“Functional” Bowel Disorders
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Transcript of “Functional” Bowel Disorders
“Functional” Bowel Disorders
Eamonn M M Quigley MD November 2010
“Functional” Bowel Disorders
• Refer to disorders of gut function where there is no obvious abnormality of structure or morphology– Cause symptoms– Impair Quality of Life– Do NOT imply/equate to
psychological/psychogenic!!
A Sub-Classification
• Defined disorders of function; i.e. motility disorders
• Putative disorders of function; “functional disorders”
SymptomsSymptoms DysfunctionDysfunction PathologyPathology
PathophysiologyPathophysiology
Well-Defined Motility Disorders
Motility Disorders
• Primary– Achalasia– Diffuse Oesophageal Spasm– Gastroparesis– Acute/Chronic Intestinal Pseudo-
obstruction– Megacolon– Hirschsprung’s disease
Achalasia• Non-relaxing LOS
– Drop-out of Inhibitory neurons (NO, VIP)
• Aperistalsis in the oesophageal body
• Causes:– Chagas’ disease– Pseudo-achalasia
• Cancers
– Idiopathic
SymptomsSymptoms DysfunctionDysfunction PathologyPathology
PathophysiologyPathophysiology
Chagas’ Disease
Achalasia - Management
• Muscle relaxants– Ca++ - blockers– Nitrates
• Dilatation– Bougie; transient
benefit only– Balloon forced
dilatation
• Surgery– Heller myotomy
• Botox
Ineffective
Diffuse Oesophageal Spasm
• True idiopathic spasm rare; usually secondary to GORD
• Non-cardiac chest pain
• Treat:– Muscle relaxants– Dilatation– ? Surgery
Pseudoobstruction
• Rare disorders resulting in diffuse motor dysfunction:– Oesophageal dysmotility– Gastroparesis– Small bowel pseudobstruction– Colonic pseudobstruction
• Myopathy or Neuropathy• Congenital or Acquired• Primary or Secondary
– Connective tissue diseases– Muscle disease– Neurologic disorders– Metabolic disorders e.g. Diabetes
Pseudoobstruction
Presents as acute or recurrent “obstruction”:• Small intestine• Colon• Acute e.g acute colonic pseudo- obstruction (acute megacolon)• post-op (Ogilvie’s syndrome)
• Chronic• results in intestinal failure• small intestinal bacterial overgrowth• inability to tolerate p.o. nutrition
SymptomsSymptoms DysfunctionDysfunction PathologyPathology
PathophysiologyPathophysiology
Scleroderma
GeneticsImmunologyGeneticsImmunology
SymptomsSymptoms DysfunctionDysfunction PathologyPathology
PathophysiologyPathophysiology
Neurological Disease:1. Brain Stem TumorNeurological Disease:2. Parkinson’s Disease
DysphagiaNauseaIleusConstipationIncontinence
DysphagiaNauseaIleusConstipationIncontinence
Hirschsprung’s Disease
• Children; rarely presents in adulthood
• Loss of inhibitory neurons
• Genetics understood
• Svenson’s pull-through procedure
SymptomsSymptoms DysfunctionDysfunction PathologyPathology
PathophysiologyPathophysiology
Hirschsprung’s Disease
“Functional” Disorders
• Functional Heartburn• Globus Sensation• Functional Dyspepsia• Irritable Bowel Syndrome• Functional Abdominal pain• Functional Diarrhoea/Constipation
Often overlap; one disorder or a number of discrete disorders
Functional GI Disorders
• Responsible for over 50% of all G.I. Responsible for over 50% of all G.I. Complaints seen by a G.P.!Complaints seen by a G.P.!
How do you make a diagnosis?
• Symptoms• No pathology• No abnormal blood tests• No abnormal X Ray’s
Diagnosis
• By exclusion• Definitive, based on symptoms ( a
consensus approach)
Rome
• Functional Dyspepsia “ A chronic pain or discomfort centred
in the upper abdomen; may be additional symptoms such as fullness, bloating, early satiety, nausea, vomiting”
Rome
• IBS– “ chronic abdominal pain or
discomfort associated with bowel movement; may be additional symptoms such as bloating, distension, constipation, diarrhoea”
IBS
• Abdo Pain +– Urge to b.m.– Relief by b.m.– Alternating diarrhoea and
constipation
• Bloating, distension• Difficult defaecation
Functional Bowel DisordersCause(s)
• Motor Dysfunction• Visceral Hypersensitivity• Low-grade inflammation• Central Perception• Psyche
FD – Pathophysiology; motility
• Gastroparesis • Impaired Fundic Accommodation• Antral Dilatation • Gastric Hypersensitivity • Abnormal Cerebral Perception • Helicobacter Pylori
IBS - Pathophysiology
• Motility• Visceral Hypersensitivity• Central Perception• Inflammation
– Post-infective– Immune activation– Microbiota different
• Psyche
Case History
• 24 year-old female graduate student, volunteers in Africa
• 2000 presented with a 2 year history of abdominal cramps and constipation
– Went on wheat-free diet– Substituted soya for cows milk– Lived in:
» Malawi age 3-10» Malaysia age 14-16
• December 2003– Every 2 weeks: diarrhoea, nausea lasting 2-3 days– Loperamide helped
• April 2004– Anticholinergic, antispasmodic and antidiarrhoeal: some
help• July 2004
Case History
• July 2004• Despite 6 diphenoxylate/day
– Every 3-4 days borborygmi and cramps followed by diarrhoea (b.o. X 5 in a.m.) and urgency
– Took tinidazole for 4 days – no effect– Family history of pernicious anaemia, coeliac
disease and Crohn’s disease
Case History
• April 2009• Intermittent symptoms
– Worse after meals and when stressed
• Has had a number of anti-biotic and anti-parasitic regimes
• No weight loss• Extensive and repeated investigations
– Blood work, gastroscopy, colonoscopy, small bowel x-rays, abdominal imaging
» All negative
Management
• Listen and appreciate– Understand aggravating factors and modify
• Symptomatic– Anti-diarrhoeals– Laxatives– Anti-spasmodics
• Tricyclic anti-depressants (low dose); SSRI’s• Behavioral and psychological therapies
Summary• Motility disorders
– Not common– May cause considerable disability– Based on disorders of intestinal nerve or
muscle or their central connections
• “Functional” disorders– Common– May cause considerable impairment in quality
of life– Pathophysiology not fully understood