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May 2019 -
Volume 17, Issue 5

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From the Editor

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Original Contribution

Job satisfaction in PHC Kuwait
[pdf]
Huda Youssef Al-Ghareeb, Rihab Abdullah Al-Wateyan
DOI: 10.5742MEWFM.2019.93640

Falls in Older People with Diabetes Mellitus: a study from Kurdistan of Iraq
[pdf]
Asso Amin, Zana A Mohammed, Osama Shukir Muhammed Amin, Raed Thanoon, Saman H Shareef, Thomas James Oakley, Teshk Shawis
DOI: 10.5742MEWFM.2019.93641

Effects of oxytocin therapy on amount of breast milk in postpartum period in Maternity Teaching Hospital

[pdf]
Ismail Bilal Ismail
DOI: 10.5742MEWFM.2019.93642

Case Report

The crescent trachea: a new radiological sign of subclinical tracheal compression in patients with large goitres
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Jason Toppi, Yik Seng Tham, Stephen Kleid
DOI: 10.5742MEWFM.2019.93643

What is the relationship between irritable bowel syndrome, smoking, hypertriglyceridemia, and fasting plasma glucose?
[pdf]
Mehmet Rami Helvaci, Abdulrazak Abyad, Lesley Pocock
DOI: 10.5742MEWFM.2019.93644

Prevalence and Risk Factors of Childhood Abuse among Hadhramout University Students in Yemen
[pdf]
Fauzia Faraj Bamatraf DOI: 10.5742MEWFM.2019.93645

Announcement

The Wael Al-Mahmeed & IAS Research Training Grants and Fellowships for the MENA Region
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Middle East Quality Improvement Program
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Chief Editor -
Abdulrazak Abyad MD, MPH, MBA, AGSF, AFCHSE

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medi+WORLD International
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May 2019 - Volume 17, Issue 5

What is the relationship between irritable bowel syndrome, smoking, hypertriglyceridemia and fasting plasma glucose?

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

Correspondence:
Mehmet Rami Helvaci, MD
07400, ALANYA, Turkey
Phone: 00-90-506-4708759
Email: mramihelvaci@hotmail.com

Received: March 2019; Accepted: April 2019; Published: May 1, 2019
Citation: Mehmet Rami Helvaci, Abdulrazak Abyad, Lesley Pocock. What is the relationship between irritable bowel syndrome, smoking, hypertriglyceridemia and fasting plasma glucose? World Family Medicine. 2019; 17(5): 35-41. DOI: 10.5742MEWFM.2019.93644

Abstract


Background:
We tried to understand whether or not there are some significant relationships between irritable bowel syndrome (IBS), smoking, and metabolic parameters.

Method: 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, and fever and abnormal physical examination findings.

Results: The study included 936 patients with the IBS and 346 control cases. Mean age of the IBS patients was 41.0 ± 14.7 (13-86) years. Interestingly, 63.2% of the IBS patients were female. Prevalence of smoking (35.2% versus 20.8%, p<0.001), chronic gastritis (CG) (80.4% versus 15.0, p<0.001), antidepressants use (46.4% versus 16.1%, p<0.001), hemorrhoids (37.1% versus 7.2%, p<0.001), and urolithiasis (22.0% versus 9.5%, p<0.001) and mean values of fasting plasma glucose (FPG) (111.9 versus 105.4 mg/dL, p= 0.002) and triglycerides (167.0 versus 147.3 mg/dL, p= 0.013) were all higher in patients with the IBS, significantly.

Conclusion: IBS may be a low-grade inflammatory process being initiated with infection, inflammation, anxiety, depression, sleep disorders, cancer fear, death fear, and smoking-like stresses, and eventually terminates with dysfunctions of the gastrointestinal and genitourinary tracts. There may be some significant associations between female sex, IBS, CG, depression, hemorrhoids, urolithiasis, smoking, higher FPG, and hypertriglyceridemia. FPG and triglyceride values may be sensitive acute phase reactants indicating some inflammatory processes like smoking and IBS in the body.

Key words: Irritable bowel syndrome, smoking, hypertriglyceridemia, fasting plasma glucose


INTRODUCTION

Recurrent upper abdominal discomfort may be the cause of nearly half of applications to Internal Medicine Polyclinics (1). Although gastroesophageal reflux disease, esophagitis, duodenal or gastric ulcers, erosive gastritis and duodenitis, celiac disease, chronic pancreatitis, and malignancies are found among possible causes, irritable bowel syndrome (IBS) and chronic gastritis (CG) may be two of the most frequently diagnosed disorders among all. Flatulence, periods of diarrhea and 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 IBS. According to literature, nearly 20% of the general population have IBS, and it is more common among females with unknown causes, yet (2). Psychological factors seem to precede onset and exacerbation of gut symptoms, and many potentially psychiatric disorders including anxiety, depression, sleep disorders, death fear, or cancer fear usually 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 examinees’ attention on gastrointestinal stimuli by reading pictures of gastrointestinal malignancies in the IBS cases (4). In another definition, although IBS is described as a physical disorder according to Rome II guidelines, psychological factors may be crucial for triggering of these 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 by means of a low-grade inflammatory state (5). As a result, IBS may even cause CG, urolithiasis, and hemorrhoids (6-8). Similarly, some authors studied the role of inflammation in the IBS via colonic biopsies in 77 patients (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 shown by some other authors (10). They demonstrated not only an increased mast cell degranulation in the colon but also a direct correlation between proximity of mast cells to neuronal elements and severity of pain in the IBS (10). In addition to the above findings, there is some evidence for extension of the inflammatory process behind the mucosa. Some authors addressed this issue in ten 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 terminating with an accelerated atherosclerotic process-induced end-organ insufficiencies all over the body. We tried to understand whether or not there are some significant relationships between IBS, smoking, and metabolic parameters in the present study.

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, alcohol consumption, urolithiasis, and already used medications including antidepressants at least for a period of six-month were learned. Patients with devastating illnesses including eating disorders, malignancies, acute or chronic renal failure, cirrhosis, hyper- or hypothyroidism, and heart failure were excluded. Current daily smokers at least for six-months and cases with a history of five pack-year were accepted as smokers. Patients with regular alcohol intake (one drink a day) were accepted as drinkers. A routine check up procedure including fasting plasma glucose (FPG), triglycerides, low density lipoproteins (LDL), high density lipoproteins (HDL), C-reactive protein, albumin, creatinine, thyroid function tests, hepatic function tests, markers of hepatitis A, B, C, and human immunodeficiency viruses, urinalysis, a posterior-anterior chest x-ray graphy, an electrocardiogram, a Doppler echocardiogram in case of requirement, an abdominal ultrasonography, an abdominal x-ray graphy in supine position, rectosigmoidoscopy in patients symptomatic for hemorrhoids, 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, and fever and abnormal physical examination findings. An upper gastrointestinal endoscopy was performed, and sample biopsies were taken in case of requirement. CG is diagnosed histologically, and infiltration of neutrophils and monocytes into gastric mucosa is the hallmark of CG (13). Additionally, microscopic examination shows stereotypical changes in epithelium such as degeneration, focal intestinal metaplasia, dysplasia, and glandular atrophy (13). An additional intravenous pyelography was performed according to the results of the urinalysis and abdominal x-ray graphy. So urolithiasis was diagnosed either by medical history or as a result of current clinical and laboratory findings. Body mass index (BMI) of each case was calculated by measurements of the same clinician instead of verbal expressions. Weight in kilograms is divided by height in meters squared (14). Cases with an overnight FPG level of 126 mg/dL or higher on two occasions or already using antidiabetic medications were defined as diabetic. An oral glucose tolerance test with 75-gram 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 diabetes mellitus (DM) (14). 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 hypertension after a 10-minute education session about proper blood pressure (BP) measurement techniques (15). The education included recommendation of upper arm 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 for a period of 5 minutes in seated position before measurements. An additional 24-hour ambulatory blood pressure monitoring was not required due to the equal efficacy of the method with HBP measurements to diagnose hypertension (HT) (16). Eventually, HT is defined as a mean BP of 140/90 mmHg or greater on HBP measurements and white coat hypertension (WCH) is defined as an OBP of 140/90 mmHg or greater, but a mean HBP value of lower than 140/90 mmHg (15). 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, CG, antidepressants use, hemorrhoids, 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 936 patients with the IBS and 346 control cases. Mean age of the IBS patients was 41.0 ± 14.7 (13-86) years. Interestingly, 63.2% of the IBS patients were female. Prevalence of smoking (35.2% versus 20.8%, p<0.001), CG (80.4% versus 15.0, p<0.001), antidepressants use (46.4% versus 16.1%, p<0.001), hemorrhoids (37.1% versus 7.2%, p<0.001), and urolithiasis (22.0% versus 9.5%, p<0.001) and mean values of FPG (111.9 versus 105.4 mg/dL, p= 0.002) and triglycerides (167.0 versus 147.3 mg/dL, p= 0.013) were all higher in patients with the IBS. On the other hand, prevalence of WCH, HT, and DM and mean values of BMI, TC, LDL, and HDL were all similar in both groups (p>0.05 for all) (Table 1 - next page). Although the high prevalence of smoking, there was no patient with regular alcohol intake either among the IBS patients or control cases.

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