1849 – w cumming 1 “ the bowels are at one time constipated, at another lax, in the same person....
TRANSCRIPT
1849 – W Cumming1
“The bowels are at one time constipated,
at another lax, in the same person.How the disease has two such different symptoms I do not profess to explain. . . .
IBS – HistoryIBS – History
Other historical termsOther historical terms–– mucous colitis mucous colitis –– colonic spasm colonic spasm –– neurogenic mucous colitis neurogenic mucous colitis –– irritable colon irritable colon –– unstable colon unstable colon–– nervous colon nervous colon–– spastic colon spastic colon–– nervous colitis nervous colitis–– spastic colitis spastic colitis
1962 – Chaudhary & Truelove1962 – Chaudhary & Truelove22
Irritable colon syndromeIrritable colon syndrome
1966 – CJ DeLor1966 – CJ DeLor33
Irritable bowel syndromeIrritable bowel syndrome
Long dismissed as a psychosomatic condition1
– no clear etiology – affects predominantly women
(~70% of sufferers are women)– condition not fatal
Attitudes now changing Incidence and prevalence not extensively
monitored in past
IBS – HistoryIBS – History
Chronic or recurrent GI symptoms– lower abdominal pain/discomfort– altered bowel function (urgency, altered stool
consistency, altered stool frequency, incomplete evacuation)
– bloating
Not explained by identifiable structural or biochemical abnormalities
IBS IBS –– Signs and symptoms Signs and symptoms
Up to 20% of the US population report symptoms consistent with IBS
The most common GI diagnosis among gastroenterology practices in the US
One of the top 10 reasons for family physician visits
The most common functional bowel disorder
IBS IBS –– Overview Overview
Can cause great discomfort, sometimes intermittent or continuous, for many decades in a patient’s life
Can significantly disrupt daily life Can have negative impact on quality of life2 Current treatment options
– dietary modification– fiber supplements– pharmacologic agents– psychotherapy
Success of current treatment options in addressing multiple symptoms of IBS has been limited
IBS IBS –– Overview Overview
IBS consultation patternIBS consultation patternSpecialistsSpecialists
Primary carePrimary care~25%~25%ConsultersConsulters
~75%~75%Non-consultersNon-consulters
~70% ~70% FemaleFemale
~30%~30%MaleMale
IBS IBS –– Epidemiology Epidemiology
US prevalence up to 20% US prevalence rates for other common
diseases:– diabetes 3%– asthma 4%– heart disease 8%– hypertension 11%
IBS IBS –– Epidemiology Epidemiology
IBS IBS –– Burden of disease Burden of disease
00
22
44
66
88
1010
1212
1414
IBSIBS Non-IBSNon-IBS
Da
ys
pe
r y
ea
rD
ay
s p
er
ye
ar
PP=0.0001=0.0001
Absenteeism from work or school Absenteeism from work or school during the last 12 monthsduring the last 12 months
Biopsychosocial Disorder◦ Psychosocial◦ Motility◦ Sensory◦ ? Infectious
Prevalence 10%, Incidence 1-2% per Year Disturbs QOL, Social Function, Healthcare
Utilization
PsychosocialFactors
AlteredMotility
S2,3,4
Vagal nuclei
Sympathetic
AlteredSensation
Visceral hypersensitivity– Increased visceral afferent response to normal as
well as noxious stimuli
– Mediators include 5-HT, bradykinin, tachykinins, CGRP, and neurotropins
Primary motility disorder of GI tract– Mediated by 5-HT, acetylcholine, ATP, motilin, nitric
oxide, somatostatin, substance P, and VIP
IBS IBS –– Pathophysiology Pathophysiology
Defects in the enteric nervous system may lead Defects in the enteric nervous system may lead to the hallmark symptoms of IBS.to the hallmark symptoms of IBS.
CNS – 5%CNS – 5%
– enterochromaffin cellsenterochromaffin cells– neuronalneuronal
IBS IBS –– Pathophysiology Pathophysiology
GI tract – 95% GI tract – 95%
Mediate reflexes controlling gastrointestinal motility and secretion
Mediate perception of visceral pain
IBS IBS –– Pathophysiology Pathophysiology
20 60 100 140 180
IBS IBS –– Physiology Physiology%
Rep
ort
ing
Pa
in%
Rep
ort
ing
Pa
in
Rectosigmoid balloon volume (mL)Rectosigmoid balloon volume (mL)
0
20
40
60
IBSIBS
NormalNormal
Pain produced by rectosigmoid balloon distensionPain produced by rectosigmoid balloon distension
IBS IBS –– Physiology Physiology
Colonic DistensionColonic Distension Ice Water ImmersionIce Water Immersion
IBSIBS
NormalNormal
IBS – IBS – DiagnosisDiagnosis
Identify abdominal pain as dominant Identify abdominal pain as dominant symptom with altered bowel functionsymptom with altered bowel function
Perform diagnostic tests/physical exam Perform diagnostic tests/physical exam to rule out organic diseaseto rule out organic disease
Initiate treatment program as part Initiate treatment program as part of diagnostic approachof diagnostic approach
Follow up in 3 to 6 weeksFollow up in 3 to 6 weeks
Look for “red flags”Look for “red flags”
Make/confirm diagnosisMake/confirm diagnosis
At Least 12 Weeks, Which Need Not Be Consecutive, in the Preceding 12 Months, of Abdominal Discomfort or Pain That Has Two of Three Features:
1. Relieved with Defecation; and/or2. Onset Associated with a Change
in Frequency of Stool; and/or3. Onset Associated with a Change
in Form (Appearance) of Stool
ConstipationConstipation DiarrheaDiarrhea
A SYSTEM FOR DIAGNOSING FUNCTIONAL GASTROINTESTINAL DISORDERS BASED ON SYMPTOMS FOR IBS:
Recurrent abdominal pain or discomfort** at least 3 days per month over the last 3 months associated with 2 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 fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis. ** "Discomfort" means an uncomfortable sensation not described as pain.
IBS EXAMINATIONS (Roma III criteria)
RECOMMENDED NOT RECOMMENDED
1. Full blood count (FBC) 1. Ultrasound
2. Erythrocyte sedimentation rate (ESR) or plasma viscosity
2. Rigid/flexible sigmoidoscopy
3. C-reactive protein (CRP) 3. Colonoscopy; Barium enema
4. Antibody testing for coeliac disease (endomysial antibodies [EMA] or tissue transglutaminase [TTG])
4. Hydrogen breath test (for lactose intolerance and bacterial overgrowth)
5. Thyroid function test (TSH)
6. Faecal ova and parasite test
7. Faecal occult blood test
Anemia
Fever
Persistent diarrhea
Rectal bleeding
Severe constipation
Weight loss
IBS – IBS – DiagnosisDiagnosis
Additional diagnostic screening needed for atypical Additional diagnostic screening needed for atypical presentations such aspresentations such as
Nocturnal symptoms of pain Nocturnal symptoms of pain and abnormal bowel functionand abnormal bowel function
Family history of GI cancer, Family history of GI cancer, inflammatory bowel disease, inflammatory bowel disease, or celiac diseaseor celiac disease
New onset of symptoms in New onset of symptoms in patients 50+ years of agepatients 50+ years of age
If patient has typical features of IBS: If 50 years of age, order CBC, electrolytes,
LFTs, screen stool for occult blood, and consider sigmoidoscopy.
If 50 years of age, order CBC, electrolytes, LFTs, and perform a colonoscopy or air-contrast barium enema with sigmoidoscopy.
IBS – IBS – DiagnosisDiagnosis
Malabsorption Dietary factors Infection Inflammatory bowel
disease Psychological disorders Gynecological disorders Miscellaneous
IBS – IBS – DiagnosisDiagnosis
Establish a positive diagnosis
Reassure patient that there is no serious organic disease or alarming symptoms
Success of current treatment options in addressing multiple symptoms of IBS has been limited
IBS – IBS – DiagnosisDiagnosis
Education Reassurance Dietary modification Fiber Symptomatic treatment Psychological/behavioral options Realistic goals
IBS – IBS – ManagementManagement
Dicyclomine HCl
Hyoscyamine sulfate (± other anticholinergics/sedatives)
Belladonna and phenobarbital
Clidinium bromide with chlordiazepoxide
Tegaserod
Alosetron
IBS – IBS – ManagementManagement
Symptomatic treatment—pain
Smooth muscle relaxants via anticholinergic effects and/or direct action on smooth muscle
IBS – IBS – ManagementManagement
Symptomatic treatment—diarrhea
Increase stool firmness
Decrease stool frequency
◦ Examples: loperamide, diphenxylate-atropine
IBS – IBS – ManagementManagement
Symptomatic treatment—constipation
IBS – IBS – ManagementManagement
Increased dietary fiber or psylliumIncreased dietary fiber or psyllium
Osmotic laxatives (MgSOOsmotic laxatives (MgSO44, lactulose), lactulose)
Stimulant laxativesStimulant laxatives
Some laxatives and bulking agents can Some laxatives and bulking agents can exacerbate abdominal pain and bloatingexacerbate abdominal pain and bloating
Symptomatic treatment—pain
Reserved for patients with severe or refractory pain
IBS – IBS – ManagementManagement
IBS – IBS – ManagementManagement
AnticholinergicsAnticholinergics11 XX XX
TricyclicTricyclicantidepressantsantidepressants XX and SSRIsand SSRIs22
AntidiarrhealsAntidiarrheals11 XX XX XX
Bulking agentsBulking agents11 X X XX XX
LaxativesLaxatives33 XX XX
Lower Lower abdominal painabdominal pain BloatingBloating
Altered Altered stool formstool form
Altered Altered stool passagestool passage UrgencyUrgency
INITIAL MANAGEMENT OF IBSINITIAL MANAGEMENT OF IBS
Review Diet History Review Diet History Re: Fiber IntakeRe: Fiber Intake
YesYes
Increase Fiber (20g),Increase Fiber (20g),Osmotic LaxativeOsmotic Laxative
YesYes
H2 Breath TestH2 Breath TestCeliac panelCeliac panel
AntidiarrhealAntidiarrheal
YesYes
Abdominal X-ray Abdominal X-ray (KUB During Pain)(KUB During Pain)
AntispasmodicAntispasmodic++ Antidepressant Antidepressant
NoNoAdditional TestsAdditional Tests
Therapeutic TrialTherapeutic Trial
Constipation Diarrhea Pain/Gas/Bloat
Symptom Features
Approved for constipation predominant IBS 1 pill given twice daily Improvement of symptoms in women but not men Use up to 12 weeks Mild side effects: diarrhea the most prominent
side effect new safety analysis has found a higher chance of
heart attack, stroke, and worsening heart chest pain that can become a heart attack in patients treated with Zelnorm compared to those treated with a sugar pill they thought was Zelnorm
Chinese Herbal Medicine◦ 116 pts randomized to CHM did better than pts receiving
placebo Peppermint Oil
◦ Relaxation of GI smooth muscle◦ Meta-analysis showed significant improvement of IBS
symptoms Acupunture Probiotics Antibiotics
IBS symptoms may be attributed to:◦ Non-functioning gallbladder disease, chronic
appendicitis, uterine fibroids, tortuous colon IBS symptoms rarely improve after surgery IBS patients 2 to 3 times more likely to undergo
unnecessary surgery
IBS is a chronic medical condition characterized by abdominal pain, diarrhea or constipation, bloating, passage of mucus and feelings of incomplete evacuation
Precise etiology of IBS is unknown and therefore treatment is focused on relieving symptoms rather that “curing disease”
Although many IBS patients complain of symptoms after eating, true food allergies are uncommon
Specific therapies are determined by individual patient symptoms
Life-style modifications and possible alternative therapies may relieve symptoms
Surgery has NO Role in treatment of IBS