ibs4
Post on 19-Oct-2014
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IBSBaku university
05-03-2014
OVB
Irritable Bowel Syndrome
• Invalidating > 60 % sick leave ( not at
work > 1,5 day/month) Dutch data
• QoL the same as in COPD or CRC !!
• Most common diagnosis in gastro-
enterology (25-50 % of diagnosis)
• Diagnose per exclusionem
IBS
• IBS is not a disease, but the sum of a
few symptoms. Difficult to explain and
no particular investigation possible.
• People with IBS can also have chronic
fatigue syndrome, fibromyalgia and
other difficult define entities.
IBS
•
IBS
• Rome III criteria.
http://romecriteria.org/assets/pdf/19_
RomeIII_apA_885-898.
IBS• Cause :??
• Post infection with
Clostridium,Salmonella, Yersinia; 6x
chance to get IBS
• SIBO ? Small intestinal bacterial
overgrowth
IBS• In NL 90 % of patients will be ”
treated “ by GP
• Only further investigation when ”
alarm signals “ or when GP thinks: ”
something wrong ?? ”
• Patient is insecure
IBS
• History
• Physical examination !! (Herniations of abd
wall ,Costa XII syndrome ,Xyphoidalgia/-
dinia,
radiating pain from vertebral column,
pathological-mass , diffuse pain? or local
pain? etc )
IBS DIFF DIAGNOSISin gastro-enterology
• CRC :Colonoscopy
• IBD: calprotectine; endoscopy
• Coeliack disease :IgA anti-ttg
• Lactose malabsorption : LTT and H2 breath test
• Microscopic/collagene colitis : biopsy
• Parasitic infection: Dientamoeba fragilis;Giardia
• Bact overgrowth: lactose breath test
Dientamoeba fragilis
Dientamoeba fragilis
• Pathogene in children, not in adults
protozoa
Feco-oral route
Abdominal pain and watrery diarrhea.
Investigation: TFT (=triple feces test) warm ! 3 days
Metronidazol 3 x 500 mg/d ; 7-10 days (adult)
Child: 15 mg/kg/day in 3 doses; 7-10 days
IBS DD
• Bile malabsorbtion : 72 hour bile in
stool/test treatment with Questran
(Cholestyramine )
• Hyperthyreoid disease : TSH
• and do not forget gyn- or urologic
disorders
IBS managment
• No strong evidence for diet or
medication
• Evidence for hypnotherapy and
cognitive behavioral therapy
• Dientamoeba fragilis: therapy
especially in children
IBS
• Reassurance, explaining that it is not
a disease etc.
• Give your patient a lot of attention
• Be careful with fibers (bloating)
IBS• Divided in predominant diarrhea
(IBS-D) and
• predominant
constipation (IBS-C)
• and IBS-M =
mixed
IBS
• Diet measures?: trial and error
• Soluble fibers like psyllium = Metamucil ?
• Lactose free ?
• Fructose free (Cola,Fanta etc)?
• No beans, broccoli, cauliflower ,
cabbage?? =Insoluble fibres
IBS
• Medication ? Not very easy
• IBS-C : laxans like lactulose , MgO , macrogol
(PEG) or psyllium( with a lot of water)
• Tegaserod : Zelnorm selective 5HT agonist:
Only for women with IBS-C. 2x 6mg/day
FDA removed it from market in 2007/08 .
(heart attack)
IBS
• Cramps : peppermint oil ( Gives
heartburn because opening of LES,
and anal- and perianal burning) 3x 2
EC tablets before meals
IBS
• IBS-D
• Therapy : loperamide= Imodium
• Or codeine 3 x 20 mg to start with.
• Questran: Start with half of sachet
IBS
IBS• Antibiotics ??? Rifaximin 3x 550
mg/day /14 days
• When positive breath test (LTT) 60-
80% improves. BUT… after 6 month
44 % of patients have the same
complaints.
IBS
• Antidepressants : TCA
• Amitriptyline (Tryptizol): low dosis !! Not dose used
in depression! > 5-10-25 mg
• imipramine (Tofranil) 25 mg > 10 mg; max 50 mg
• SSRI: duloxetine(Cymbalta) ; effective, expensive
and obstipation
Fluoxetine ( Prozac ) when also depression
IBS
• Probiotics ??
• Google quick search : 3 reports 2 of
them funded by industry
• Third study : meta analysis with
weak positive efffect. Not very
convincing but not negative
IBS
• Probiotics ??
IBS conclusion ?
Most patients need reassuring and
support
Try to avoid medication. Try change in
food habbits. Exclude coeliac disease.
Good physical examination.
Behaveour therapy if
available ;Hypnosis if available ??
Treat diarrhea or constipation
IBS conclusion ?
• Antidepressants in low dose
• Probiotics not really helpful .
• A good long walk at the beach is
probably better
New medication in IBS-C
• Linaclotide 290 microgr/day
• Peptide of 14 aminoacids.
• FDA approved 2012/13
• Constella Linzess
• 2 studies : 32,5% vs 13,2 %
(p<0.0001) NNT 5,1
New medication in IBS-C
• Lubiprostone: 2 dd 8 mcg
• Not much data available.
• Maybe in future candidate as
therapeutic agent
IBS
• Thank you for your attention