Efficacy of Probiotics in Irritable Bowel Syndrome-a Randomized , Double Blind Placebo-controlled Study

Background :Gut flora have important trophic effects on intestinal epithelia and on immune structue and function.They also protect colonized host against invasion by alien microbes.Recent research suggests that an imbalance of the intestinal microbiota and a dysfunctional intestinal barrier might higger irritable bowel syndrome (IBS). As probiotics have been reported to restore the intestinal microbiota and the gut barier, the therapeutic potential of probiotics within IBS became of strong interest. Objectives:To assess the efficacy of probiotics in IBS. Methods :Patients of 15 to 60 years old and both sexes were included from the out patient department (OPD) of gastroenterology, Bangabandhu Sheikh Mujib Medical University (BSMMU). A validated IBS-QOL instrument consisted of 34 questions used to assess improvement of quality of life before and after treatment. A total of 65 diarhoea predominant IBS patients were randomised to receive either probiotics(n-33) or placebo(n-32) rwice daily for 6 weeks. Results: At the end of 6 weeks therapy, improvement in various symptoms(abdominal pain, stool frequency, consistency and flatulence) in probiotics group was statistically significant. Mean QOL score before treatment was 103 in probiotics group and 106 in placebo group. After 6 weeks of treatment mean QOL score was 82 in probiotics group and 102.58 in placebo group . No side effects of the therapeutic agents were observed in any patient during the trial. Conclusions :Probiotics effectively alleviates global IBS and improves IBS symptoms simultaneously with an improvement of quality of life.


Introduction :
Irritable bowel syndrome (IBS) is the most common functional gastrointestinal disorder in clinical partice 1 .It is also one of the poorly understood chronic conditions in partbecause it is not a disease but a syndrome composed of a number of symptoms with similar manifestati on 2,3.
Several hypoththeses attempt to account for the patho- physiology of IBS, but the etiology still remains uncertain or obscure, perhaps multifactoral.Recent research has provided increasing support for the idea that disturbances of intestinal microbiota (in particular a significant reduc- tion in the amount of intraluminal Bifidobacteria or Lacto-Address of correspondence: Dr Md Zahidur Rahman, Assistant professor Dept. of Gastroenterology, Bangabandhu Sheikh Mtjib Medical University ( BSMMU ).
The prevalence of IBS has not been firmly established, but it has been estimated that IBS affected 14-24% of women and 5-I5% of men in a western country6.The world wide prevalence is 10-20 percent6.IBS is more 2t in female in a rural community in BangladeshT.
No specific diagnostic procedures identi$r IBS, because the underlying pathophysiology remains unknown.Thus, the diagnosis remains dependent on symptoms and exclusion of major organic diseasest''.IBS has almost always been incurable and the approach therefore, can only be palliative.Many drugs have been advocated in treatment of IBS, for instance, spasmolytics, bulking and psycho- tropic agents, 5-HT receptor arrtagonists and probiotics.
Probiotics are supplements that are made up of live strains of good bacteriathat are found normally in the body.There is growing awareness that the microflora make-up of the human body affects the overall health and risks for subse- quent diseases.IBS symptoms are thought to come from the imbalance of the bacteria in the gut.A balance of the microflora to noffnal conditions might reduce symptoms in those who suffer from IBS. Probiotics promote health by its ability to improve the balance of good bacteria in the gut.Probiotics regulate fermentation of non-degradable dietary fiber and intraluminal mucoproteins,favors lactose digestion,modulate intraluminal gas production, reducing the bacterra that produce it (E.coli, Veillonetla) and increasing the bactena that do not (Lactobacilli, Bifidobacterra).Probiotics increase in trophic responses and regulate intestinal motility (fasting and postprandial)10.
Although probiotics are being widely used in Bangladesh for treating IBS patients for a long time, their efficacy has not been studied in well designed clinical trial.So, this prospective randomtzed clinical trial has been conducted in diarrhea predominant IBS patients, using probiotics and placebo in separate group of patients to see the short-term efficacy in relation to change of symptoms score in all groups of patients and to see the change of quality of life (QOL) score before and after treatment .

Methods:
This prospective randomized, double blind placebo- controlled study was conducted among the patients attending to gastroenterology OPD of BSMMU during the period from December 2010 to December 2011.
Patients aged between 15 to 60 years, fulfilling the Rome II criteria for IBS diagnosis, having no red flags sign and having secondary education level so that they could fill-up questionnaire perfectly were included in the study.Pregnant and lactating mother and patients having concomitant severe illness were excluded from the study.
Detailed history was taken and meticulous physical examination was done.Complete blood count, blood glucose, serum TSH, serum tissue transglutaminase (TTG) ,stool VM/E , endoscopy of UGIT with distal duodenal biopsy,barium follow through of small intestine and colonoscopy was done in all patients to exclude any organic disease.All the patients were advised to exclude milk and milk products during the study period.Any patients having treatment for IBS were excluded from the study sample.Only diarrhea predominant patients were included.For the purposes of this study diarrhea was defined as patients self described passage of wet, soft stool more than 3 motions per day.A total of 72 patients were included in this study.Total number of Patients were divided into two groups randomly by lottery method.Each group consisted of 36 patients.One group treated with probiotics (Cap Probio, Square Herbal and Nutraceuticals Ltd containing Lactobacillus acidophilus 2bi11ion, Lactobacillus bulgaricus 1 billion, Bifidobacterium bifidun I billion and Fructo-oligosaccharides 100mg) twice daily and another group treated with placebo (components were lacfulose ,whe at ear,colloidal silicon dioxide, talc and magnesium stearate) twice daily for 6 weeks.Changes of symptoms and quality of life of patient were assessed by using a previously used validated IBS-QOL instrumentl 1. Symptoms scoring systern of IBS (table-1) included four major symptoms- abdominal pain, stool frequency, consistency and flatulence.Symptoms score was applied before starting the treatment as baseline and 2 weekly for 6 weeks.This scoring was done by doctor on the basis of 2 weekly interview.If stool frequency occurs > 3 times lday less than 25% of times from baseline per week, it indicates significant improvement.

Table-I
If soft stool and flatulence occurs less than 25% of times from baseline per week, it indicates significant improve- ment.
QOL instrument were translated into Bengali and were given to each patients before treatment.Patient himself scored on IBS-QOL instrument.A11 data were recorded in a printed data sheet.Paired T test done to compare the symptom before and after treatment for probiotics and placebo group and Chi square test is applied to compare between probiotics and placebo group. Results: Among 72 patients following ran domrzation, 36 patients (male 32,Female 4) were assigned to receive Cap Probio, 36 patients (male 30, female 6) to receive placebo prepa- ration.There were no statistically significant difference There were no significant differences in severity of symptoms between probiotic and placebo group at baseline.Total 1 patients were dropped out from this study, of which 3 were from probiotic group and 4 were from the placebo group due to unknown causes.Total 65 patients completed the trial.
Among 33 patients in probiotic group, 30 patients suffered from a pain score between 5 and 10 points at baseline.At the end of this study ,only 8 patients (25 .61%)had same level of pain, 22 patients (73 .33%)had marked improve- ment in pain score (less than a) (Table -3).In the placebo group, 25 patients had a pain score between 5 and 10 points at the baseline.At the end of the study,l 1 patients (44%) had same level of pain, improvement observed in 14 patients(56%)(Table -3).Improvement of pain score after treatment in probiotic group was statistically significant (p value <0.05 ) but improvement of pain score after treatment in placebo group was not statistically signifi- cant (p value <0.1).Difference of improvement between probiotic and placebo groups was also statistically significant (p<0.05)Of the patients receiving probiotic ,30 patients had stool improvement observed in 14 patients(48.28%)(frequencymore than 3 times/day inmore that25Yo of time . Imrovement in patients in respect to bowel at baseline. After 6 weeks, only 7 patients (B3a%)had frequency in probiotic groups was statistically signifi- the same frequency of stool motion,23 patients (76.34%) cant (p<0,05 ) in respect to baseline,but Imrovement in had marked improvement (Table-4).In the placebo group, patients in respect to bowel frequency in placebo group 29 patients had stool frequency more than 3 times/day in was not statistically significant (p<0.5 ) .The difference more than 25o/o of .time at baseline.After 6 weeks ,15 ofimprovementbetweenprobioticandplacebo groupsis patients (51.72%) had same frequency of stool motion, statistically significant (p<0.05).
Among the placebo group 30 patients had soft stool in more than 25% of time at the baseline.After 6 weeks, 24 patients (80%) had the same level of consistenclimprovement 24 observed in only 6 patrents(20%)( (Table - 5).Improvement in probiotic group in respect to soft stool was statistically significant (p <0.05) in respect to baseline.But Improve- ment in placebo group in respect to soft stool was not statis- tically significant (p <0.5) .The difference of improvement between probiotic and placebo groups is also statistic ally  Among the patients receiving probiotic , 30 patients had flatulence more than 25% of time at baseline.After G weeks, 7 patients (23.34%) had the same level of flatulence,23 patients (76.66%) had marked improvement (Tab1e-6).In the placebo group, 26 patients had flatulence more than 25% of time at baseline.After 6 weeks ,24 patients (92.30%) had the same level of flafulence,improvement observed in only 2 patients(7.7%)(Table -6).Improvement in patients in respect to flatulence in probiotic group was statistically significant (p<0.05) in respect to baseline.But improve- ment in placebo group was not statistically significant (P<0.5).The difference of improvement between probi- otic and placebo groups is also statistically significant (p <0.02).The emerging epidemiologic, physiological, and clinical data over the past few years have provided evidence that the intestinal microbiota play an important role in main- taining norrnal gastrointestinal (GI) functio rr" .It has been stated that the imbalance of the microbiotic composition may lead to a different fermentation pattern, especially with increased hydrogen production resulting in bloatingl3.
AdrJitionally, gut mucosal barrier disruption has been proven to be associated with bacterial translocation and inflammatory conditionsr4'rs.Furtherrnore, recent clinical data indicate that manipulation of the intestinal microbiota by probiotics may be efl-ective in alleviating symptoms of IBS16.
Probiotics reportedly bind to small and large bowel epithe- lium and produce substances with antibiotic properties that may inhibit attachment and invasion by pathogenic organ- isms.Probiotics may also modulate gastrointestinal luminal immunity by changing the cytokine and cellular milieu from a proinflammatory to anti-inflammatory state .They may also cohvert undigested carbohydrates into short chain fatty acids, which act as nutrients for colono- cytes and alter gut motility.Therefore, it has been theorized that probiotics may lead to symptomatic improvements in patients rvith 185'6.
Taking into consideration the pathophysiology of IBS and the role of adherence of probiotics regarding the restora- tion of the intestinal microbiota as well as of the gut barrier,probiotics might be effective for treatment of rhamnosus Lc705, Propionobacterium freudenreic-hii spp., Propionobacterium shernranii JS. tsifidobacteritun breve 8b99.Similar 1o our findings, the results obtained in these studies suggest some beneficial effect of probiotics over placeho in the relief of IBS sy'rnptonls"*-" .
A recent well-designed stud),, in u,hich Bifidobacterium infanti s 35624 was used, demonstrated also a signit-rcant improvement of global assessment with a 2aoA gain over placebo".There is also initial evidence that Bifidobacte- rium animalis DN-173 010 could improve health-related quality of life in IBS patients26 w'hich is similar to the findings of our study.It is interesting to note that some studies have also evaluated the impact of probiotics on certain pathophysiologic f-eatures of IBS.In their stnd,r,', O'Mahony et al have shown that B. infantis 35624 was able to reduce systemic proinflammatory cytokine profile, thus providing a possible mechanism through which this probiotic could be beneficial in IBS24.Kim et al have demonstrated thatYSL#3 delays colonic transit in IBS patients with bloating".Interestingl,r,, there is elso initial evidence indicating the beneficial eff-ect of a multi- initial evidence indicating the beneficial effect of a multispecies probiotic formulation on certain metabolic aspects of intestinal microbiota in IBS patients'o.Recently, Brenner et al. published a systematic review of randomtzed controlled trials(RCTs) aimed at the evaluation of the efficacy, safety and tolerability of probiotics in the treatment of IBS.A total of 16 RCTs were included in the analysis and showed improvement of IBS sympto*s's.Together with these studies,our study results further support the hypothesis that the beneficial effects of manipulation of the intestinal microbiota in patients with IBS have effects on global relief of GI symptoms.
In the present study, it was found thatprobiotics are effec- tive in relieving various symptoms of IBS.Significant improvements in abdorninal pain occurred in patients taking probiotics (73.33%) compared to placebo(56%).
It showed that probiotics also significantly improve the QOL.The improvement of patients taking probiotics is also significantly different from the placebo group.Toler- ance of the drug was excellent, and no difference in adverse events was noted between probiotics and placebo group; So probiotics generally regarded as safe.
There were several limitations of this study .Patients were selected from atertraqy health care center only and number of patients w'ere small.Larger scale sfudies are needed for further evaluation of the efficacy of probiotics for the IBS patients seen in the primary and secondary health care centers.Also we follow the patients only for 6 weeks, so extent of the benefit were not evaluated.In this study we use probiotics containing 3 organism-Lactobacillus acidophilus, Lactobacillus bulgaricus and Bifidobacterium bifidun.So further study can be done with probiotics containing multispecies.

Conclusion:
This study provides additional support to the hypothesis that manipulation of the intestinal microbiota may be beneficial in patients with IBS.Our findings suggest that the combination of probiotic bacteria used in this study may be helpful in alleviating symptoms in patients with functional GI disorders.The clinical benefit of this intervention needs further investigation.
Scoring system-for weekly assessment of symptoms of IBS }l4.d.Zahidur Rahman et al decreases to 25% of times in a week from baseline afer treatment(pain score decreases to less than 4), indicates significant improvement.

Table - Vl
QOL has been used which consist of 34 questions.Each had potential score of 1 to 5 points.So minimum scor is 34 and maximum score is I70.Patient himself/herself scored on QOL instrument before and after treatment.In probiotic group score before treatment was103.64and in placebo group mean score was 106.36.After treatment, mean score of probiotic group was 82.80 and in placebo group was 102.58 (Table-7).The improve- ment in QOL score in probiotic group after treatment was statistically significant (p value <0.05).But The improvement in QoL score in placebo group after treatment was not statistically significant (p value<0.138).Difference in improvement between probiotics and placebo group at the end of treatment was also statis- tically significant (P value <0.05) (Table-S).

Table - VIII
IBS-QOL score between probiotic and placebo group after 6 weeks of'treatment IBS.As the conventional medicaL treatment of IBS is unsatisfactory w'e have evaluated the efflr cacy of probiot- ics.This randomized,double blind, placebo-controlled study indicates that probiotics have beneficial effects in the treatment of IBS.Primary end points of this study were global relief of GI symptoms and satisfaction with treatment.Secondary end points were change in symptoms severity, well -being and quality of life.Improvement of in IBS patients have attempted to rarget changes in intestinal microflora with differcnt therapeutic approaches, including the use of prebiotics, probiotics.synbiotics, and nonabsorbable and sy'stemic antibiotics' .Single strains of Lactobacilli or Ilificlobarcteria have beerr used in the maiority of probiotic trialsls-26.Two studics used a composite prohiotic (VSL#3 ), containing multiplc strains of Bitldobacteria and Lactobacilli.andI strain of Streptococci."-'*Anotherrecent sfudy used a multispe- cies probiotic inctuding Lactobacilli rharnnosus GG.I-. Studies