1849 – W Cumming 1 “ The bowels are at one time constipated, at another lax, in the same person....

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


GI tract – 95% GI tract – 95%

Mediate reflexes controlling gastrointestinal motility and secretion

Mediate perception of visceral pain


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


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.


Malabsorption Dietary factors Infection Inflammatory bowel

disease Psychological disorders Gynecological disorders Miscellaneous


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


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


Symptomatic treatment—pain

Smooth muscle relaxants via anticholinergic effects and/or direct action on smooth muscle


Symptomatic treatment—diarrhea

Increase stool firmness

Decrease stool frequency

◦ Examples: loperamide, diphenxylate-atropine


Symptomatic treatment—constipation


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



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

1849 – W Cumming 1 “ The bowels are at one time constipated, at another lax, in the same person....

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Transcript of 1849 – W Cumming 1 “ The bowels are at one time constipated, at another lax, in the same person....