Background & Aims: Visceral hypersensitivity is a hallmark of irritable bowel syndrome (IBS), but the relationship with clinical symptoms and psychological factors has not been fully established. We aimed to (1) evaluate these variables in a large cohort of IBS patients, recruited from both hospital and general practice, and in healthy controls and (2) assess which of these factors predicts the occurrence of visceral hypersensitivity in IBS. Methods: Rectal compliance and perception (intensity, perception thresholds; visual analogue scale, 0–100 mm) were assessed by a rectal barostat study (ramp distention) in 101 IBS patients and 40 healthy volunteers. IBS symptom severity was scored by using a 14-day 5-item diary. Anxiety, depression, somatization, vigilance, pain coping, dysfunctional cognitions, psychoneuroticism, and quality of life were assessed with psychometric questionnaires. Results: Rectal compliance was significantly reduced in IBS patients compared with controls (P < .01), as were thresholds for pain (27 ± 15 vs 35 ± 8 mm Hg; P < .01) and urge (P < .05). Levels of anxiety, depression, neuroticism, somatization, and dysfunctional cognitions were significantly increased in IBS patients versus controls, whereas pain coping and quality of life were significantly worse. Hypersensitivity to rectal distention occurred in 33% of patients and was associated with increased symptom severity (P = .016), but not with demographic characteristics or psychological disturbances. Conclusions: Hypersensitivity to balloon distention occurs in 33% of IBS patients and is predicted by symptom severity but not by psychological or demographic characteristics.

Irritable bowel syndrome (IBS) is characterized by recurrent abdominal discomfort or pain and disturbed bowel habits.Several pathophysiologic mechanisms have been suggested in symptom generation, including altered intestinal motility,autonomic dysfunction,inflammation,and immune system alterations.Particularly, visceral hypersensitivity appears to play an important roleand has been proposed as a biologic marker of IBS.

Visceral hypersensitivity might result from disturbances at different levels of the brain-gut axis, in which peripheral sensitization of intestinal nerve endings,hyperexcitability of spinal dorsal horn neurons,and altered central processing of visceral afferent informationare implicated. Abnormalities in regional brain activation, especially in areas involved in pain processing such as the anterior cingulate cortex and thalamus, have been reported in IBS patients in response to rectal balloon distention.These regions belong to the emotional limbic system and are involved in psychological and cognitive events.

IBS symptomatology is associated with psychological factors, and these might affect clinical outcome.For instance, psychological distress is more prevalent among IBS patients who seek health care.Little is known about the relationship between psychological variables and visceral hypersensitivity. Such information is relevant because it might provide a better understanding of the pathogenesis of IBS and thereby improve its treatment. The few studies that explored this relationship have been criticized because of methodologic shortcomings such as sample size and patient selection (tertiary referrals).

The aims of the present study were to (1) explore in a large cohort of IBS patients the prevalence of rectal hypersensitivity, levels of psychological distress, and IBS symptom severity and (2) assess which demographic, clinical, and psychological variables predict the occurrence of visceral hypersensitivity in IBS.

Finally, binary logistic regression and backward stepwise analysis (method, likelihood ratio; entry at 0.05 probability, removal at 0.10 probability) was performed to identify demographic, clinical (symptom severity), and psychological characteristics that predict the occurrence of visceral hypersensitivity. Age, gender, health care level, predominant bowel habit, postinfectious symptom onset, rectal compliance, symptom severity, anxiety, depression, somatic symptoms, psychoneuroticism, dysfunctional cognitions regarding functional bowel disorders, vigilance, pain coping, somatization, and quality of life (general health subscale) were entered in the analysis as separate predictors. Data were expressed as mean ± SD. The level of significance was set at P < .05.

All statistical analyses were carried out with SPSS for Windows, version 11.0.1 (SPSS Inc, Chicago, IL). Demographic characteristics were compared between groups by Student t test, Mann-Whitney, or χ 2 analysis as appropriate. Differences in rectal compliance and visceroperception were analyzed for statistical significance by using mixed models, with patient numbers as indicator for repeated measurements. One model analyzed pressure, volume, and pressure by volume interaction as separate contributors to the model; a second model did the same for pressure, visceral perception, and pressure by perception interaction. Compliance, perception of urge and pain at maximum rectal pressure (30 mm Hg), and perception thresholds for urge were compared by Mann–Whitney (patients versus controls) or Kruskal–Wallis analysis (IBS subgroups). Because the pain threshold during ramp distention was not reached in all participants, the best estimates for the mean pain threshold and SD were obtained by maximum likelihood estimation by using software for parametric survival models. Normal distribution for the pain scores was assumed. These estimates were compared by log-rank analysis.

We aimed to enroll at least 40 subjects in each group to be able to detect a 5-mm Hg difference in mean pain threshold, which we considered clinically relevant, with a power of 0.80 and SD of 8 mm Hg on the basis of previous studies by our group.

Patients with a pain perception threshold ≥2 standard deviations (SDs) below the mean threshold in controls were considered to be hypersensitive to balloon distention.

Dynamic compliance was assessed by calculating volume increments for each individual pressure step in each study participant. Compliance was defined by the largest volume increment (ie, the steepest slope of the pressure-volume curve) for each participant and averaged over groups. Perception scores were expressed as the mean score at each pressure step. Perception thresholds were defined as the first pressure level at which perception scores exceeded 10 mm.

The experimental protocol consisted of a slow ramp distention to assess rectal compliance. Intrabag pressure was increased at a rate of 1 mm Hg/min, starting at 5 mm Hg, until a maximum of 30 mm Hg. Patients rated the urge to defecate and level of abdominal pain on the 100-mm VAS scale at all even pressures (6, 8, … 30 mm Hg). After the experiment had ended, the rectal balloon was deflated and removed, and each participant was provided with a 14-day symptom diary card and a stamped envelope to return the diary. Subjects were instructed to start filling out their symptom diary on the day after the experiment.

After completion, the rectum was evacuated by using a tap water enema. Participants were then placed in a hospital bed, and with the subject in the left lateral position, a lubricated, tightly folded, highly compliant polyethylene bag (maximum capacity, 1000 mL) tied to the end of a multilumen tube (19F) was inserted through the anus and positioned in the rectal ampulla. Bag position was checked by manual inflation of 150 mL of air and subsequent retraction of the catheter until prevented by the external anal sphincter. After balloon deflation, the catheter was introduced an additional 2 cm, secured to the subject’s upper leg by a piece of tape, and connected to the barostat. The hospital bed was placed in a 15-degree recumbent supine position (Trendelenburg) to avoid interference of abdominal mass with barostat measurements. Barostat measurements commenced approximately 4 hours after the light breakfast.

A small standardized, low caloric breakfast was permitted at 8:00 am on the day of the barostat recordings. After arrival at our department at 10:00 am , subjects filled out all questionnaires consecutively. Each participant was allowed the necessary time to complete the questionnaires, which took 80–90 minutes on average.

Quality of life was assessed by using the validated Short Form 36 (SF-36) questionnaire.This survey measures quality of life in 8 domains, ie, physical functioning, social functioning, role limitations due to physical problems and emotional problems, mental health, vitality, bodily pain, and general health.

The SCL-90 was also used to record non–IBS-related somatic symptoms. There are 12 items concerning general complaints, including headache, vertigo, backache, myalgia, difficulties with breathing, intolerance for high or low temperatures, dysphagia, etc.

Pain coping was measured by 1 of 4 subscales of the Pain Coping and Cognition List (PCCL). This inventory has been widely used in The Netherlands and awaits future validation. Patients were asked to rate the extent to which they agreed with 11 statements concerning pain coping on a 7-point scale, ranging from “I completely disagree” to “I completely agree.”

The recently developed 31-item Cognitive Scale for Functional Bowel Disorders (CSFBD) was used to measure patients’ levels of dysfunctional cognitions concerning their IBS.

We used the previously validated 10-item Somatosensory Amplification Scale (SAS)to determine the extent to which an individual is likely to report enhanced perception of physical symptoms (ie, lower cognitive perception thresholds).

A validation study of the Whitely Index, the Illness Attitude Scales, and the Somatosensory Amplification Scale in general medical and general practice patients.

The role of the abovementioned psychological factors in IBS has been studied previously.In addition, we considered the following psychological variables relevant, because they might confound the abovementioned determinants.

We used the abridged Dutch version (NVM) of the Minnesota Multiphasic Personality Inventory (MMPI) to measure somatization, which is 1 of 5 subscales on this questionnaire.

The level of psychoneuroticism was determined by summing up all 90 items of the SCL-90.

We used the Symptom Checklist 90 (SCL-90) to measure levels of anxiety (10 items) and depression (16 items). The SCL-90 is a validated survey and consists of 90 items addressing a range of physical and psychological problems.

The SCL-90 and the MMPI: a step in the validation of a new self-report scale.

A battery of questionnaires was administered to both IBS patients and control subjects to determine the following psychological characteristics of each group.

Patients and controls rated the severity of any abdominal discomfort, abdominal pain, constipation, diarrhea, and bloating daily for 14 days on a 5-point Likert scale (0, no symptoms; 1, mild; 2, moderate; 3, severe; 4, very severe symptoms) by using a symptom diary card. A composite score was computed by summing up the 14-day mean scores for each symptom (range, 0–20).

The demographic group characteristics of interest were age, sex, and level of health care (general practice or referral).

Perception of urge to defecate and abdominal pain during rectal distention was quantified on a 100-mm visual analogue scale (VAS). End points ranged from none to intolerable.

An electronic barostat (Synectics Visceral Stimulator; Synectics Medical, Stockholm, Sweden) was used to assess rectal compliance and perception. This device measures rectal motor activity as volume changes in a rectal balloon, in which constant pressure is maintained by injecting air when the rectal wall relaxes and aspirating air during rectal contraction. Intrabag pressure is directly measured via a separate lumen. Maximal airflow is 38 mL/s. Pressure and volume are continuously monitored and recorded on a personal computer (Polygram for Windows SVS module; Synectics Medical).

To obtain a representative sample from the IBS population, patients were recruited from both the hospital IBS population (patients referred to the outpatient Department of Gastroenterology of the Leiden University Medical Center) and the general population through local advertisement. Healthy volunteers were recruited through advertisement for comparison with the patient sample. All eligible participants were screened by one of the investigators (P.vd.V). Each patient met Rome II criteria for IBS.Exclusion criteria were organic disease, previous abdominal surgery (except cholecystectomy and appendectomy), and pregnancy. Use of antispasmodics, laxatives, bulking agents, and occasional use of analgesics was permitted. We used the Mini International Neuropsychiatric Interview (Dutch version 5.0.0)to exclude patients with severe psychopathology (psychosis or risk of suicide). Informed consent was obtained from each participant. The Leiden University Medical Center ethics committee had approved the study protocol.

The Mini-International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10.

This study was part of a large randomized controlled trial of psychological treatment in IBS, the results of which were recently published.IBS patients between 18 and 65 years of age were invited to participate. Baseline evaluation included detailed psychological assessment, rectal barostat measurements, and IBS symptom severity scores.

Of all tested variables, only IBS symptom severity remained as a predictor of visceral hypersensitivity in the logistic regression analysis (odds ratio, 1.25; 95% confidence interval, 1.04–1.50; P = .016). Table 5 lists demographic, clinical, and psychological characteristics in hypersensitive and normosensitive patients. IBS symptom scores were significantly higher in hypersensitive compared with normosensitive patients (5.4 ± 2.5 vs 4.0 ± 2.4, P = .007). No other differences were found.

The threshold for hypersensitivity to balloon distention was set at 18.9 mm Hg (35.3 minus 16.4 [ie, 2 × 8.2 SD] mm Hg). Thirty-three IBS patients (33%), compared with 0 controls, were identified as hypersensitive to balloon distention (χ= 17.06, P < .0001) ( Table 4 ). Thus, pain thresholds fell outside the range of control subjects in approximately 1 in 3 IBS patients.

Urge thresholds were reached in all participants, but they were somewhat reduced in IBS patients (15.6 ± 6.1 mm Hg) compared with controls (18 ± 6.0 mm Hg) (P = .042). No differences were found between IBS subgroups ( Table 3 ). In contrast, only 10 of 40 control subjects (25%), compared with 55 of 101 IBS patients (54%), reached the threshold for rectal pain during balloon distention (χ= 10.01, P = .002) ( Figure 4 ). Maximum likelihood estimation of the mean pain threshold and SD in each group and subsequent log-rank analysis showed that the threshold was significantly reduced in IBS patients (27.5 ± 15 mm Hg) compared with controls (35.3 ± 8.2 mm Hg) (P = .0009) but did not differ between IBS subgroups ( Table 3 ).

Individual pain thresholds in IBS patients and healthy controls. Significantly more patients (N = 55, 54%) compared with controls (N = 10, 25%) reached the pain threshold before the end of the ramp distention (dotted line, 30 mm Hg).

Figure 4 Individual pain thresholds in IBS patients and healthy controls. Significantly more patients (N = 55, 54%) compared with controls (N = 10, 25%) reached the pain threshold before the end of the ramp distention (dotted line, 30 mm Hg).

Urge perception at high rectal pressure distention (30 mm Hg) was not significantly different between IBS patients (6.6 ± 2.7 cm) and controls (6.1 ± 2.6 cm) (P = .30). The pressure-urge curves were also not significantly different between patients and controls (pressure by group interaction, P = .82; Figure 2 ). In contrast, pain perception at high rectal pressure was significantly increased in IBS patients compared with controls (2.5 ± 2.7 vs 1.0 ± 1.4 cm, P = .003), and the pressure-pain curves differed significantly between groups (pressure by group interaction, P < .0001; Figure 3 ). No differences between IBS subgroups were found ( Table 3 ).

NOTE. Data for the group with unknown bowel habit are not shown because of the small number of patients (N = 8). Data are expressed as mean ± SD.

Intensity of pain perception in 101 IBS patients (squares) and 40 controls (triangles). Pain perception was significantly increased in patients compared with controls (pressure by group interaction, P < .0001). Data are expressed as mean ± standard error of the mean.

Figure 3 Intensity of pain perception in 101 IBS patients (squares) and 40 controls (triangles). Pain perception was significantly increased in patients compared with controls (pressure by group interaction, P < .0001). Data are expressed as mean ± standard error of the mean.

Intensity of urge perception in 101 IBS patients (squares) and 40 controls (triangles). Urge did not differ between patients and controls. Data are expressed as mean ± standard error of the mean.

Figure 2 Intensity of urge perception in 101 IBS patients (squares) and 40 controls (triangles). Urge did not differ between patients and controls. Data are expressed as mean ± standard error of the mean.

Rectal compliance was significantly reduced in the IBS group compared with healthy control subjects (29.7 ± 13 vs 41.8 ± 18 mL/mm Hg, P < .0001) ( Figure 1 A). Subgroup analysis showed that rectal compliance was particularly reduced in patients with a diarrhea-predominant bowel habit (IBS-D; P = .04) and those with alternating bowel habit (IBS-A; P = .05) compared with constipation-predominant IBS (IBS-C) ( Figure 1 B).

(A) Dynamic rectal compliance (mL/mm Hg) in 101 IBS patients (squares) and 40 controls (triangles). Compliance was significantly decreased in patients compared with controls. Data are expressed as mean ± standard error of the mean. (B) Dynamic rectal compliance (mL/mm Hg) in IBS-D, IBS-C, and IBS-A patients and 40 controls. Compliance was significantly increased in IBS-C compared with IBS-D and IBS-A, but similar compared with controls. Data are expressed as mean ± standard error of the mean.

Figure 1 (A) Dynamic rectal compliance (mL/mm Hg) in 101 IBS patients (squares) and 40 controls (triangles). Compliance was significantly decreased in patients compared with controls. Data are expressed as mean ± standard error of the mean. (B) Dynamic rectal compliance (mL/mm Hg) in IBS-D, IBS-C, and IBS-A patients and 40 controls. Compliance was significantly increased in IBS-C compared with IBS-D and IBS-A, but similar compared with controls. Data are expressed as mean ± standard error of the mean.

Demographic, clinical, and psychological characteristics of patients and controls are listed in Table 1 . Mean age and male to female ratio were not different between groups. Symptom severity and levels of anxiety, depression, psychoneuroticism, somatization, other somatic symptoms, and dysfunctional cognitions were all slightly but significantly increased in IBS patients compared with healthy controls. Pain coping scores were significantly reduced in IBS. Compared with controls, patients had impaired quality of life on 6 of 8 SF-36 subscales. Psychological measures were not different between patients from the tertiary referral center and those from the general population ( Table 2 ).

NOTE. Score ranges from best to worst are indicated after each parameter. Data are expressed as mean ± SD.

Psychological Profile of Patients Recruited From the Tertiary Referral Center and From the General Population

Table 2 Psychological Profile of Patients Recruited From the Tertiary Referral Center and From the General Population

NOTE. Score ranges from best to worst are indicated after each parameter. Data are expressed as mean ± SD.

We screened 130 patients, 26 of whom did not meet Rome II criteria, and 40 healthy volunteers. Two patients declined to participate in the barostat study, and 1 patient was diagnosed with conversion disorder. All healthy volunteers and 101 patients provided informed consent and were included in the final analysis. Thirty-one patients (31%) were recruited through the outpatient department, and 70 patients (69%) were recruited through advertisement. All patients in the latter group had previously consulted a physician and had been evaluated for their abdominal symptoms. Healthy controls were also recruited through advertisement.

Discussion

The present study showed that (1) visceral hypersensitivity is an important feature of IBS but is not present in all patients, and (2) hypersensitivity to rectal balloon distention is predicted by IBS symptom severity but not by demographic or psychological characteristics.

11 Mertz H.

Naliboff B.

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et al. Altered rectal perception is a biological marker of patients with irritable bowel syndrome. Our data confirmed previous findings that rectal compliance and pain thresholds are reduced and that the intensity of pain perception is increased in IBS patients when compared with healthy controls. Urge intensity at any given pressure was similar in patients and controls, with slightly lower thresholds for urge in IBS patients. Our observation that pain perception rather than urge is increased is consistent with other reports demonstrating decreased perception thresholds in IBS only for noxious stimuli and not for stool.

27 Sun W.M.

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et al. Sensory and motor responses to rectal distention vary according to rate and pattern of balloon inflation. , 28 Whitehead W.E.

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et al. Rectal tone, distensibility, and perception: reproducibility and response to different distensions. It is presumed that a phasic distention protocol (ie, rapid balloon inflation to predefined pressure levels) is the preferred procedure to test visceral hypersensitivity, because this would elicit rectal sensations at lower volumes or pressures compared with slow ramp distention.However, we chose to perform only ramp distentions because we considered rectal compliance to be an important factor in the model on predictors of visceral hypersensitivity, and compliance is best measured by means of slow ramp distention.Phasic distentions were not performed because assessment of sensory thresholds during phasic distentions after preceding ramp distention might introduce perceptual response bias, and phasic distentions before ramp distention might affect subsequent rectal compliance measurements. The pain thresholds we observed during ramp distention are similar to those reported by others using phasic distentions,which supports previous findings that the type of distention procedure (phasic, ramp, etc) does not affect perception.

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et al. Altered rectal perception is a biological marker of patients with irritable bowel syndrome. 11 Mertz H.

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et al. Altered rectal perception is a biological marker of patients with irritable bowel syndrome. One of our main findings is that hypersensitivity to balloon distention was less likely to occur in patients with milder symptoms. This challenges the view that visceral hyperalgesia is a biologic marker of IBS,because hypersensitivity might be absent in Rome II–positive patients with mild symptoms. The difference in the proportion of hypersensitive patients in the study by Mertz et al(95%) and our study (33%) might in part be due to the use of different parameters to define visceral hypersensitivity. Mertz et alused 3 parameters to score rectal perception simultaneously (ie, perception thresholds, intensity of sensations, and altered viscerosomatic referral), whereas we only identified patients having decreased pain thresholds and not those having decreased discomfort thresholds or altered pain referral patterns. It is, of course, essential to use equal definitions of visceral hypersensitivity when comparing its prevalence between studies. Because no accepted definition of visceral hypersensitivity is currently available, we decided to use a statistical point of view and consider patients with a pain perception threshold ≥2 SDs below the mean threshold in healthy controls as hypersensitive to rectal balloon distention. In general, this method is accepted to define outliers. Although this cutoff is arbitrary, our data suggested that hypersensitivity to rectal distention is not a suitable biologic marker to identify patients with IBS.

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et al. Altered rectal perception in irritable bowel syndrome is associated with symptom severity. The pathophysiology of visceral hyperalgesia in IBS remains poorly understood. Recent evidence suggested that disturbances might occur at different levels of the brain-gut axis. First, sensitization of peripheral nerve endings at the intestinal level might occur during or after acute inflammation,leading to higher excitability and/or increased firing of these neurons. Second, some studies suggested that alterations in the spinal dorsal horn neurons might provide an explanation for the extended viscerosomatic referral pattern that is often seen in IBS.Third, altered processing of afferent visceral information in the brain, particularly in the prefrontal cortex, anterior cingulated cortex, and thalamus, has repeatedly been demonstrated in IBS patients.These regions are not only involved in pain processing but are also part of the emotional limbic system and are therefore involved in numerous psychological and cognitive events.Because nociception (becoming aware of a painful stimulus) and emotional pain management both occur in similar regions of the brain, we hypothesized that psychological disturbances are related to visceral hypersensitivity. However, our results did not support this hypothesis, because none of the psychological variables we studied predicted the occurrence of hypersensitivity to balloon distention. These findings substantiated previous observations that psychological characteristics such as anxiety, somatization, and neuroticism do not correlate with sensory thresholds.Similar results were obtained in a recent study in which multivariate analysis demonstrated that abdominal pain and bloating were significantly associated with altered rectal perception, whereas psychological symptoms such as anxiety were not.Our data also showed that rectal hyperalgesia is not associated with other psychological factors (vigilance, dysfunctional cognitions, pain coping), demographic characteristics (age, gender), quality of life, or predominant bowel habit.

34 Whitehead W.E.

Palsson O.S. Is rectal pain sensitivity a biological marker for irritable bowel syndrome: psychological influences on pain perception. Previously Whitehead et alproposed a model for psychological factors that influence pain perception in IBS. It was suggested that low pain thresholds in IBS are influenced by 2 related cognitive traits, ie, selective attention to gut sensations and a tendency to interpret these sensations as symptoms of disease. Our data showed that neither vigilance (selective somatic attention) nor cognitions regarding functional bowel disorders (interpretation of normal sensations as symptoms of disease) were different between hypersensitive and normosensitive IBS patients. These findings suggested that hypersensitive patients do not perceive or manage their symptoms differently from normosensitive patients. Although vigilance and cognitions on functional bowel disorders differed significantly between patients and controls, these parameters were not associated with increased rectal sensitivity.

18 Drossman D.A.

McKee D.C.

Sandler R.S.

et al. Psychosocial factors in the irritable bowel syndrome: a multivariate study of patients and nonpatients with irritable bowel syndrome. , 19 Guthrie E.

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Fernandez L.

et al. Cluster analysis of symptoms and health seeking behaviour differentiates subgroups of patients with severe irritable bowel syndrome. , 35 Longstreth G.F.

Hawkey C.J.

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et al. Characteristics of patients with irritable bowel syndrome recruited from three sources: implications for clinical trials. 19 Guthrie E.

Creed F.

Fernandez L.

et al. Cluster analysis of symptoms and health seeking behaviour differentiates subgroups of patients with severe irritable bowel syndrome. We aimed to obtain a representative sample from the IBS population by recruiting patients both from the outpatient clinic and by advertisement. Levels of psychological distress were low and did not differ significantly between groups. One might argue that low levels of psychopathology explained why we found no correlation between psychological variables and visceral hypersensitivity, because a certain degree of parameter variability was required for correlations to be detected. Although some studies found significantly more psychological disturbances in IBS patients recruited from tertiary care,one of these studies found no relation between psychological distress and visceral hypersensitivity in clinic patients with IBS,supporting our finding that visceral hypersensitivity was not affected by psychopathology, regardless of level of health care.

Allowing patients to take antispasmodics, laxatives, and, occasionally, analgesics during barostat measurements is a limitation of this study because it might interfere with visceral sensitivity and affect sensory thresholds in general. Although use of these medications was similar in hypersensitive and normosensitive patients, prohibiting the use of these medications might have further increased the number of patients with hypersensitivity to balloon distention in both groups.

In conclusion, we found that patients with IBS had impaired rectal compliance and reduced sensory thresholds to rectal distention compared with controls. Visceral hypersensitivity was present in one third of our IBS population and was associated with increased symptom severity. Although psychological parameters did not predict the occurrence of visceral hypersensitivity, this does not exclude a common neuropsychological basis in the pathophysiology of IBS. Future studies should focus on the role of the brain-gut axis in the development of IBS.