IBS AND FOOD ALLERGY

Food allergy and irritable bowel syndrome


Dr Widodo Judarwanto MD, Children Allergy Center Jakarta Indonesia


Irritable bowel syndrome (IBS) is a common disorder which causes abdominal pain, abdominal distension, and bowel dysfunction, characterised by loose bowels, constipation, or a fluctuation between these two extremes.1 This condition significantly impairs quality of life and places a large burden on health care resources. Treatment of IBS is largely based on the use of antispasmodics, antidepressants, and medications that modify bowel habit, depending on whether constipation or diarrhoea is the predominant problem. The notorious inadequacies of current drug therapy lead to much patient dissatisfaction and a tendency for patients to seek a variety of alternative remedies, especially of a dietary nature.
The notion of food allergy in irritable bowel syndrome (IBS) is not new. However, recent evidence suggests significant reduction in IBS symptom severity in patients on elimination diets, provided that dietary elimination is based on foods against which the individual had raised IgG antibodies. These findings should encourage studies dissecting the mechanisms responsible for IgG production against dietary antigens and their putative role in IBS
Bringing empirical observations ad fontes advances science. In astrophysics, the term "black hole" was introduced to describe an extremely dense star which had collapsed into a singularity under its own gravity. A black hole radiates nothing; it absorbs all matter and energy falling within its sphere. The name was coined only after revisiting the initial theoretical achievements of Karl Schwarzschild, when observations made outside the earth’s atmosphere gave astrophysicists empirical x ray data on a new type of cosmic object. In allergology, in contrast, adherence to a paradigm whereby allergy is defined by the presence of specific IgE antibodies has hampered disentanglement. As a result, allergy remains a dubiously defined term with no unambiguous empirical content or explanatory power. The time has come to seize upon the available empirical data and plunge into the original theory of Clemens von Pirquet.
The term allergy was introduced by von Pirquet to denote a changed immunological reactivity which manifests itself on second exposure to an antigen. This altered reactivity is uncommitted, giving no indication of the direction of change; equally harmful and protective immune reactivity reflects prior encounte. In modern terms, altered reactivity can be seen to evince either the most common mode of immune response elicited by the intestinal immune system, tolerance, recently defined as any mechanism by which a potentially injurious immune response is prevented, suppressed, or shifted to a non-injurious class of immune response, or abrogation of such an actively maintained process, which is currently linked to immunoinflammatory disease. Reassessment of the original theory of allergy is important as it would appear that it is not the immunological resources gained during antigen exposure, measurable by specific antibodies or specifically responding lymphocytes, which are decisive for the presence or absence of disease, but the complex cascade of events determining their use.
The notion of food allergy in irritable bowel syndrome (IBS) resurfaces in scientific thinking in this issue of Gut3 on the basis of a solid randomised placebo controlled trial conducted by Atkinson and colleagues . Determination of serum IgG antibodies against foods was used to guide the construction of elimination diets.
Most patients with IBS have attempted at least some form of dietary modification, which in some cases can be very extreme. Conflicting results have been reported using exclusion diets and this approach also suffers from the limitation that it has to be empirical. Thus potentially offending foods can only be identified after their elimination and subsequent reintroduction. This time consuming process would be much reduced if the offending foods could be identified beforehand. The observation that adherence to the diet is critical in determining a good outcome in the "true" diet group but not the "sham" group is indicative of the fact that the diet is an "active treatment" which if not adhered to, does not seem to have an effect.
There is currently considerable interest in the concept that at least in some patients, IBS may have an inflammatory component. Most of the work in this area has centred on post dysenteric IBS, with gut pathogens being viewed as the initiators of this process which can be identified by subtle changes on histology. However, if, as indicated in this study, IgG antibodies to food are important in the pathogenesis of IBS in some patients, they too may be of relevance. Not all patients exhibiting histological features consistent with post dysenteric IBS give a history of a previous dysenteric illness. This is usually assumed to be due to the fact that this has been forgotten by the patient but our results may suggest an alternative mechanism for immune activation and inflammation without the need for prior infection.
It is now well recognised that up to 70% of patients with IBS have evidence of hypersensitivity of the rectum, which probably extends to involve most of the gut in many individuals. It is possible that this hypersensitivity renders patients more reactive to a low grade inflammatory process which would not necessarily cause symptoms in a normal individual.
The presence of specific IgG class antibodies is often accepted as uncommitted or protective "altered reactivity", unlike those of the IgE class. Detection of antigen specific IgE is invariably taken as an attribute of causality, a condition called "IgE mediated disease" and, more specifically, of "allergy".1 However, empirical data are accumulating to suggest that transient increases in antigen specific IgE antibodies prevail in most healthy asymptomatic children during the first five years of life. Secondly, generation of these antibodies (sensitisation) on antigen exposure may not necessarily induce clinical disease (atopic disease).5 Thirdly, reducing the risk of atopic disease does not necessitate reduction of sensitization and, finally, resolution or aggravation of clinical disease is not invariably associated with a corresponding alteration in antibody concentration. Bearing these limitations in mind, however, the clinician may successfully profit from determination of specific IgE to complete the clinical history in an attempt to identify potential offending antigens in a symptomatic patient’s diet for the explicit diagnostic elimination-challenge procedure. This is precisely what Atkinson et al did, with specific IgG antibodies. They identified a significant reduction in IBS symptom severity in patients on elimination diets, provided that dietary elimination was based on foods against which the individual had raised IgG antibodies; fully compliant patients showed the best clinical improvement. The reverse pattern was observed after reintroduction of the respective foods.
"IBS appears to result from an interplay between susceptibility genes and impaired gut barrier functions, immunological dysregulation, together with bacterial and viral infections and other environmental factors"
In common with allergic disease, IBS appears to result from an interplay between susceptibility genes and impaired gut barrier functions, immunological dysregulation, together with bacterial and viral infections and other environmental factors. It is no easy matter to describe succinctly "gut barrier function". In the gastrointestinal tract, the external and internal environments are in close proximity. The dilemma of the mucosal surface of the intestine is to fend off the constant challenge from antigens, such as microorganisms, in mounting a brisk response to pathogens, and to enable assimilation of innocuous antigens derived from food. In order to perform these opposing functions, the intestine is in a state of continuous immune responsiveness, and a delicate balance is generated and maintained between concomitant facilitation and suppression of inflammatory responses.
Gut barrier function consists of physiological and immunological factors which exclude and degrade antigens and restrict their adherence, penetration, and transfer. Antigen presenting cells, and more precisely dendritic cells, are pivotal in directing mucosal immune responses. Three dendritic cell derived signals are required for an effective T cell response.11 The nature of signal 1 depends on the antigen in question and its processing; necessary costimulatory molecules create the second signal and the pericellular cytokine milieu is the basis of the third. On antigen recognition, maturation of dendritic cells and secretion of cytokines and chemokines occur. These secretions direct the polarisation of a naïve T helper cell to type 1, type 2, or a regulatory T cell and thus regulate other adaptive immune responses, such as B cell derived immunoglobulin production.11 Tolerance to lumenal dietary and microbial antigens is likely to be achieved through those dendritic cells which induce production of regulatory T cells secreting interleukin 10 and transforming growth factor ß. These cytokines promote gut barrier function by suppressing the production of both T helper 1 and 2 cytokines, overexpression of which is associated with increased gut permeability. Moreover, the anergic T cells induced by interleukin 10 exposed dendritic cells appear to be able to suppress other T cells in an antigen specific manner. Transforming growth factor ß downregulates both T helper 1 and 2 responses directly and indirectly by modulating the activity of antigen presenting cells and favouring the development of regulatory T cells.20 After intestinal priming, these cells migrate to the periphery, thus mediating peripheral tolerance on reactivation. In addition to its effects on T cell function, transforming growth factor ß is a key factor in IgA production and thus contributes to maintenance of gut barrier function and to immune responses at other mucosal surfaces also. Taken together, "gut barrier function" strongly depends on antigen processing and presentation and the cytokine milieu in the mucosal immune system, and determines the nature of the immune response (that is, tolerance or inflammation) elicited to a particular antigen.
"Inflammation can cause profound alterations in the function of smooth muscle and enteric nerves as well as in deeper neuromuscular layers"
In certain circumstances, such as metabolic stress, the peaceful coexistence across the barrier is disturbed and an inflammatory response ensues. Abrogated barrier function of the gut mucosa leads to greater antigen transfer when the routes of transport are also altered, thereby evoking aberrant immune responses and release of proinflammatory cytokines with further impairment of barrier function. Inflammation can cause profound alterations in the function of smooth muscle and enteric nerves as well as in deeper neuromuscular layers. Indeed, a subtle inflammatory response and exaggerated sensitivity to that type of response has been suggested to be causative in IBS. In view of recently reported alterations in the immunological defence in IBS, the trigger(s) of the vicious circle can be depicted among the intraluminal antigens.
In this issue of Gut, Atkinson and colleagues3 describe IgG antibody responses to dietary antigens of clinical significance and an apparent causal relation to symptoms in IBS, in a fashion resembling the elimination-challenge procedure in food allergy. To broaden this concept, it is intriguing to speculate that IBS may perhaps also be associated with IgG antibodies against other intraluminal antigens such as those from the indigenous microbiota, partially analogously to loss of tolerance to gut microbiota in inflammatory bowel disease.
The human gastrointestinal tract harbours a complex collection of microorganisms which form the individual microbiota typical for each person. Defence is facilitated by peristalsis, secretion of mucus and antimicrobial peptides such as defensins and cathelicidins, and commensal induced IgA. Intestinal epithelial cells further contribute to the homeostasis of gut barrier function by a scarcity of both pattern recognition receptors (PRRs; for example, toll-like receptors and nucleotide binding oligomerisation domain proteins) and their coreceptors, expression of active negative regulators of PRR signalling, and secretion of the suppressive cytokines interleukin 10 and transforming growth factor ß. All of these characteristics assist in preventing unnecessary and even hazardous systemic immunity to commensals while allowing local protective mucosal immune responses. In addition, some specific strains of non-pathogenic bacteria have been shown to attenuate intestinal inflammation by selective inhibition of intracellular signalling pathways elicited by diverse potentially deleterious stimuli. A healthy gut microbiota is thus an indispensable component of "gut barrier function".
The mechanisms responsible for IgG production against dietary antigens and their putative role in IBS. This may serve not only IBS research but also that into allergy and allergic diseases. In the perspectives of both normal gut barrier function and the vague findings in a few studies of probiotic supplementation in IBS, we suggest that the possible role of the gut microbiota in the pathogenesis of IBS may deserve closer attention. If the host-microbe cross talk is misinterpreted in IBS, a working target for novel therapeutic interventions beyond elimination diets could be provided in modulating the composition and/or activity of the gut microbiota and promoting gut immune defence. Research interest in the science of nutrition is directed towards improvement of defined physiological functions beyond the nutritional impact of food. The search for active non-nutritive compounds is also a focus for research in the treatment and prevention of allergic diseases.
IBS is likely to be a multifactorial condition involving a number of different mechanisms although the prominence of any particular factor may vary from patient to patient. However, patients often strongly believe that dietary intolerance significantly contributes to their symptomatology and some sufferers seem to benefit from eliminating certain foods from their diet. Detection of food intolerance is often difficult due to its uncertain aetiology, non-specific symptomatology, and relative inaccessibility of the affected organ. Thus most previous studies have relied on the use of exclusion diets, which are extremely labour intensive and time consuming. Attempts to "test" for food intolerance in IBS have largely focused on "classic" food allergy based on the presence of IgE mediated antibody responses, although it appears that these "immediate type" reactions are probably quite rare in this condition. It is therefore possible that adverse reactions to food in patients with IBS might be due to some other form of immunological mechanism, rather than dietary allergy.

Selected references on IBS, Food Allergies and related issues on IBS
Jones VA, McLaughlan P, Shorthouse M, et al. Food intolerance: a major factor in pathogenesis of irritable bowel syndrome. Lancet 1982;2:1115–17.
Nanda R , James R, Smith H, et al. Food intolerance and the irritable bowel syndrome. Gut 1989;30:1099–104.
Crowe SE, Perdue MH. Gastrointestinal food hypersensitivity: basic mechanisms of pathophysiology. Gastroenterol 1992;103:1075–95.
el Rafei A , Peters SM, Harris N, et al. Diagnostic value of IgG4 measurements in patients with food allergy. Ann Allergy 1989;62:94–9.
Host A , Husby S, Gjesing B, et al. Prospective estimation of IgG, IgG subclass and IgE antibodies to dietary proteins in infants with cow’s milk allergy. Levels of antibodies to whole milk protein, BLG and ovalbumin in relation to repeated milk challenge and clinical course of cow’s milk allergy. Allergy 1992;47:218–29.[
Awazuhara H , Kawai H, Maruchi N. Major allergens in soybean and clinical significance of IgG4 antibodies investigated by IgE and IgG4 immunoblotting with sera from soybean-sensitive patients. Clin Exp Allergy 1997;27:325–32.
Barnes RMR, Johnson PM, Harvey MM, et al. Human serum antibodies reactive with dietary proteins: IgG subclass distribution. Int Arch Allergy Appl Immunol 1988;87:184–8
Lessof MH, Kemeny DM, Price JF. IgG antibodies to food in health and disease. Allergy Proc 1991;12:305–7
Husby S , Mestecky J, Moldoveanu Z, et al. Oral tolerance in humans. T cell but not B cell tolerance after antigen feeding. J Immunol 1994;152:4663–70.
Haddad ZH, Vetter M, Friedmann J, et al. Detection and kinetics of antigen-specific IgE and IgG immune complexes in food allergy. Ann Allergy 1983;51:255
Husby S , Oxelius VA, Teisner B, et al. Humoral immunity to dietary antigens in healthy adults. Occurrence, isotype and IgG subclass distribution of serum antibodies to protein antigens. Int Arch Allergy Appl Immunol 1985;77:416–22
Kruszewski J , Raczka A, Klos M, et al. High serum levels of allergen specific IgG-4 (asIgG-4) for common food allergens in healthy blood donors. Arch Immunol Ther Exp 1994;42:259–61.
Zwetchkenbaum J , Burakoff R .The irritable bowel syndrome and food hypersensitivity. Ann Allerg 1988;61:47–9.
Zar S , Kumar D, Benson M. J. Review article: food hypersensitivity and irritable bowel syndrome, Aliment Pharm Ther 2001;15:439–43.
Petitpierre M , Gumowski P, Girard JP. Irritable bowel syndrome and hypersensitivity to food. Ann Allergy 1985;54:538–40.
Barau E , Dupont C. Modifications of intestinal permeability during food provocation procedures in pediatric irritable bowel syndrome. J Pediatr Gastroenterol Nutr 1990;11:72–7.
Roussos A , Koursarakos P, Patsopoulos D, et al. Increased prevalence of irritable bowel syndrome in patients with bronchial asthma. Respir Med 2003;97:75–9.
Finn R , Smith MA, Youngs GR, et al. Immunological hypersensitivity to environmental antigens in the irritable bowel syndrome. Br J Clin Pract 1987;41:1041–3.
Niec AM, Frankum B, Talley NJ. Are adverse reactions to food linked to irritable bowel syndrome? Am J Gastroenterol 1998;93:2184–90.
Bentley SJ, Pearson DJ, Rix KJB. Food hypersensitivity in irritable bowel syndrome. Lancet 1983;2:295–7.
McKee AM, Prior A, Whorwell PJ. Exclusion diets in irritable bowel syndrome: Are they worthwhile? J Clin Gastroenterol 1987;9:526–8.
Spiller RC, Jenkins D, Thornley JP, et al. Increased rectal mucosal enteroendocrine cells, T lymphocytes, and increased gut permeability following acute Campylobacter enteritis and in post-dysenteric irritable bowel syndrome. Gut 2000;47:804–11.
Gonsalkorale WM, Perrey C, Pravica V, et al. Interleukin 10 genotypes in irritable bowel syndrome: evidence for an inflammatory component? Gut 2003;52:91–3.
Collins SM. A case for an immunological basis for irritable bowel syndrome. Gastroenterology 2002;122:2078–80.
Kay AB. Concepts of allergy and hypersensitivity. In: Kay AB, ed. Allergy and allergic diseases. Oxford: Blackwell Science Ltd, 1997:23–35.
Atkinson W , Sheldon TA, Shaath N, et al. Food elimination based on IgG antibodies in irritable bowel symdrome: a randomised controlled trial. Gut 2004;53:1459–
Pulendran B , Banchereau J, Maraskovsky E, et al. Modulating the immune response with dendritic cells and their growth factors. Trends Immunol 2001;22:41–7.
· Vasiadi et. al. (2007). Progesterone inhibits mast cell secretion. Int J Immunopathol Pharmacol. 2006 Oct-Dec;19(4):787-94.
· Hill et. al. (2007). Confirmation of the association between high levels of immunoglobulin E food sensitization and eczema in infancy: an international study. Clin Exp Allergy. 2007 Nov 19; [Epub ahead of print].
· Lupp et. al. (2007). Host-mediated inflammation disrupts the intestinal microbiota and promotes the overgrowth of Enterobacteriaceae. Cell Host Microbe. 2007 Sep 13;2(3):204.
· Swoger et. al (2007). Eosinophilic esophagitis: is it all allergies? Mayo Clin Proc. 2007 Dec;82(12):1541-52.
· Hill et. al. (2007). The efficacy of amino acid-based formulas in relieving the symptoms of cow's milk allergy: a systematic review. Clin Exp Allergy. 2007 Jun;37(6):808-22.
· Borowiec and Fedorak. (2007). The role of probiotics in management of irritable bowel syndrome. Curr Gastroenterol Rep. 2007 Oct;9(5):393-400.
· Collado et. al. (2007). Role of commercial probiotic strains against human pathogen adhesion to intestinal mucus. Lett Appl Microbiol. 2007 Oct;45(4):454-60.
· Ivec et. al. (2007). Interactions of macrophages with probiotic bacteria lead to increased antiviral response against vesicular stomatitis virus. Antiviral Res. 2007 Sep;75(3):266-74. Epub 2007 Apr 23.
· Rona et. al. (2007). The prevalence of food allergy: a meta-analysis. J Allergy Clin Immunol. 2007 Sep;120(3):638-46. Epub 2007 Jul 12.
· Rayan et. al. (2007). Prevalence and clinical features of Dientamoeba fragilis infections in patients suspected to have intestinal parasitic infection. J Egypt Soc Parasitol. 2007 Aug;37(2):599-608.
· Wang et. al. (2007). Potential non-immunoglobulin E-mediated food allergies: Comparison of open challenge and double-blind placebo-controlled food challenge. Otolaryngol Head Neck Surg. 2007 Nov;137(5):803-809.
· Hill et. al. (2007). IgE food sensitization in infants with eczema attending a dermatology department. J Pediatr. 2007 Oct;151(4):359-63. Epub 2007 Aug 6.
· Golebiowska-Wawrzyniak et. al. (2007). [Contribution of indicators of sensitized T lymphocytes in the diagnosis of IgE independent and IgE dependent cow's allergy in children] [Article in Polish] Med Wieku Rozwoj. 2007 Jan-Mar;11(1):25-34.
· Wahnschaffe et. al. (2007). Predictors of clinical response to gluten-free diet in patients diagnosed with diarrhea-predominant irritable bowel syndrome. Clin Gastroenterol Hepatol. 2007 Jul;5(7):844-50. Epub 2007 Jun 5.
· Barbara et. al. (2007). Mast Cell-Dependent Excitation of Visceral-Nociceptive Sensory Neurons in Irritable Bowel Syndrome. Gastroenterology Volume 132, Issue 1, January 2007, Pages 26-37
· Stark et. al. (2006). Irritable bowel syndrome: A review on the role of intestinal protozoa and the importance of their detection and diagnosis. International Journal for Parasitology Volume 37, Issue 1, January 2007, Pages 11-20
· Yang et. al. (2007). TIM-4 expressed by mucosal dendritic cells plays a critical role in food antigen specific Th2 differentiation and intestinal allergy. doi:10.1053/j.gastro.2007.08.006 PMID: 17915221
· Borthakur et. al. (2006). Carrageenan induces interleukin-8 production through distinct Bcl10 pathway in normal human colonic epithelial cells. Am J Physiol Gastrointest Liver Physiol 292: G829–G838, 2007. First published November 9, 2006; doi:10.1152/ajpgi.00380.2006.
· Drisko et. al.(2006). Treating Irritable Bowel Syndrome with a Food Elimination Diet Followed by Food Challenge and Probiotics. Journal of the American College of Nutrition, Vol. 25, No. 6, 514-522
· Zuo, et. al.(2007). Alterations of food antigen-specific serum immunoglobulins G and E antibodies in patients with irritable bowel syndrome and functional dyspepsia. Clinical & Experimental Allergy 37 (6), 823–830.
· Uz, et. al.(2007). Risk factors for irritable bowel syndrome in Turkish population: role of food allergy. J Clin Gastroenterol. 2007 Apr;41(4):380-3. Abstract Only
· Cranney, et. al.(2007). The Canadian Celiac Health Survey. Dig Dis Sci. 2007 Apr;52(4):1087-95. Epub 2007 Feb 22
· Grazioli, Barbara et. al.(2006). Giardia lamblia infection in patients with irritable bowel syndrome and dyspepsia: A prospective study. World Journal of Gastroenterology, World J Gastroenterol 2006 March 28; 12(12): 1941-1944
· Wood, J.D. (2006). Histamine, mast cells, and the enteric nervous system in the irritable bowel syndrome, enteritis,and food allergies. Gut 2006;55;445-447
· Khan, W.I. and S.J. Collins (2006). Gut motor function: immunological control in enteric infection and inflammation. Clinical and Experimental Immunology 2006; 143:389–397
· Zar et. al. (2005). Food-Specific Serum IgG4 and IgE Titers to Common Food Antigens in Irritable Bowel Syndrome. American Journal of Gastroenterology 2005; 100:1550-1557
· Yamaguchi et. al. (2006). Gastrointestinal Candida colonisation promotes sensitisation against food antigens by affecting the mucosal barrier in mice. Gut 2006;55:954-960
· Whorwell, P.J. et. al. (2006). Efficacy of an encapsulated probiotic Bifidobacterium infantis 35624 in women with irritable bowel syndrome. American Journal of Gastroenterology 2006 Jul;101(7):1581-90. (abstract only)

Related Study
· Amadi, B. (2002). Role of food antigen elimination in treating children with persistent diarrhea and malnutrition in Zambia. Journal of Pediatric Gastroenterology and Nutrition, 34(Suppl. 1), S54-S56.
· Armentia, A., Rodriguez, R., Callejo, A., Martin-Esteban, M., Martin-Santos, J. M., Salcedo, G., Pascual, C., Sanchez-Monge, R., & Pardo, M. (2002). Allergy after ingestion or inhalation of cereals involves similar allergens in different ages. Clinical and Experimental Allergy, 32(8), 1216-1222.
· Augustin MT, Kokkonen J, Karttunen R, Karttunen TJ. (2004). Serum granzymes and CD30 are increased in children's milk protein sensitive enteropathy and celiac disease. Journal of Allergy and Clinical Immunology. Jan;115(1):157-62. Abstract Only
· Avonts, L., & De Vuyst, L. (2001). Antimicrobial potential of probiotic lactic acid bacteria. Meded Rijksuniv Gent Fak Landbouwkd Toegep Biol Wet, 66(3b), 543-550.
· Ayadi A, Bahri I. (1999). [Dientamoeba fragilis: pathogenic flagellate?] [Article in French]. Bull Soc Pathol Exot. 1999 Dec;92(5):299-301. Abstract Only
· Brown, S., Kerrigan, P., & Waterston, T. (2000). A six-year old suffering from constipation. Practitioner, 244(1607), 63-68
· Carroccio, A., Montalto, G., Custro, N., Notarbartolo, A., Cavataio, F., D'Amico, D., Alabrese, D., & Iacono, G. (2000). Evidence of very delayed clinical reactions to cow's milk in cow's milk-intolerant patients. Allergy, 55(6), 574-579.
· Cavataio, F., Carroccio, A., & Iacono, G. (2000). Milk-induced reflux in infants less than one year of age. Journal of Pediatric Gastroenterology and Nutrition, 30(Suppl.), S36-S44.
· Chin, K. C., Tarlow, M. J., & Allfree, A. J. (1983). Allergy to cows' milk presenting as chronic constipation. British Medical Journal (Clinical Research Edition), 287(6405), 1593.
· Cremonini, F., Di Caro, S., Santarelli, L., Gabrielli, M., Candelli, M., Nista, E. C., Lupascu, A., Gasbarrini, G., & Gasbarrini, A. Probiotics in antibiotic-associated diarrhoea. Digestive and Liver Disease, 34(Suppl. 2), S78-S80.
· Dae-Won et. al. (2006). Food intolerance and skin prick test in treated and untreated irritable bowel syndrome. World J Gastroenterol 2006 April 21;12(15):2382-2387 Full Article
· Daher, S., Tahan, S., Sole, D., Naspitz, C. K., Da Silva Patricio, F. R., Neto, U. F., & De Morais, M. B. (2001). Cow's milk protein intolerance and chronic constipation in children. Pediatric Allergy and Immunology, 12(6), 339-342.
· de Boissieu, D., & Dupont, C. (2000). Infant food allergy: Digestive manifestations [Article in French]. Allergie et Immunologie, 32(10), 378-380.
· Delgado, S., Florez, A. B., & Mayo, B. (2005). Antibiotic susceptibility of Lactobacillus and Bifidobacterium species from the human gastrointestinal tract. Current Microbiology, 50(4), 202-207.
· Elmer, G. W. (2001). Probiotics: "Living drugs." American Journal of Health-System Pharmacy, 58(12), 1101-1109.
· Floch, M. H., & Narayan, R. (2002). Diet in the irritable bowel syndrome. Journal of Clinical Gastroenterology, 35(1, Suppl.), S45-S52.
· Foster, A. P., Knowles, T. G., Moore, A. H., Cousins, P. D., Day, M. J., & Hall, E. J. (2003). Serum IgE and IgG responses to food antigens in normal and atopic dogs, and dogs with gastrointestinal disease. Veterinary Immunology and Immunopathology, 93(3-4), 113-124.
· Fox, C. H., & Dang, G. (2004). Probiotics in the prevention and treatment of diarrhea. Journal of Alternative and Complementary Medicine, 10(4), 601-603.
· Girginkardes,ler N, Kurt O, Kilimciog(lu AA, Ok UZ. (2007). Transmission of Dientamoeba fragilis: Evaluation of the role of Enterobius vermicularis. doi:10.1016/j.physletb.2003.10.071 Abstract Only
· Goldin, B. R. (1998). Health benefits of probiotics. British Journal of Nutrition, 80(4), S203-S207.
· Guarner, F. & Malagelada, J. R. (2003). Gut flora in health and disease.. Lancet, 361(9356), 512-519.
· Heine, R. G., Elsayed, S., Hosking, C. S., Hill, D. J. (2002). Cow's milk allergy in infancy. Current Opinion in Allergy and Clinical Immunology, 2(3), 217-225.
· Iacono, G., Carroccio, A., Cavataio, F., Montalto, G., Cantarero, M. D., & Notarbartolo, A. (1995). Chronic constipation as a symptom of cow milk allergy. Journal of Pediatrics, 126(1), 34-39.
· Iacono, G., Cavataio, F., Montalto, G., Florena, A., Tumminello, M., Soresi, M., Notarbartolo, A., & Carroccio, A. (1998). Intolerance of cow's milk and chronic constipation in children. New England Journal of Medicine, 229(16), 1100-1104.
· Iacono, G., Cavataio, F., Montalto, G., Soresi, M., Notarbartolo, A., & Carroccio, A. (1998). Persistent cow's milk protein intolerance in infants: the changing faces of the same disease. Clinical and Experimental Allergy, 28(7), 817-823.
· Ishida, Y., Nakamura, F., Kanzato, H., Sawada, D., Hirata, H., Nishimura, A., Kajimoto, O., & Fujiwara, S. (2005). Clinical effects of Lactobacillus acidophilus strain L-92 on perennial allergic rhinitis: A double-blind, placebo-controlled study. Journal of Dairy Science, 88(2), 527-533.
· Jirapinyo, P., Densupsoontorn, N., Thamonsiri, N., & Wongarn, R. (2002). Prevention of antibiotic-associated diarrhea in infants by probiotics. Journal of the Medical Associatioin of Thailand, 85(Suppl. 2), S739-S742.
· Kaya S, Cetin ES, Aridogan BC, Arikan S, Demirci M. (2007). Pathogenicity of Blastocystis hominis, a clinical reevaluation. Turkiye Parazitol Derg. 2007;31(3):184-187. Abstract Only
· Klein, K. B. (1988). Controlled treatment trials in the irritable bowel syndrome: A critique. Gastroenterology, 95, 232-241.
· Knight AK, Blazquez AB, Zhang S, Mayer LF, Sampson HA, Berin MC. (2007). CD4 T cells activated in the mesenteric lymph node mediate gastrointestinal food allergy in mice. Am J Physiol Gastrointest Liver Physiol. 2007 Oct 4; [Epub ahead of print]
· Kokkonen J, Tikkanen S, Karttunen TJ, Savilahti E. (2002). A similar high level of immunoglobulin A and immunoglobulin G class milk antibodies and increment of local lymphoid tissue on the duodenal mucosa in subjects with cow's milk allergy and recurrent abdominal pains. Pediatric Allergy Immunology Apr;13(2):129-36. Abstract Only
· Kokkonen, Jorma; Tikkanen, Sami; Savilahti, Erkki (2001). Residual Intestinal Disease After Milk Allergy in Infancy. Journal of Pediatric Gastroenterology & Nutrition. 32(2):156-161, February 2001. Abstract Only
· Kokkonen, J., Ruuska, T., Karttunen, T. J., & Niinimaki, A. (2001). Mucosal pathology of the foregut associated with food allergy and recurrent abdominal pains in children. Acta Paediatrica, 90(1), 16-21. Abstract Only
· Latcham, F., Merino, F., Lang, A., Garvey, J., Thomson, M.A., Walker-Smith, J. A., Davies, S. E., Phillips, A. D., & Murch, S. H. (2003). A consistent pattern of minor immunodeficiency and subtle enteropathy in children with multiple food allergy. Journal of Pediatrics, 143(1), 39-47.
· Lee, M. C., Lin, L. H., Hung, K. L., & Wu, H. Y. (2001). Oral bacterial therapy promotes recovery from acute diarrhea in children. Acta Paediatrica Taiwanica, 42(5), 301-305.
· Lembo, A. (2004 Irritable bowel syndrome medications side effects survey. Journal of Clinical Gastroenterology, 38(9), 776-781
· McGrath, J. (1984). Allergy to cow's milk presenting as chronic constipation. British Medical Journal (Clinical Research Edition), 288(6412), 236.
· Magazzu, G., & Scoglio, R. (2002). Gastrointestinal manifestations of cow's milk allergy. Annals of Allergy, Asthma, & Immunology, 89(6, Suppl. 1), 65-68.
· Marshall et. al. (2006). Incidence and epidemiology of irritable bowel syndrome after a large waterborne outbreak of bacterial dysentery. Gastroenterology. 2006 Aug;131(2):445-50; Abstract Only
· Matto J, Maunuksela L, Kajander K, Palva A, Korpela R, Kassinen A, Saarela M. (2005). Composition and temporal stability of gastrointestinal microbiota in irritable bowel syndrome--a longitudinal study in IBS and control subjects. FEMS Immunology and Medical Microbiology, 2005 Feb 1;43(2):213-22.
· Mekkel G, Barta Z, Ress Z, Gyimesi E, Sipka S, Zeher M. (2005). [Increased IgE-type antibody response to food allergens in irritable bowel syndrome and inflammatory bowel diseases] [Article in Hungarian] Orv Hetil. 2005 Apr 24;146(17):797-802 Abstract Only
· Moon, A., & Kleinman, R. E. (1995). Allergic gastroenteropathy in children. Annals of Allergy, Asthma, & Immunology, 74(1), 5-12.
· Mora, W. (2003). Cow's milk protein intolerance and childhood constipation. American Family Physician, 68(6), 1016.
· Nadasdi, M. (1992). Tolerance of a soy formula by infants and children. Clinical Therapeutics, 14(2), 236-241.
· Orenstein, S. R., Shalaby, T. M., Di Lorenzo, C., Putnam, P. E., Sigurdsson, L., Mousa, H., & Kocoshis, S. A. (2000). The spectrum of pediatric eosinophilic esophagitis beyond infancy: A clinical series of 30 children. American Journal of Gastroenterology, 95(6), 1422-1430.
· Parry S, Forgacs I. (2005). Intestinal infection and irritable bowel syndrome. Eur J Gastroenterol Hepatol. 2005 Jan;17(1):5-9. Abstract only.
· Pelto, L., Impivaara, O., Salminen, S., Poussa, T., Seppanen, R., & Lilius, E. M. (1999). Milk hypersensitivity in young adults. European Journal of Clinical Nutrition, 53(8), 620-624.
· Petitpierre M, Gumowski P, Girard JP. (1985). Irritable bowel syndrome and hypersensitivity to food. Annals of Allergy, 1985 Jun;54(6):538-40.
· Rastall, R. A. (2004). Bacteria in the gut: Friends and foes and how to alter the balance. Journal of Nutrition, 134(8, Suppl.), S2022-S2026.
· Romanczuk, W., & Samojedny, A. (2003). The assessment of the influence of IgE-mediated food allergy on colonic transit time in children with chronic constipation [Article in Polish]. Pol Merkuriusz Lek, 15(87), 226-230.
· Saalman, R., Dahlgren, U. I., Fallstrom, S. P., Hanson, L. A., Ahlstedt, S., & Wold, A. E. (2003). Avidity progression of dietary antibodies in healthy and coeliac children. Clinical and Experimental Immunology, 134(2), 328-334.
· Santelmann, Heiko a; Howard, John McLaren b (2005). Yeast metabolic products, yeast antigens and yeasts as possible triggers for irritable bowel syndrome. European Journal of Gastroenterology & Hepatology. 17(1):21-26, January 2005. Abstract only.
· Sabra, A., Bellanti, J. A., Rais, J. M., Castro, H. J., de Inocencio, J. M., & Sabra, S. (2003). IgE and non-IgE food allergy. Annals of Allergy, Asthma, & Immunology, 90(6, Suppl. 3), 71-76.
· Saggioro, A. (2004). Probiotics in the treatment of irritable bowel syndrome. Journal of Clinical Gastroenterology, 38(6, Suppl.), S104-S106.
· Salvatore, S., & Vandenplas, Y. (2002). Gastroesophageal reflux and cow milk allergy: Is there a link? Pediatrics, 110(5), 972-984.
· Shah, N., Lindley, K., & Milla, P. (1999). Cow's milk and chronic constipation in children. New England Journal of Medicine, 340(11), 891-892.
· Shahbazkhani et. al. (2003). Coeliac disease presenting with symptoms of irritable bowel syndrome. Aliment Pharmacol Ther. 2003 Jul 15;18(2):231-5. Abstract only.
· Sicherer, S. H. (2003). Clinical aspects of gastrointestinal food allergy in childhood. Pediatrics, 111(6, Pt. 3), 1609-1616
· Simadibrata M, Tytgat GN, Yuwono V, Daldiyono, Lesmana LA, Syam AF, Ariawan I, Rani A.(2004), Microorganisms and parasites in chronic infective diarrhea. Acta Medica Indonesiana, 2004 Oct-Dec;36(4):211-4.
· Speer, F. (1975). The allergic child. American Family Physician, 11(2), 88-94.
· Stricker, T., & Braegger, C. P. (2000). Constipation and intolerance to cow's milk. Journal of Pediatrics Gastroenterology and Nutrition, 30(2), 224.
· Strobel, S,, & Hourihane, J. O. (2001). Gastrointestinal allergy: Clinical symptoms and immunological mechanisms. Pediatric Allergy and Immunology, 12(Suppl. 14), 43-46.
· Taylor, C. J., Hendrickse, R. G., McGaw, J., & Macfarlane, S. B. (1988). Detection of cow's milk protein intolerance by an enzyme-linked immunosorbent assay. Acta Paediatrica Scandinaica, 77(1), 49-54.
· Veres G, Westerholm-Ormio M, Kokkonen J, Arato A, Savilahti E. (2003). Cytokines and Adhesion Molecules in Duodenal Mucosa of Children with Delayed-Type Food Allergy. Journal of Pediatric Gastroenterology & Nutrition. 37(1):27-34 Abstract Only
· Vanderhoof, J. A., & Young, R. J. (2001). Allergic disorders of the gastrointestinal tract. Current Opinion in Clinical Nutriton and Metabolic Care, 4(6), 553-556.
· Walter SA, Skagerstrom E, Bodemar G. (2004). Subgroups of irritable bowel syndrome: a new approach. Eur J Gastroenterol Hepatol. 2004 Oct;16(10):991-4. Abstract only.
· Wynne AG, McCartney AL, Brostoff J, Hudspith BN, Gibson GR. (2004). An in vitro assessment of the effects of broad-spectrum antibiotics on the human gut microflora and concomitant isolation of a Lactobacillus plantarum with anti-Candida activities. Anaerobe. 2004 Jun;10(3):165-9. Abstract only.
· Yimyaem, P., Chongsrisawat, V., Vivatvakin, B., & Wisedopas, N. (2003). Gastrointestinal manifestations of cow's milk protein allergy during the first year of life. Journal of the Medical Association of Thailand, 86(2), 116-123.
· Zoppi, G. (1996). The most common gastrointestinal problems in pediatric practice [Article in Italian]. Pediatria Medica e Chirurgica, 18(2), 131-139.

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