Diagnosis and Treatment Diagnosis and Treatment of IBS in the IBD Patientof IBS in the IBD PatientDiagnosis and Treatment Diagnosis and Treatment of IBS in the IBD Patientof IBS in the IBD Patient
Richard MacDermott MDRichard MacDermott MDRichard MacDermott MDRichard MacDermott MD
Case 1: IBS Diagnosed and Treated as IBDCase 1: IBS Diagnosed and Treated as IBD
Presentation:Presentation:•• 21 y/o F: Diarrhea, abd pain, nausea21 y/o F: Diarrhea, abd pain, nausea•• Crohn’s dx age 19, while at college Crohn’s dx age 19, while at college •• Intermittently on Prednisone for 2 yearsIntermittently on Prednisone for 2 yearsy yy yEvaluation:Evaluation:•• Blood work, EGD, Colonoscopy, Abd CT negBlood work, EGD, Colonoscopy, Abd CT neg•• Hx stress, anxiety, depressionHx stress, anxiety, depressionHx stress, anxiety, depressionHx stress, anxiety, depressionTreatment:Treatment:•• Pt treated for IBS. Steroids discontinuedPt treated for IBS. Steroids discontinued
IBS Versus IBDIBS Versus IBD
Hi tHi t W i ht l GI Bl diW i ht l GI Bl di•• History:History: Weight loss; GI BleedingWeight loss; GI Bleeding•• Exam:Exam: Fever; Mass; MalnutritionFever; Mass; Malnutrition•• Labs:Labs: Elevated WBC, Sedimentation Rate, Elevated WBC, Sedimentation Rate,
CC R ti P t i Pl t l t C t A iR ti P t i Pl t l t C t A iCC--Reactive Protein, Platelet Count; Anemia; Reactive Protein, Platelet Count; Anemia; Electrolyte Abnormalities; Low AlbuminElectrolyte Abnormalities; Low Albumin
•• Procedures:Procedures: Abnormal findings on Abnormal findings on Colonoscopy; Upper Endoscopy; CT Scan;Colonoscopy; Upper Endoscopy; CT Scan;Colonoscopy; Upper Endoscopy; CT Scan; Colonoscopy; Upper Endoscopy; CT Scan; SBFT; Capsule EndoscopySBFT; Capsule Endoscopy
Case 2: Crohn’s Disease and IBSCase 2: Crohn’s Disease and IBSPresentation:Presentation:Presentation:Presentation:•• 27 y/o F S/P severe Crohn’s disease of colon. 27 y/o F S/P severe Crohn’s disease of colon.
Perirectal and RectoPerirectal and Recto--vaginal fistulae vaginal fistulae •• Excellent response to Remicade for 3 yearsExcellent response to Remicade for 3 yearsp yp y•• Two episodes severe diarrhea, abd pain, nauseaTwo episodes severe diarrhea, abd pain, nauseaHistory:History:•• Pt had gone to NYC for Yankees game: hot Pt had gone to NYC for Yankees game: hot
d b d l i l NYCd b d l i l NYCdogs, beer and multiple NYC restaurantsdogs, beer and multiple NYC restaurants•• Week later: family spaghetti sauce that took Week later: family spaghetti sauce that took
three days to make three days to make
IBS in Chronic IBDIBS in Chronic IBD
•• IBS may occur in 33IBS may occur in 33 40% of chronic IBD pts40% of chronic IBD pts•• IBS may occur in 33 IBS may occur in 33 --40% of chronic IBD pts40% of chronic IBD pts•• May contribute to high placebo response ratesMay contribute to high placebo response rates•• Similar symptoms: diarrhea, abd painSimilar symptoms: diarrhea, abd pain
IBD i fl ti IBSIBD i fl ti IBS•• IBD inflammation may worsen IBSIBD inflammation may worsen IBS•• IBS symptoms too often treated with IBD medsIBS symptoms too often treated with IBD meds•• Differentiate IBS from IBD by history: gas and Differentiate IBS from IBD by history: gas and
bloating; cramping abd pain; heartburn;bloating; cramping abd pain; heartburn;bloating; cramping abd pain; heartburn; bloating; cramping abd pain; heartburn; symptoms worsened by foods and beveragessymptoms worsened by foods and beverages
•• Procedures and labs helpful if normalProcedures and labs helpful if normal
IBS in Chronic IBD: IBS in Chronic IBD: Treatment of DiarrheaTreatment of Diarrhea
•• Use Daily:Use Daily:Lomotil in divided dosesLomotil in divided dosesImodium in divided dosesImodium in divided dosesFiberFiberTricyclic antidepressants (low dose) Tricyclic antidepressants (low dose) y p ( )y p ( )
IBS in Chronic IBD: Treatment IBS in Chronic IBD: Treatment of Abdominal Pain/Crampingof Abdominal Pain/Crampingp gp g
•• Use Daily in Divided Doses:Use Daily in Divided Doses:B lB lBentylBentylLevsinLevsinDonnatolDonnatolLibraxLibrax
IBS in Chronic IBD: IBS in Chronic IBD: Treatment of ConstipationTreatment of Constipation
•• Use Daily:Use Daily:FiberFiberColaceColace
•• Use as Needed or Daily:Use as Needed or Daily:MiralaxMiralaxLactuloseLactulose
IBS in Chronic IBD: IBS in Chronic IBD: Medication Side EffectsMedication Side Effects
•• Major side effect of meds for diarrhea: Major side effect of meds for diarrhea: ConstipationConstipationM j id ff t f d f ti tiM j id ff t f d f ti ti•• Major side effect of meds for constipation: Major side effect of meds for constipation: DiarrheaDiarrhea
•• Each patient needs to learn to adjust the Each patient needs to learn to adjust the d d f f IBS dd d f f IBS ddose and frequency of IBS meds dose and frequency of IBS meds
IBS in Chronic IBD: Treatment of IBS in Chronic IBD: Treatment of Stress/Anxiety/DepressionStress/Anxiety/Depression
•• Cognitive TherapyCognitive Therapy•• BiofeedbackBiofeedback•• Stress RelaxationStress Relaxation•• AntidepressantsAntidepressants•• AnxiolyticsAnxiolyticsyy•• Psychiatric evaluationPsychiatric evaluation
IBS in Chronic IBD: Use of Tricyclic IBS in Chronic IBD: Use of Tricyclic and SSRI Antidepressantsand SSRI Antidepressants
TricyclicTricyclic SSRISSRI
IndicationsIndications DepressionDepression DepressionDepressionChronic Pain AnxietyChronic Pain Anxiety
TricyclicTricyclic SSRISSRI
IndicationsIndications DepressionDepression DepressionDepressionChronic Pain AnxietyChronic Pain AnxietyChronic Pain AnxietyChronic Pain Anxiety
Chronic PainChronic Pain
Side EffectsSide Effects
Chronic Pain AnxietyChronic Pain AnxietyChronic PainChronic Pain
Side EffectsSide EffectsConstipationConstipationDry MouthDry Mouth
DiarrheaDiarrheaInsomnia Insomnia Dry Mouth Dry Mouth
SedationSedation Agitation Agitation HeadacheHeadache
Narcotics Narcotics Pain ReliefPain ReliefNarcotics Narcotics
Pain ReliefPain ReliefDelayed Delayed TransitTransitDelayed Delayed TransitTransit
IBS in Chronic IBD: Avoid Narcotics IBS in Chronic IBD: Avoid Narcotics
Pain & Narcotics: Pain & Narcotics: Narcotic DependenceNarcotic Dependence
Pain & Narcotics: Pain & Narcotics: Narcotic DependenceNarcotic Dependence
Pain ReliefPain ReliefPain ReliefPain Relief TransitTransitTransitTransit
IleusIleusIleusIleusNarcoticsNarcoticsNarcoticsNarcoticsNarcotic DependenceNarcotic DependenceNarcotic DependenceNarcotic Dependence
DistensionDistensionDistensionDistensionIncreased Increased IIntestinalntestinal
SSpasm / pasm / PPainainIncreased Increased IIntestinalntestinal
SSpasm / pasm / PPainainpppp
Nausea /Nausea /VomitingVomitingNausea /Nausea /VomitingVomitingNarcotic
WithdrawalNarcotic
Withdrawal
IBS in Chronic IBD: Problems With IBS in Chronic IBD: Problems With Our Current Treatment ApproachOur Current Treatment Approach
•• Current approach: medications used to allow Current approach: medications used to allow patients to eat and drink what they want patients to eat and drink what they want
•• Patients already on multiple medicationsPatients already on multiple medications•• Common: instead of diet and weight loss Common: instead of diet and weight loss
1. Statins for high cholesterol 1. Statins for high cholesterol 2. Oral hypoglycemics for type 2 diabetes2. Oral hypoglycemics for type 2 diabetes3 A i i f i3 A i i f i3. Antihypertensives for hypertension3. Antihypertensives for hypertension
•• Medications for IBS often ineffective against Medications for IBS often ineffective against food and beverage stimulation of GI tractfood and beverage stimulation of GI tract
Food and Beverage Stimulation Food and Beverage Stimulation of Normal GI Tractof Normal GI Tract
•• Gastric motility Gastric motility •• Acid secretionAcid secretion•• Gallbladder contractionGallbladder contraction•• Pancreatic enzyme secretionPancreatic enzyme secretion•• Small bowel motilitySmall bowel motilityyy•• GastroGastro--colic reflexcolic reflex
2000200020002000
MealMeal--Stimulated Sigmoid Motility in Stimulated Sigmoid Motility in IBSIBS20002000
15001500
10001000
20002000
15001500
10001000SigmoidSigmoid
MealMealMealMeal
500500500500
MotilityMotilityIndexIndex IBSIBSIBSIBS
NormalNormalNormalNormal
1001001001000000
0000 50505050 130130130130
MinutesMinutesMinutesMinutesRogers J, Gut; 1989Rogers J, Gut; 1989Rogers J, Gut; 1989Rogers J, Gut; 1989
Effects of Food on Serotonin in IBS Effects of Food on Serotonin in IBS 1400
800
1000
1200
1400
Plasma Plasma Plasma Plasma
IBS PatientsIBS PatientsNormal PatientsNormal PatientsIBS PatientsIBS PatientsNormal PatientsNormal Patients
200
400
600SerotoninSerotoninSerotoninSerotonin
011 22 33 44 55 66 77 88 99 1010 1111
Bearcroft, Gut; 1993Bearcroft, Gut; 1993Bearcroft, Gut; 1993Bearcroft, Gut; 1993 Normal PatientsNormal Patients IBS PatientsIBS Patients
IBS in Chronic IBD: IBS in Chronic IBD: Visceral Hypersensitivity To FoodVisceral Hypersensitivity To Food
Serotonin Serotonin ReleaseRelease
Serotonin Serotonin ReleaseRelease Spinal AfferentSpinal AfferentSpinal AfferentSpinal Afferent Normal GI Normal GI
MotilityMotilityNormal GI Normal GI
MotilityMotility
Food in Normals Food in Normals
Increased Increased Serotonin Serotonin ReleaseRelease
Increased Increased Serotonin Serotonin ReleaseRelease
Spinal AfferentSpinal AfferentSpinal AfferentSpinal Afferent Increased GI Increased GI MotilityMotility
Increased GI Increased GI MotilityMotility
Food in chronic IBD patients with IBSFood in chronic IBD patients with IBS
ReleaseReleaseReleaseRelease
Inflammatory Inflammatory MediatorsMediators
Inflammatory Inflammatory MediatorsMediators
Increased Increased SensitizationSensitizationIncreased Increased SensitizationSensitization
IBS in Chronic IBD: Foods and IBS in Chronic IBD: Foods and Beverages that Cause DiarrheaBeverages that Cause Diarrhea
•• Caffeinated Beverages, SodasCaffeinated Beverages, Sodas•• Milk Products, Ice Cream, Cheese, ChocolateMilk Products, Ice Cream, Cheese, Chocolate•• AlcoholAlcohol•• Dietetic Beverages, Foods, Gum, CandyDietetic Beverages, Foods, Gum, Candy•• Spices, Sauces, Red MeatsSpices, Sauces, Red Meats•• Gravies, Soups, Spaghetti SauceGravies, Soups, Spaghetti Sauce•• Fruits, Fruit JuicesFruits, Fruit Juices
IBS in Chronic IBD: Foods and IBS in Chronic IBD: Foods and Beverages that Cause Gas and BloatingBeverages that Cause Gas and Bloating
Delayed Fermentation ProcessDelayed Fermentation Process•• Milk Products, Cheese, Ice Cream, Yogurt, Milk Products, Cheese, Ice Cream, Yogurt,
Chocolate, Cake, Cookies.Chocolate, Cake, Cookies.C oco e, C e, Coo esC oco e, C e, Coo es•• Salad Dressings, Mayonnaise.Salad Dressings, Mayonnaise.•• Beans, Cabbage, Raw VegetablesBeans, Cabbage, Raw Vegetables•• Bagels, Sourdough Bread, Multigrain Bread.Bagels, Sourdough Bread, Multigrain Bread.Bagels, Sourdough Bread, Multigrain Bread.Bagels, Sourdough Bread, Multigrain Bread.•• Fast Foods, Pizza, Fried Foods.Fast Foods, Pizza, Fried Foods.•• Carbonated BeveragesCarbonated Beverages
IBS in Chronic IBD: Food and Beverage IBS in Chronic IBD: Food and Beverage Intolerance, Avoidance DietIntolerance, Avoidance Diet
•• Food and Beverage intolerances vary: Different Food and Beverage intolerances vary: Different for each person.for each person.
•• Food intolerances:Food intolerances: Not food allergiesNot food allergiesFood intolerances: Food intolerances: Not food allergiesNot food allergies..•• Amount dependent and cumulative.Amount dependent and cumulative.•• Additive within and between meals. Additive within and between meals. •• Symptoms can occur within 15 minutes or canSymptoms can occur within 15 minutes or can•• Symptoms can occur within 15 minutes or can Symptoms can occur within 15 minutes or can
be delayed for 6 to 48 hours.be delayed for 6 to 48 hours.
Food and Beverage Intolerances in IBS Food and Beverage Intolerances in IBS in Chronic IBD: Taking the Historyin Chronic IBD: Taking the History
P iP iPatient statementsPatient statements•• “After I eat I have pain and diarrhea”“After I eat I have pain and diarrhea”•• ““All foods go right through”All foods go right through”Questions to AskQuestions to Ask•• What foods/beverages do you avoid?What foods/beverages do you avoid?•• Trouble eating out?Trouble eating out?•• Recent dietary change?Recent dietary change?Most helpful approach: “What do you eat forMost helpful approach: “What do you eat forMost helpful approach: “What do you eat for Most helpful approach: “What do you eat for
breakfast, lunch, dinner, and snacks? What do breakfast, lunch, dinner, and snacks? What do you drink during the day?”you drink during the day?”
Problematic Foods in Recent PatientsProblematic Foods in Recent Patients
•• Crystal Light; Diet Sodas; Snapple Iced TeaCrystal Light; Diet Sodas; Snapple Iced Tea•• Milk, Cheese, Ice Cream, ChocolateMilk, Cheese, Ice Cream, Chocolate•• Bagels; Donuts Bagels; Donuts •• Cookies; PretzelsCookies; Pretzels•• Diet: Fruits; Vegetables; Granola Bars; Fiber Diet: Fruits; Vegetables; Granola Bars; Fiber •• Barbecue Sauce; Chicken Wings; PizzaBarbecue Sauce; Chicken Wings; Pizza
Input From Spouse Often Very Helpful !!Input From Spouse Often Very Helpful !!
IBS in Chronic IBD: SubstitutionIBS in Chronic IBD: Substitution
•• Milk Products: Milk Products: Soy and Rice Products; No LactaidSoy and Rice Products; No Lactaid•• Caffeine, Fruit Juice, Alcohol, Sodas, Diet Sodas: Caffeine, Fruit Juice, Alcohol, Sodas, Diet Sodas: WaterWater•• Bagels/Donuts: Bagels/Donuts: English Muffins; White BreadsEnglish Muffins; White Breads•• Salad Dressings: Salad Dressings: Oil and VinegarOil and Vinegar•• Red Meats: Red Meats: Plain Fish, Chicken, TurkeyPlain Fish, Chicken, Turkey•• Fresh Fruits, Vegetables: Fresh Fruits, Vegetables: Cooked, CannedCooked, Canned•• Sauces Gravies Spices Fast Foods Fried FoodsSauces Gravies Spices Fast Foods Fried FoodsSauces, Gravies, Spices, Fast Foods, Fried Foods, Sauces, Gravies, Spices, Fast Foods, Fried Foods,
Condiments: Condiments: Avoid CompletelyAvoid Completely
Advice on Foods and Beverages in IBSAdvice on Foods and Beverages in IBS
•• What you eat and drink is influenced by your What you eat and drink is influenced by your taste buds, which make your brain happy.taste buds, which make your brain happy.
•• Stomach, and intestine do not have taste buds Stomach, and intestine do not have taste buds ,,•• Tongue and brain happy; GI tract suffers Tongue and brain happy; GI tract suffers •• No damage is done; does not make IBD worse No damage is done; does not make IBD worse •• Goal is to avoid treatment of IBS with IBDGoal is to avoid treatment of IBS with IBDGoal is to avoid treatment of IBS with IBD Goal is to avoid treatment of IBS with IBD
medicationsmedications
PsychiatryPsychiatry
IBS in Chronic IBD: TreatmentIBS in Chronic IBD: Treatment OverviewOverview
PsychiatryPsychiatryPain ManagementPain Management
Cognitive Therapy/ Cognitive Therapy/ Stress Reduction/ Stress Reduction/ BiofeedbackBiofeedback
Antidiarrheals /Anxiolytics /Antidiarrheals /Anxiolytics /Antidepressants/Fiber/Antidepressants/Fiber/Miralax/LactuloseMiralax/Lactulose
Education / ReassuranceEducation / ReassuranceDietary ModificationDietary Modification