hepatitis C virus, and human immunodeficiency virus, a posterior-anterior chest x-ray film, an electrocardiogram, a Doppler echocardiogram in case of requirement, an abdominal ultrasonography, an abdominal X-ray graphy in supine position, and a questionnaire for IBS was performed. IBS is diagnosed according to Rome II criteria in the absence of red flag symptoms including pain and diarrhea that awakens/interferes with sleep, weight loss, fever, and abnormal physical examination findings. An additional intravenous pyelography was performed just in suspected cases from presenting urolithiasis as a result of the urinalysis and abdominal X-ray graphy. So urolithiasis was diagnosed either by medical history or as a result of clinical findings. Patients with a history of eating disorders including anorexia nervosa, bulimia nervosa, compulsive overeating, or binge eating disorder, insulin using diabetics, and patients with devastating illnesses including malignancies, acute or chronic renal failure, cirrhosis, hyper- or hypothyroidism, and heart failure were excluded to avoid their possible effects on weight. Current daily smokers at least for six months and cases with a history of five pack-year were accepted as smokers. Body mass index (BMI) of each case was calculated by the measurements of the same physician instead of verbal expressions. Weight in kilograms is divided by height in meters squared (13). Cases with an overnight FPG level of 126 mg/dL or higher on two occasions or already using antidiabetic medications were defined as diabetics. An oral glucose tolerance test with 75 grams glucose was performed in cases with FPG levels between 100 and 126 mg/dL, and diagnosis of cases with 2-hour plasma glucose levels of 200 mg/dL or higher is DM (13). Office blood pressure (OBP) was checked after a 5-minute rest in seated position with mercury sphygmomanometer on three visits, and no smoking was permitted during the previous 2 hours. Ten-day twice daily measurements of blood pressure at home (HBP) were obtained in all cases, even in normotensives in the office due to the risk of masked HT after a 10-minute education session about proper blood pressure (BP) measurement techniques (14). The education included recommendation of upper arm while discouraging wrist and finger devices, using a standard adult cuff with bladder sizes of 12 x 26 cm for arm circumferences up to 33 cm in length and a large adult cuff with bladder sizes of 12 x 40 cm for arm circumferences up to 50 cm in length, and taking a rest at least for a period of 5 minutes in the seated position before measurements. An additional 24-hour ambulatory blood pressure monitoring (ABP) was not required due to an equal efficacy of the method with HBP measurement to diagnose HT (15). Eventually, HT is defined as a mean BP of 140/90 mmHg or higher on HBP measurements and white coat hypertension (WCH) is defined as an OBP of 140/90 mmHg or higher, but a mean HBP value of lower than 140/90 mmHg (14). Eventually, all patients with the IBS were collected into the first and age and sex-matched controls were collected into the second, groups. Mean BMI, FPG, total cholesterol (TC), triglycerides, LDL, and HDL values and prevalences of smoking, antidepressants use, urolithiasis, WCH, HT, and DM were detected in each group and compared in between. Mann-Whitney U test, Independent-Samples T test, and comparison of proportions were used as the methods of statistical analyses.

RESULTS

The study included 647 patients with the IBS and 340 control cases, totally. The mean age of the IBS patients was 41.4 ± 14.4 (15-86) years. Interestingly, 64.2% (416) of the IBS patients were female. Prevalence of smoking was significantly higher in cases with the IBS (36.4% versus 20.5%, p<0.001). Similarly, prevalence of antidepressants use was higher in cases with the IBS (48.0% versus 15.5%, p<0.001). Beside that prevalence of urolithiasis was also higher in the IBS group (23.3% versus 9.4%, p<0.001). Mean BMI values were similar both in the IBS and control groups (27.5 versus 27.7 kg/m2, p>0.05, respectively). Additionally, prevalence of WCH was similar in both groups, too (29.3% versus 31.4%, p>0.05, respectively). Although prevalence of HT and DM and mean values of TC, triglycerides, LDL, and HDL were all similar in both groups (p>0.05 for all), mean value of FPG was significantly higher in the IBS group with unknown reasons, yet (110.1 versus 105.6 mg/dL, p= 0.013) (Table 1).

Table 1: Comparison of patients with irritable bowel syndrome and control cases
*Irritable bowel syndrome †Nonsignificant (p>0.05) ‡Body mass index §White coat hypertension ?Hypertension **Fasting plasma glucose ***Diabetes mellitus ****Total cholesterol *****Low density lipoproteins ******High density lipoproteins

DISCUSSION

Smoking may be found among one of the most common causes of vasculitis all over the world. It is a major risk factor for the development of atherosclerotic endpoints including coronary heart disease (CHD), peripheric artery disease (PAD), chronic obstructive pulmonary disease (COPD), cirrhosis, chronic renal disease (CRD), and stroke (16, 17). Its atherosclerotic effects are the most obvious in Buerger's disease. Buerger's disease is an obliterative disease characterized by inflammatory changes in small and medium-sized arteries and veins, and it has never been reported in the absence of smoking in the literature. Although the well-known strong atherosclerotic effects of smoking, some studies reported that smoking in humans and nicotine administration in animals are associated with a decreased BMI (18). Evidence revealed an increased energy expenditure during smoking both on rest and light physical activity (19), and nicotine supplied by patch after smoking cessation decreased caloric intake in a dose-related manner (20). According to an animal study, nicotine may lengthen intermeal time and simultaneously decreases amount of meal eaten (21). Additionally, BMI seems to be the highest in the former, the lowest in the current and medium in never smokers (22). Smoking may be associated with postcessation weight gain but evidence suggests that risk of weight gain is the highest during the first year after quitting and declines over the years (23). Similarly, although CHD was detected with similar prevalence in both genders in a previous study (24), prevalence of smoking and COPD were higher in male patients with CHD against the higher prevalences of BMI, WCH, LDL, triglycerides, HT, and DM in female patients with CHD as the other atherosclerotic risk factor. This result may indicate both the strong atherosclerotic and weight decreasing roles of smoking (25). Similarly, the incidence of a myocardial infarction is increased sixfold in women and threefold in men who smoke at least 20 cigarettes per day compared to the never smoked cases (26). In other words, smoking is more dangerous for women regarding the atherosclerotic endpoints probably due to the higher BMI and its consequences in them. Parallel to the above results, the proportion of smokers is consistently higher in men in the literature (17). So smoking is probably a powerful athersclerotic risk factor with some suppressor effects on appetite. Smoking induced loss of weight gain may be related with the smoking induced chronic vascular endothelial inflammation all over the body, since loss of appetite is one of the major symptoms of inflammation in the