Post on 29-May-2020
Dr. Melvyn Letier
Constantiaberg Mediclinic
October 2016
This presentation will enable you to:
Understand the pathophysiology of IBS
Recognize the clinical manifestations of IBS
Make a confident diagnosis of IBS
Be better able to treat your patients with IBS
IRRITABLE BOWEL SYNDROME
“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…”
W Cumming, London Medical Gazette, 1849
Recurrent abdominal pain or discomfort for at least 3 days/month in last 3 months, associated with 2 or more of the following:
Improved with
defaecation
Onset associated
with change in stool
frequency
Onset associated
with change in stool
form
Criteria fulfilled for at least 3 months, and symptom onset at least 6 months prior to diagnosis
Longstreth GF Gastroent 2006
The history and physical examination, and where appropriate selected laboratory tests, should exclude alarm symptoms and signs
Anaemia
Fever
Unexplained weight loss
Persistent Diarrhoea
Severe Constipation
Nocturnal symptoms
Coeliac disease
Rectal bleeding
Family history of colorectal cancer or IBD
New onset symptoms > 50
Not Routinely Recommended
May be helpful Recommended
FBC, ESR, CRP Coeliac serology in D-IBS, M-IBS s-tTG
Colonoscopy in patients with family history of CRC; over 50 years
Serum Chemistry H2 Breath testing for lactose intolerance
Thyroid functions H2 Breath test for small bowel bacterial overgrowth
Stool MC+S*
Abdominal imaging *
Am J Gastroenterol 2009; 104; S1
Adapted from Camilleri and Choi. Aliment Pharmacol Ther. 1997;11:3.
Enhanced
Perception
Sympathetic
Vagal
Nuclei
5-HT
Altered
Motility
Visceral
Hypersensitivity
Have analgesic as well as mood improving effects
Modes of action of TCAs and SSRIs are: endogenous endorphin release, blockade of noradrenalin reuptake, and blockade of serotonin
A meta-analysis showed antidepressants more effective than placebo for pain relief and global symptoms, in a 1-3 month period. (NNT=4)
TCAs exert benefit at lower than antidepressant doses e.g. 10-20mg nocte. Treat initially for 3-4 weeks
Post-infectious IBS (PI-IBS)-odds increased six fold after acute gastroenteritis
Risk factors for PI-IBS include young age, prolonged fever, anxiety and depression, longer illness duration
Causes of PI-IBS thought to include malabsorption, increased lymphocytes and entero-endocrine cells, and antibiotic use
Alteration in faecal microflora.
Small intestinal bacterial overgrowth: positive H2- breath test, response to antibiotics
Food sensitivity/food allergy; carbohydrate malabsorption, gluten sensitivity.
FODMAPS (fermentable oligo-, di-, and monosaccharides and polyols) enter distal small bowel and colon and undergo fermentation
Abdominal Pain
Chronic
Variable sites and intensity
Triggers include food and
stress
Nocturnal pain is unusual
HMO group (Kaiser Permanente)
Surgical predisposition in IBS; misdiagnosis important underlying factor
Women undergoing hysterectomy for pain more likely to have IBS
Increased multidisciplinary collaboration may improve diagnosis and reduce surgery
Longstreth, Yao. Gastroent 2004;126
Surgery IBS (%)
N=4587
Non IBS(%)
N=84421
Cholecyst. 12.4 4.1
Appendicec. 21.1 11.7
Hysterect. 33.2 17.0
Back surg 4.4 2.9
CABG 2.8 2.4
Peptic ulcer 0.5 0.3
Diarrhoea Constipation
Small-moderate volume loose stools; more frequent
Hard, pellet-like stools; may have normal or loose stools; less frequent
Crampy pain, relieved after stool Crampy pain, relieved after stool
Sense of incomplete evacuation Sense of incomplete evacuation
Mucus in ± 50%
Reproduced by kind
permission of Dr K W Heaton,
Reader in Medicine at the
University of Bristol. 2000
Norgine Ltd.
Often worse post-prandial
Worse as day goes on
Increased abdominal girth, without increase in total gas content
Mechanism: gas trapping in small intestine
12
88
Family Practice
IBS
OTHER
28
72
Gastroenterology
IBS
OTHER
12% of GP Visits 28% of Gastro Visits
Prevalence – 4 to 30% (average + 20%)
Up to 75% of persons with IBS do not seek medical attention
8 – 15% of primary care and 20 – 40% of referrals to gastroenterologists
Remains common in the elderly (Often misdiagnosed as symptomatic diverticulosis)
Increased health care burden and more days off work
Medical costs - + $8 billion in USA annually
The North-West University (Potchefstroom) study. The purpose of the study:
To investigate the relationship of job burnout and work
engagement with self-reported received treatment for health conditions (Cardiovascular condition, High cholesterol, Depression, Diabetes, Hypertension and Irritable bowel syndrome), while controlling for age, gender, smoking and alcohol use.
Results: The results showed that job burnout had a positive relationship with self-reported received treatment for Depression, Diabetes, Hypertension and Irritable bowel syndrome.
Reference : Leon T. de Beer1*†, Jaco Pienaar1 & Sebastiaan Rothmann Jr.2 Published online 10 April 2014 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/smi.2576
Reference : Leon T. de Beer1*†, Jaco Pienaar1 & Sebastiaan Rothmann Jr.2 Published online 10 April 2014 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/smi.2576
1. Why present now?
2. Establish therapeutic relationship
3. Patient education
4. Dietary modification
5. Physical activity
6. Psychosocial therapy
7. Medication
8. Alternative therapies
Change in symptoms e.g. medication, diet
Concern about serious illness
Stressors
Hidden agenda e.g. disability, request for opiates or tranquillizers
Psychological co-morbidity
Non-judgmental
Establish realistic expectations
Involve patient in treatment decisions
Patients with established, positive physician interactions have fewer IBS related follow-up visits
Education helps validate patients illness experience
www.uptodate.com/patients www.aboutibs.org
Sets the basis for therapeutic intervention
Stress the chronic, benign nature of IBS
The diagnosis of IBS (well validated) is robust and unlikely to change over time
IBS has no effect on lifespan
Take a careful dietary history
Consider Lactose intolerance, trial of Lactose-free diet, FODMAP diet
Reduced intake of gas forming foods in patients with increased gas
Food allergy testing not recommended
Gluten restriction in non-Coeliac patients may be of benefit
Fermentable oligo-di-monosaccharide and polyols (FODMAPs) enter distal small bowel and colon, fermented, and cause symptoms
FODMAPs include Fructans, Galactans, Lactose, Fructose, Sorbitol, Xylitol and Mannitol
Several studies on low FODMAPs diet have been shown to be of benefit in patients with IBS
A trial of low FODMAPs diet is reasonable, provided nutritional status is monitored
Gibson PR APT 2005
30
Modes of action: increased water holding in stool; gel formation to lubricate stool; bulking of stool; bile salt binding
Bulking agents showed no benefit over placebo for reducing IBS global symptoms
Hi-fiber foods e.g. All Bran® may aggravate bloating
Because of safety and placebo effect a trial of therapy is reasonable, especially in C-IBS (<30g/d)
Increased physical activity may help with symptoms of IBS
In a Scandinavian study of 102 IBS patients, moderate to vigorous exercise 3-5 times per week showed
significant benefit over non-exercising.
Active Exercise Group
Non-active Group
Decrease in symptom score
51 5
Worsening Symptoms
8% 23%
Am J Gastroent 2011
Behavioral treatment e.g. Hypnotherapy, Biofeedback, Psychotherapy may be useful
They reduce anxiety levels, encourage health promoting behavior, involve patients in treatment and improve pain tolerance
A 2009 meta-analysis of 20 studies (n=1278) showed Psychological therapy including Antidepressants to be significantly more effective vs. control or standard of care
Ford AC GUT 2009
Medication must be considered an ADJUNCT to IBS treatment
Drug selection will vary with dominant symptoms
Chronic drug use should be minimized: IBS is a lifelong condition; lack of convincing evidence of efficacy
High placebo response rate in IBS
1. Antispasmodics
2. Antidepressants
3. Anti-diarrhoeal agents
4. Anti-constipation agents
5. Probiotics
6. Alternative therapies
Pain and Bloating
Constipation Diarrhoea
Anti-spasmodics Tricyclics SSRIs
Laxatives Prucalopride* Lubiprostone* Linaclotide*
Loperamide 5HT3 Antagonists e.g. Alosetron*
IBS Drug Treatment
IBS
Most widely used drugs in IBS
Should be used “on demand” rather than on a regular basis
May be useful in patients with post-prandial pain, gas, bloating and faecal urgency
Agents available in SA include Mebeverine, Hyoscine, Peppermint oil, Librax ®
Poynard T et al APT 2001
More effective than placebo for pain relief and global symptom improvement; NNT=4
Tricyclics effective at lower than antidepressant doses e.g. amitriptyline 10-25 mg daily. Use with caution in constipated patients. Aim at 3-4 week trial of therapy given delayed onset of action
SSRI treatment data less consistent than TCAs
Reupert L Cochrane Database 2011
Use step-up approach
Osmotic laxatives; Bulking agents
Irritant laxatives + Bulking agent
Irritant Laxatives
Others
Administration of Bifidobacterium Infantis alleviated IBS symptoms including abdominal pain, bloating and normalized bowel movement.
An abnormal IL10/IL12 ratio at baseline was normalized by feeding B. Infantis.
B. Infantis changed a pro-inflammatory ratio to an anti-inflammatory state i.e. Immune modulating effect
A prospective placebo-controlled study found patients with diarrhoea predominant IBS taking Saccharomyces Boulardii, a probiotic yeast, had a significant reduction on the number and improvement in consistency of bowel movements.
O’Mahoney et al Clin Gastroenterol Hepatol 2005
Meta-analysis of 14 probiotic trials:
Small improvement in overall IBS symptoms
Effects on individual symptoms i.e. bloating, pain, flatulence – conflicting evidence
No adverse effects
Systematic review of 18 trials:
Most used combination or Lactobacilli/ Bifidobacteria
Statistically significant effect over placebo wrt Global IBS symptoms, pain & flatulence but not bloating
ACG guidelines give probiotics a weak recommendation due to lack of long term data
Hoveyda et al – Gastroenterology 2009; Moayyedi et al – Gut 2010
Iberogast (German Herbal medication)
Rifaximin (Antibiotic – not available in S.A)
Tranquilizers e.g. Librax
Hypnotherapy
Acupuncture
Recent studies have suggested that Rifaximin, a non-absorbable antibiotic, can be used as an effective treatment for abdominal bloating and flatulence, giving more credibility to the potential role of bacterial overgrowth in some patients with IBS.
A double-blind, randomized, placebo-controlled trial compared the multi-herbal extract Iberogast versus placebo in the treatment of all three forms of irritable bowel syndrome. This multi-target phytopharmaceutical was found to be significantly superior to placebo via both an abdominal pain scale (p value = 0.0009) and an IBS symptom score (p value = 0.001) after four weeks of treatment.
Enteric coated Peppermint oil capsules has been advocated for IBS symptoms in adults and children; however, results from trials have been inconsistent. Peppermint may exacerbate GORD.
There is a strong brain-gut component to IBS, and Cognitive therapy may improve symptoms in a proportion of patients in conjunction with Antidepressants. In a randomized controlled trial of referred patients, Cognitive behavioural therapy helped even though patients in this study did not have any psychiatric diagnoses.
Gut-directed or gut-specific Hypnotherapy or self-hypnosis is one of the most promising areas of IBS treatment. Current research shows that symptom reduction/elimination from IBS hypnotherapy can last at least five years.
Pharmaceutical companies – Financial potential (High prevalence, Affliction of affluence, Lack of effective therapy)
Will these patients ever uniformly benefit from drug treatment?
Animal models for functional disorders do not accurately reflect the human condition
Recent phase 3 trials fundamentally flawed
Only 6/93 trials of IBS intervention found to be scientifically adequate in recent review
Great difficulty in defining end-points in clinical trials to reflect beneficial effect on global well-being & IBS symptoms
Pressure groups – may have +ve or –ve impact on decisions by licensing authorities and politicians
“It’s not life-threatening, after all, it’s not cancer.”
“You need to learn to live with it. Come back and see me if you get a new symptom, but otherwise it’s just IBS.”
“Heck I can't even find a doctor to actually diagnose me for IBS.”
“A virus that needs to work its way out? Has this doctor never heard of the Rome 3 criteria? Don’t they teach this stuff in Medical school?”
Aim to make a positive diagnosis with Rome criteria
history, examination
Beware alarm symptoms: Wt loss, PR bleeding, recent change
in bowel habit, etc
Basic Ix: stool culture, FBC, U&E, LFT, CRP, TFT, anti tTG Ab, glucose, Ca
Refer for further investigation
IBS-C IBS-D Pain/Bloating
Explanation, reassurance, dietary and lifestyle advice
Increase dietary fibre / fluid Bulk forming laxative(s) Consider Citalopram
Dietary modification Anti-diarrhoeal agents Consider Amitriptyline
Reduced fibre intake Increased fluids Antispasmodics Consider TCA’s/Citalopram
In refractory cases consider Counselling, Hypnotherapy, Biofeedback, role of Probiotics
IBS is a chronic medical condition characterized by abdominal pain, diarrhoea 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”
A complex multifactorial ‘disease’
Huge resource usage
Probably grossly over investigated in many cases
Targeted drug therapy difficult
New therapies but modest results
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
Current drug therapy often provides inadequate relief of IBS symptoms, leading many patients to consider CAM therapies (Complementary and Alternative Medicine).
Aloe barbadensis Miller Extract (AVH200®) is a CAM therapy that is well tolerated, safe and has been shown to be a promising treatment option for patients with IBS.
PROIBS® which contains AVH200®has successfully completed a randomized placebo study at the Sahlgrenska University Hospital in Sweden.
The results from the study showed that symptoms in adults with diagnosed IBS improved significantly when the diet was supplemented with AVH200® compared to the placebo. AVH200® was seen to reduce problems of discomfort and perceived feeling of bloating.
Thus, PROIBS® containing this unique extract is seen as a promising treatment adjunct for the dietary management of IBS.