Supplementation With a Multi-strain Probiotic Formulation (Bio-Kult®) in the Management of Diarrhea-predominant Irritable Bowel Syndrome - a Randomized, Double-blind, Placebo-controlled Clinical Trial
Phase: PHASE4
Conditions: Irritable Bowel Syndrome
Sponsor: Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh

1 
 
PROTOCOL 
Supplementation with a multi-strain probiotic formulation (Bio-
Kult®) in the management of diarrhoea-predominant irritable bowel 
syndrome - a randomized, double-blind, placebo-controlled clinical 
trial 
 
 
 
 
PREPARED BY 
 
Prof. Dr. Shamsuddin M. Ishaque 
MBBS, MD, DTM 
Professor, Department of Gastroenterology, BSMMU, Dhaka 
 
 
 
 
 
 
 
 
 
 
Department Of Gastroenterology 
Bangabandhu Sheikh Mujib Medical University 
Dhaka, Bangladesh 
 
2015 

2 
 
 

3 
 
TABLE OF CONTENT 
 
  CONTENTS                                                                                                 PAGE NO. 
• Abstract 
…………………….. 
03 
• Introduction & background of the study …………………….. 
04 
• Rationale of the study 
…………………….. 
07 
• Objectives of the study  
…………………….. 
10 
• Material and methods 
…………………….. 
11 
• Ethical Consideration 
…………………….. 
21 
• References 
…………………….. 
22 
 
 
 
 
 
 

4 
 
ABSTRACT 
Background: Irritable Bowel Syndrome (IBS) is a common functional 
gastrointestinal disorder. Common clinical manifestation include abdominal pain, 
bloating, altered bowel habit which bears a great impact on the quality of life of an 
individual. Previously limited number of studies carried out in our country to assess 
the effect of probiotics on IBS patients which yielded mixed results. Further study 
preferably with larger sample and longer duration was recommended. Aims and 
objectives: This study aims to see the effect of probiotics on IBS.  
Material and method: This is a controlled randomized clinical trial. The patient will 
be selected on the basis of Rome III criteria. IBS patients with a sample size of 400 
will be taken. Purposive non probability method of sampling will be employed. In this 
method the patients who will be readily available and in close proximity will be 
selected according to the selection criteria. Patient will be collected from 
gastroenterology outpatient department. After full explanation of the study procedure, 
informed written consent will be taken. Participants will be randomized to receive 
either probiotics (Biocult®, Sandooz Bd. Ltd.) with standard treatment or only 
standard treatment for 8 weeks. All participants will be interviewed with baseline 
symptom score. Similar interview for symptom score will take place at 1 month 
interval for 3 times (including 1 month post treatment). All data will be processed by 
the SPSS program values will be expressed as frequencies or mean±SD unless 
otherwise mentioned. Between groups analysis will be done by Chi-square test, 
unpaired or paired students t-test as applicable; while predictive values will be seen 
by regression analysis. Only P values <0.05 will be considered as significant.  
Result: This study will see the effect of two months use of probiotics on IBS and 
thereby highlight over the longer treatment of IBS. 

5 
 
INTRODUCTION & BACKGROUND 
Irritable Bowel Syndrome (IBS) is the most common functional disorder in clinical 
practice (Thompson WG et al.1992). IBS is characterized by abdominal pain, bloating 
and change in stool frequency and consistency in the absence of an organic cause. 
Although the prevalence has not been firmly established, it has been estimated that 
IBS affected 14-24% of women and 5-15% of men in western countries. The 
worldwide prevalence is approximately 10- 20% of the adult (Drossman et al.1993). 
IBS was shown to be more common in females in a rural community in Bangladesh. ( 
Masud MA et al, 2001) Although the one year prevalence is about 19%, only a third 
present to their GPs (Jones R, Lydeard S, 1992). If the strict Rome III criteria for IBS 
are used, it affects around 5-11% of individuals, with similar prevalence in developed 
or developing countries (Guidelines--Rome III Diagnostic Criteria for Functional 
Gastrointestinal Disorders, 2006).  
 IBS may present at any age with peak prevalence in 30s and 40s - female 
predominance is most obvious in the 3rd decade and declines afterwards. (Spiller R et 
al, 2006). Symptoms may arise from the whole gut rather than just the colon. There is 
no structural lesion, but there appears to be a significant subgroup of patients in whom 
IBS is precipitated by an episode of bacterial gastroenteritis (Neal KR et al, 2002). 
The pathogenesis of IBS is multi factorial, including roles for genetics, abnormal pain 
processing, behavioral pathways and the gastrointestinal microbiota (Chang JY et al. 
2011). No specific diagnostic procedures identify IBS, because the underlying 
pathophysiology remains unknown. Thus, the diagnosis is dependent on symptoms 
and exclusion of major organic causes (Thompson WG et al.1989). A large case–

6 
 
control study (Porter CK et al.2011) demonstrated that infectious gastroenteritis 
resulted in almost a fourfold increase in the odds of developing IBS within the 
subsequent 2 years. An imbalanced microbiota may contribute to GI symptoms 
through altered colonic fermentation resulting in increased formation of gas, an 
abnormal pattern of short chain fatty acid production and motility or sensitivity 
disturbances of the intestinal tract. The symptoms are not specific for IBS. The 
diagnosis of IBS rarely alters over time, but one always needs to be prepared to 
reconsider the diagnosis if the clinical picture changes. IBS has a significant negative 
impact on quality of life and social functioning in many patients, but it is not 
associated with the development of serious disease or with excess mortality. Although 
IBS is still considered as a functional disorder, there is increasing evidence that 
organic disease of the gastrointestinal tract (IBD), bacterial overgrowth, altered 
serotonin level and central dysregulation can be identified in subsets of patients. 
Probiotics are supplements that are made up of live strains of beneficial bacteria. The 
Food and Agriculture Organization of the WHO provides the most widely accepted 
definition of probiotics as ‘a live organism that, when ingested in adequate amounts, 
exerts a health benefit to the host’ (FAO/WHO, 2001). There is growing body of 
opinion that the micro flora make up of the human body affects the overall health and 
risks for subsequent diseases. An imbalance of gut bacteria are thought to contribute 
to IBS symptoms. (Pimentel M et al. 2006).Restoration on the micro flora to normal 
conditions might reduce symptoms in those who suffer from IBS. Probiotics promote 
health by their ability to improve the micro flora in the gut, increasing numbers of 
beneficial species and reducing  numbers of pathogenic bacteria.. Probiotics increase 
in trophic responses and regulate intestinal motility. Probiotics also modulate luminal 

7 
 
immunity by changing cytokine and cellular milieu from a pro inflammatory to anti 
inflammatory state. Probiotics regulate fermentation of non-degradable dietary fibre, 
intraluminal mucoproteins, favour lactose digestion and modulate intraluminal gas 
production (Douglas LC, Scanders ME, 2008). Evidence has accumulated to suggest 
the efficacy of certain probiotics which may be capable of bringing about a significant 
reduction in pain; abdominal distension and flatulence, while increasing health-related 
quality of life in IBS (M. Bixquet Jimenez, 2009). Several studies with L. acidophilus, 
S. thermophilus, L. plantarum have shown improvement of bowel symptoms in IBS 
patients (Sen S et al, 2002).  
 
 
 

8 
 
RATIONALE OF THE STUDY 
 
Many drugs have been advocated in the treatment of IBS, for instance, spasmolytics, 
bulking agents, psychotropic agents, and5-HT receptor antagonists. However, in 
many cases all these options remain disappointing for the relief of symptoms. The 
therapeutic efficacy in IBS is probably impacted by the heterogeneous pathogenesis 
of the disease which includes altered intestinal motility, visceral hypersensitivity, 
abnormal brain gut interaction, food intolerance, altered intestinal permeability and 
post infectious changes. Recently, the adverse role of alteration of gut micro flora at 
the onset of symptoms has been emphasized. Therefore, rationale exists for the 
therapeutic use of probiotics in IBS. In 2004-2005 a randomized, double blind 
placebo controlled trial (Kabir MA et al, 2011) on the effect of S. boulardii in diarrhea 
predominant IBS patients was conducted at BSMMU but the result was not 
satisfactory. Another study (Rahman MZ et al, 2013) at BSMMU during 2010-2011 
with multistrain probiotics yielded a beneficial outcome which was significant both 
clinically and statistically. On both occasions, further study was suggested preferably 
with a larger sample size. These recommendations for further study prompted this 
study to be carried out in order to assess the effect of multistrain probiotics in relation 
to change of symptom scores in IBS patients and also to see changes of quality of life 
before and after the treatment. As per EMEA guideline, previous study (Spiegel B et 
al, 2009) revealed that abdominal pain is the most prevalent and distressing symptom 
in IBS patients and changes in the severity of pain were reflected as a more reliable 
outcome of successful treatment. IBS shouldn’t be diagnosed in the absence of 
abdominal pain or discomfort. The pain or discomfort is typically relieved by 

9 
 
defecation or its onset is associated with an increased or decreased frequency of stool 
or looser or harder stool. The pain often is poorly localized, waxes and wanes, may be 
aggravated by eating & can occur in any part of abdomen; although it is more 
typically located in the lower abdomen. It can be referred to different areas in the 
abdomen or to the chest or back. Exacerbation of pain by stressful life events or 
difficult life situation is common.  As abdominal pain is the hallmark feature of IBS 
and is recommended for the time being to assess the main symptomatology in at least 
partially validated scale. So, improvement of abdominal pain or discomfort along with 
abnormalities in defecation is considered as primary outcome. For other subtypes of 
IBS, and for “global” development programs intending to treat two or more subtypes, 
the use of the global assessment is, however, still recommended. Both endpoints 
should be evaluated as responder rates. The numerical evaluation of changes in scales 
is regarded to be a secondary endpoint. As per EMEA Guidance on The Evaluation of 
Medicinal Products for the Treatment of IBS, a responder has to demonstrate 
abdominal pain score which has improved at least 30% compared to baseline. Recent 
studies also show that there is high placebo response rate in functional bowel 
disorders which has a negative correlation with duration of study. So to overcome this 
confusion of high placebo response, this study is designed, unlike previous studies in 
our country, with a longer study period along with a larger sample size. 
 
 
 
 

10 
 
RESEARCH QUESTION 
 
Is multistrain probiotics with standard treatment more effective at reducing IBS 
symptoms than standard treatment of IBS? 
 

11 
 
OBJECTIVES OF THE STUDY 
 
Primary Objectives: 
1. To assess the effect of multistrain probiotics on abdominal pain using a 
validated symptom severity score in IBS patients. 
2. To assess the efficacy of a multi-strain probiotic supplement as a treatment 
option for IBS in a tertiary referral centre 
 
Secondary Objectives: 
1. To assess the effect of probiotics on global symptom severity scores which 
includes other symptoms of IBS (stool consistency, frequency, bloating) using 
a validated symptom severity score. 
2. To assess changes in the use of rescue medication (i.e. laxatives or anti 
diarrhea medication such as Loperamide). 
3. To assess any adverse events reported with probiotic use. 
 
 
 
 
 
 
 
 

12 
 
MATERIALS AND METHODS 
 
a. Study Population: 
Diagnosed cases of IBS using Rome III criteria. 
Ethnicity   
- Bangladeshi 
Age  
     
- 18-55 years 
Sex 
     
- Male and female 
 
b. Study design:  Randomized controlled clinical trial. 
 
c. Main outcome variables to be studied: 
Changes in abdominal pain for primary objective and overall symptom severity 
score as a secondary objective.   
 
d. Checklist of Variables: 
Height  
Weight 
BMI 
 
DM 
Psychological disorder(depression, anxiety) 
 
e. Screening method: 
     Subjects will be screened by FBC, ESR, CRP, Coeliac serology following Rome 
III criteria for diagnosis of IBS. 

13 
 
f. Eligibility: 
g. Inclusion Criteria: 
1. Diagnosed case of  IBS using Rome III criteria 
2. Absence of red flag sign: anemia, fever, wt loss, per rectal bleeding, 
nocturnal frequency, family history of IBD, cancer     
3. Age 18-55 years 
4. No probiotics used in prior 3 months. 
5. Agreed not to start any other drug unless clinically indicated. 
6. No antibiotics in previous 2 months of enrolment. 
 
h. Exclusion Criteria: 
1. Age<18 or >55 years 
2. Previous treatment  with probiotics within last 3 months  
3. Pregnant or lactating lady 
4. Concurrent severe illness (Uncontrolled DM, Renal Dysfunction, Liver 
disease, hyper and hypothyroidism) 
5. Chronic organic bowel disorders e.g. inflammatory bowel diseases, TB, 
Diverticular disease etc 
6. Any previous gastrointestinal surgery  
 
i. Sample Size: 
For our trial, we will take equal sample size for both the groups (n1  = n2). The sample 
size is to be determined using the following formula -  
Sample size in each group, n1 = 2 σ2(Zβ+ Zα) 2 / (μ1 – μ2)2 
Here,  
Zβ= 0.84 at 80% power 
Zα = 1.96 at 95% confidence interval 

14 
 
μ1 – μ2= Minimum clinically important difference = 30 %( a minimal 
clinically significant reduction of 30% is desirable in probiotics group 
compared to placebo) 
σ = Standard deviation = 87.77 (G. Sisson, et al. 2013) 
Since there is no such study or trial carried out in Bangladesh, we could not 
find any reference value of Standard deviation of IBS-QOL or IBS-SSS scale 
among patients of Bangladesh. Hence we used a recent study (G. Sisson, 
2013) to estimate the standard deviation. 
The standard deviation found in the G. Sisson, et al. 2013 trial was 13.21 for 
IBS-QOL scale and 87.77 for IBS-SSL. Our study objectives include both the 
measures; hence we have considered the higher value of standard deviation so 
that the sample size is sufficient to cover both objectives.  
Sample size in each group, n1 = 2 x (87.77)2x(0.84+ 1.96) 2/ (30)2 
 
 
 
= 135 
Total sample size, n = 270 
 
Adjustment for non-compliance/cross-over 
We also need to consider dropouts and poor adherence in calculating the sample size. 
It is estimated that around 5%-8% patients in both groups will drop out in different 
stages of the trial. The adjusted sample size is calculated based on the following 
formula –  
Adjusted sample size, nadj= n/(1-c1-c2)2 
Here, n = 270 
c1 = Dropout rate in control group = 8% 
c2= Dropout rate in control group = 8% 
Adjusted sample size, nadj= 270 / (1-.08-.08)2 
                                                     = 384 ≈400 
The adjusted sample size in each group = 200 
 

15 
 
j. Operatinal definition: 
Rome III criteria for diagnosing IBS 
Recurrent abdominal pain or discomfort (an uncomfortable sensation not described as 
pain) at least three days a month in the past three months, associated with two or more 
of the following: 
• 
Improvement with defecation. 
• 
Onset associated with a change in frequency of stool. 
• 
Onset associated with a change in form (appearance) of stool. 
Criteria should be fulfilled for the past three months with symptom onset at least six 
months before diagnosis. 
IBS patients will be diagnosed by translated and validated enhanced Asian ROME III 
questionnaires in Bengali language for diagnosis of IBS. (Mohammed et al, 2014). 
 
Outcome variables: 
According to the EMEA Guidance on the Evaluation of Medicinal Products for the 
Treatment of IBS, a responder is defined as a patient one whose abdominal pain score 
has improved at least 30 % compared to baseline.  
 
Confounding variables: 
These are the factors that may influence the course of the study and modulate the 
findings on interpretations. 
Following are the confounding variables in this study and these will be addressed 
accordingly:  
1. Psychological status- IBS is a functional gastrointestinal disorder and by 
definition psychological attributes i.e. anxiety and depression may influence the 
appearance and/or severity of pain and bowel motion. Such patients in this study 

16 
 
will be managed by anxiolytics and the antidepressants in appropriate cases so that 
their psychological status does not influence the outcome of the study. 
2. Dietary factors: Some dietary components may aggravate abdominal pain and 
frequency of bowel motion in IBS. Patient of both groups will be provided with 
similar dietary advices. So that dietary component can not influence the outcome 
of the study.  
3. Drugs: Spasmolytics, antidiarrhoeal and bulk forming agents will be prescribed in 
both the groups similarly according to the needs of the patients. So that they do 
not influence the outcome of the study.  
 
Follow up schedule:  
Participants will be followed up before intervention for baseline information and 1 
month interval during treatment  including 1 month post treatment. 
 
 
 

17 
 
k. Flow chart showing the sequence of tasks: 
Assessed for eligibility (n=  ) 
Excluded  (n=   ) 
   Not meeting inclusion criteria (n=  ) 
   Declined to participate (n=  ) 
   Other reasons (n=  ) 
Analysed  (n=  ) 
 Excluded from analysis (give reasons) (n=  ) 
Lost to follow-up (give reasons) (n=  ) 
Discontinued intervention (give reasons) (n=  ) 
Allocated to intervention (n=  ) 
 Received allocated intervention (n=  ) 
 Did not receive allocated intervention (give 
reasons) (n=  ) 
Lost to follow-up (give reasons) (n=  ) 
Discontinued intervention (give reasons) (n=  ) 
Allocated to intervention (n=  ) 
 Received allocated intervention (n=  ) 
 Did not receive allocated intervention (give 
reasons) (n=  ) 
Analysed  (n=  ) 
 Excluded from analysis (give reasons) (n=  ) 
Allocation 
Analysis 
Follow-Up 
Randomized (n=  ) 
Enrollment 

18 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Review patients attending to OPD of  dept. of 
Gastroenterology of BSMMU who are aged 
18-55 years 
One or more exclusion 
criteria; record details 
                       No exclusion criteria 
Informed consent obtained following 
discussion of study design and purpose 
Consent or assent declined; record 
reason given, if any 
Allocate next identification number from 
randomized allocation sequence and provide 
corresponding numbered investigational 
medical product 
Collect baseline, demographic and quality of life data 
Commence intervention, either probiotics with 
standard treatment or standard treatment only for 8 
weeks 
Follow up at 1 month interval during on treatment and 
1 month after end of treatment to document 
• 
Alternation  in symptoms 
• 
Any adverse event 
Participants withdrawn due to any 
reason, drugs will be stopped but data 
included for intention to treat analysis  

19 
 
l. Procedures of preparing and organizing materials: 
In people who meet the IBS diagnostic criteria, the following tests should be 
undertaken to exclude other diagnoses: 
– Full blood count (FBC) 
– Erythrocyte sedimentation rate (ESR) or C - reactive protein (CRP) 
– Antibody testing for coeliac disease 
 
(Endomysial antibodies [EMA] or tissue transglutaminase [TTG]). 
 
Participants who fulfill the inclusion criteria in the absence of exclusion criteria will 
be included in the study. IBS patients will be diagnosed by translated and validated 
enhanced asian ROME III questionnaires in Bengali language for diagnosis of IBS. 
(Mohammed et al, 2014) Informed written consent will be obtained from participants. 
Data will be collected in questionnaire. 
All the participants are advised to remain on their usual normal diet during the study 
period. Approximately total of 400 participants will be recruited in this study. They 
will be divided into two groups by randomization software, consisting of 200 in each 
group. One group will receive two capsules of probiotics (Bio-Cult, Sandors BD Ltd.) 
twice daily before or during a meal with standard treatment, while the other group 
will receive only standard treatment for 8 weeks. 
 
Bio-Cult is a 14 strain probiotic formulation in a capsule form. Two capsules twice a 
day is equivalent to 8 billion CFUs (2 billion per capsule). The strains are-  
[Bacillus subtilis PXN 21, Bifidobacterium spp. (B. bifidum PXN 23, B. breve PXN 
25, B. infantis PXN 27,B. longum PXN 30), Lactobacillus spp. (L. acidophilus PXN 
35, L. delbrueckii spp. Bulgaricus PXN39, L. casei PXN 37, L. plantarum PXN 47, L. 
rhamnosus PXN 54 , L.helveticus PXN 45,L. salivarius PXN 57) Lactococcus Lactis 
PXN 63, Streptococcus thermophilus PXN 66]. 
Changes of symptoms will be assessed by using a previously used validated IBS 
instrument. (Richard Lea et al.2001). Symptom severity scoring system of IBS is 
shown in diagram-1 (C.Y. Francis et al. 1997). Symptom severity scores specially for 
abdominal pain, global symptom severity will be assessed as baseline and at 1 month 

20 
 
interval during treatment along with 1 month post treatment. This scoring will be done 
on the basis of monthly interviews.  
 
The collective scores to these individual domains give rise to the total score. The IBS-
SSS total score ranges from 0 to 500; a higher score indicating worse condition. 
Scores below 175 represent mild IBS, 175–300 represent moderate severity, and 
scores above 300 represent severe IBS.  
Patients will be asked to keep a diary with details of use of concomitant medication 
provided used consistently over last 2 months with a stable dose i.e. Loperamide or 
laxative including amount, frequency and duration. 
 
All data will be recorded in a printed data sheet. 
 
m. Randomization: 
Randomization procedure will be done by randomizer software (www.randomizer.org) 
n. Equipments to be used: 
For data collection:  Data collection sheet. 
 
o. Assurance of compliance in trial: 
The patient will be motivated for compliance. They will be assessed for willingness 
before selection. Adequate information will be provided regarding dose and duration 
of drugs. Patient will be followed up monthly for 3 months for improvement and also 
for compliance. Compliance will be assessed by counting the foils/boxes of use 
medication. Compliance will also assessed by asking about other medications and 
dietary patterns of the patient.  

21 
 
p. Procedure of data analysis and interpretation: 
Data will be analyzed using computer based SPSS program (version 13.0). All data 
will be expressed as frequencies and mean (±SD or ± SE). Comparison of symptom 
score between subgroups will be done by Student’s unpaired t-test. Pearson’s 
correlation test will be used to see correlation among different variables. P values less 
than or equal to 0.05 will be considered as significant. 
q. Intention to treat analysis: 
After randomization, some patient may become non complaint to the allocated 
treatment and will be lost to follow-up. Randomization is a key process in a 
randomized controlled trial. So exclusion of this non complaint and drop out patients 
from the analysis of the result may create bias, reduce the sample size and thereby 
reduce the power of statistical tests and increase the probability of type II error.  
Treatment group and control group will be analyzed with respect of their random 
allocation regardless of what will happen subsequently (whether they will actually 
receive the treatment or not). 
r. Time table: 
                          
 
(Activities with time schedule) 
Topic selection:                           
 
03 month (Sept-Nov, 2014) 
Literature search:                        
 
All through the study period 
Protocol writing and approval:                 
03 months (Dec-Feb, 2014) 
Data collection:                            
 
12 months (Apr, 2015 –Mar, 2016) 
Data analysis:                               
 
01 month (April, 2016) 
Thesis writing:                              
 
02 months (March-April, 2016) 
Revision, binding and submission:        
02 months (May-June, 2016) 

22 
 
s. Good clinical practice: 
According to the principles of GCP developed by International Conference on 
Harmonisation (ICH) following principles will be ensured in this study - 
• Data and reported results of clinical investigations are credible and accurate, 
and 
• Rights, safety and confidentiality of participants in clinical research are 
respected and protected (Guidance for Implementation. WHO, 2002). 
 
Ethical Consideration: 
a) 
Before starting this study, the research protocol was submitted and approved by 
the Ethical Review Committee of BSMMU, Dhaka. 
b) 
All participants will be informed about the objectives, methodology and purpose 
of the study in an easy understandable way. 
c) 
All information regarding benefits and hazards will be delivered to the all 
participants & those who agree to participate will be included in the study. 
d) 
Verbal and written consents will be taken from all participants without any 
influences prior to sample collection. 
e) 
If the participants have any question or any other problems, they will be 
requested to contact. 
f) 
Data obtained from the study will be used only for the research purpose and the 
confidentiality of all study information will be maintained strictly. 
g) 
Participants can withdraw themselves from the study any time even after giving 
consent. 
 
 

23 
 
References: 
Chang JY, Talley NJ. An update on irritable bowel syndrome: from diagnosis to 
emerging therapies. Curr Opin Gastroenterol 2011; 27:72–78. 
Douglas LC, Scanders ME.Probiotics and Prebiotics in dietics practice. J AM Diet 
Assoc. 2008; 108: 510-21. 
Drossman DA, Liz Andruzi E.US householder survey of functional GI disorder, 
prevalence, socio demography and health impact. Dig Dis Sci. 1993; 38:1569-80.  
FAO/WHO. FAO/WHO ‘Health and Nutritional Properties of Probiotics in Food 
including Powder Milk with Live Lactic Acid Bacteria’. Report of a Joint FAO/WHO 
Expert Consultation on Evaluation of Health and Nutritional Properties of Probiotics 
in Food Including Powder Milk with Live Lactic Acid Bacteria (Octobe2001). 
Guidelines on the Irritable Bowel Syndrome: Mechanisms and Practical Management. 
British Society of Gastroenterology, 2007. 
http://www.who.int/foodsafety/publications/fs_management/en/probiotics.pdf 
[Accessed 23 November 2012]. 
Jones R, Lydeard S. Irritable bowel syndrome in the general population. BMJ, 1992 
Jan 11; 304(6819):87-90. 
Kabir MA, Ishaque SM, Ali MS, Mahmuduzzaman M, Hasan M. Role of 
Saccharomyces Boulardii in Diarrhea Predominant Irritable Bowel Syndrome. 
Mymensingh Medical Journal. 2011;Vol 20, No 3:397-401. 
M.Bixquet Jimenez.Treatment of Irritable Bowel Syndrome with probiotics. An 
etiopathogenetic approach at last? Rev Esp Dig. 2009; 101:553-64. 
Masud MA, Hasan M, Azad Khan AK. Irritable Bowel Syndrome in a rural 
community in Bangladesh. Prevalence, symptom pattern and health seeking behavior. 
AM J Gastroenterol. 2001; 96:1547-52. 

24 
 
Mohammed Rahman, Uday Ghoshal, Faruque Ahmed, Md Kibria, Mahmud Hasan, 
Ann Gwee et al. Translation and Validation of Enhanced Asian Rome 3 
Questionnaires (EAR3-Q) in Bengali Language for Diagnosis of Functional 
Gastrointestinal Disorders. AM J Gastroenterol. October-2014; Vol-109. 
Neal Kr, Barker L, Spiller RC. Prognosis in post-infective irritable bowel syndrome: a 
six year follows up study. Gut, 2002 Sep; 51(3):410-3. 
Porter CK, Gormley R, Tribble DR, et al. The incidence and gastrointestinal 
infectious risk of functional gastrointestinal disorders in a healthy US adult 
population. Am J Gastroenterol. 2011; 106:130–138. 
Rahman MZ, Chowdhury MS, Rahman MA, Parveen S, Barua R, Ishaque SM, 
Ahmed DS, Raihan ASMA. Efficacy of Probiotics in Irritable Bowel Syndrome-a 
randomized, double blind placebo controlled study. BSMMU J. Vol. 6, Issue 1, Jan 
2013:21-28. 
Sen S, Mullan MM, Parker TJ, Woolner JT, Tarry SA, Hunter JO. Effect of 
Lactobacillus plantarum 299v on colonic fermentation and symptoms of irritable 
bowel syndrome. Dig Dis Sci. 2002;47:2615-2620. 
Spiller R, Aziz Q, Creed F et al.Guidelines for the management of Irritable Bowel 
Syndrome. Gut, 2007 
Thompson WG, Dotevall G, Drossman DA, Binder V, Kreiner S  et al. Irritable 
Bowel Syndrome: Guideline for the diagnosis. Gastroenterol. 1989; 2: 92-95. 
Thompson WG, Gred F, Drossman da, Heaton KW, Mazzacea G. Functional bowel 
disorder and functional abdominal pain. Gastroenterol. 1992; 5:75-91. 
Thompson WG, Heaton KW, Smyth GT, Smyth C. Irritable bowel syndrome in 
general practice: prevalence, characteristics, and referral. Gut. 2000; 46:78-82 

25 
 
APPENDIX - I 
DATA COLLECTION SHEET 
1. Baseline demographic profile of the patients: 
 
 
 
Date:  
a) 
Group 
:  
 
 
 
 
 
 
 
 
b) 
Patients ID no. 
:  
c) 
Name 
:  
d) 
Age 
:  
e) 
Sex 
: 
f) 
Religion 
: 
g) 
Occupation 
:  
h) 
Address 
: 
i) 
Contact no. 
:  
 
Symptom severity score questionnaire: 
1. a) Do you currently suffer from abdominal pain?  
Before treatment 
 
At 1st month 
 
At 2nd month 
 
At 3rd month 
□Yes/□No 
 
□Yes/□No 
 
□Yes/□No 
 
□Yes/□No 
 
 
b) If yes, how severe is your abdominal pain? 
 
 
Before treatment 
 
At 1st month 
 
At 2nd month 
 
At 3rd month 
 
 
 
 
 
 
 
c) Please enter the number of days that you get the pain in every 10 days. 
Before treatment 
 
At 1st month 
 
At 2nd month 
 
At 3rd month 
 
 
 
 
 
 
 
2.  a) Do you currently suffer from abdominal distension (bloating, swollen or tight)?  
Before treatment 
 
At 1st month 
 
At 2nd month 
 
At 3rd month 
□Yes/□No 
 
□Yes/□No 
 
□Yes/□No 
 
□Yes/□No 
No pain 
Not very severe 
Quite severe 
Severe 
Very severe 
100% 
0% 

26 
 
b) If yes, how severe is your abdominal distension/tightness?  
 
 
Before treatment 
 
At 1st month 
 
At 2nd month 
 
At 3rd month 
□Yes/□No 
 
□Yes/□No 
 
□Yes/□No 
 
□Yes/□No 
 
3. How satisfied are you with your bowel habit? 
 
 
Before treatment 
 
At 1st month 
 
At 2nd month 
 
At 3rd month 
 
 
 
 
 
 
 
 
4. Please indicate with a cross on the line below how much your irritable bowel syndrome is 
affecting or interfering with your life in general. 
 
 
 
Before treatment 
 
At 1st month 
 
At 2nd month 
 
At 3rd month 
 
 
 
 
 
 
 
 
5.  a) What is the number of times you open your bowels per day/week/month? 
Before treatment 
 
At 1st month 
 
At 2nd month 
 
At 3rd month 
/day 
 
/day 
 
/day 
 
/day 
 
 
b) What is the list number of times you open your bowels per day/week/month? 
Before treatment 
 
At 1st month 
 
At 2nd month 
 
At 3rd month 
 
 
 
 
 
 
 
 
No pain 
Not very severe 
Quite severe 
Severe 
Very severe 
100% 
0% 
100% 
0% 
Very happy 
Quite happy 
Unhappy 
Very unhappy 
100% 
0% 
Not al all 
Not much 
Quite a lot 
Completely 

27 
 
6.  In the following questions you may circle more than one answer: 
 
Are your motions ever:  
Before treatment 
At 1st month 
a) 
Normal : 
b) 
Hard: 
c) 
Very thin (like string): 
d) 
In small pieces (like rabbit pellets): 
e) 
Musky (like porridge): 
f) 
Watery: 
a) 
Normal : 
b) 
Hard: 
c) 
Very thin (like string): 
d) 
In small pieces (like rabbit pellets): 
e) 
Musky (like porridge): 
f) 
Watery: 
At 2nd month 
At 3rd month 
a) Normal: 
b) Hard: 
c) Very thin (like string): 
d) In small pieces (like rabbit pellets): 
e) Musky (like porridge): 
f) 
Watery: 
a) 
Normal : 
b) 
Hard: 
c) 
Very thin (like string): 
d) 
In small pieces (like rabbit pellets): 
e) 
Musky (like porridge): 
f) 
Watery: 
 
7.  In the following questions you may circle more than one answer: 
 
Do you ever:  
 
Before 
treatment 
At 1st 
month 
At 2nd 
month 
At 3rd 
month 
a) Pass mucus (or slime or jelly) with 
your motions. 
□Yes/□No 
□Yes/□No 
□Yes/□No 
□Yes/□No 
b) Pass blood with your motion 
□Yes/□No 
□Yes/□No 
□Yes/□No 
□Yes/□No 
c) Have to hurry/rush to the toilet to 
open your bowels 
□Yes/□No 
□Yes/□No 
□Yes/□No 
□Yes/□No 
d) Strain to open your bowels 
□Yes/□No 
□Yes/□No 
□Yes/□No 
□Yes/□No 
e) Feel you haven’t emptied your 
bowel completely after your have 
passed a motion 
□Yes/□No 
□Yes/□No 
□Yes/□No 
□Yes/□No 
 
8. Do you ever:  
 
a) Notice your stools are more frequent or loose when you get pain.. 
Before treatment 
 
At 1st month 
 
At 2nd month 
 
At 3rd month 
□Yes/□No 
 
□Yes/□No 
 
□Yes/□No 
 
□Yes/□No 
 
 

28 
 
b) Notice whether the pain is frequently eased by opening your bowels. 
 
Before treatment 
 
At 1st month 
 
At 2nd month 
 
At 3rd month 
□Yes/□No 
 
□Yes/□No 
 
□Yes/□No 
 
□Yes/□No 
 
9.  In the last year on approximately how many weeks were you:  
 
a) Absent from work due to IBS  
……………………………………………… 
 
b) At work suffering from IBS  
………………………………………………