IBS Presentation

1

IRRITABLE BOWEL SYNDROMEIRRITABLE BOWEL SYNDROME (IBS)(IBS)

Dr. Muhammad Imran

Associate` Professor MedicineServices Institute of Medical SciencesVisiting Physician & GastroenterologistServices Hospital, Lahore.

2

Functional bowel disorderFunctional bowel disorder

……. is a functional gastrointestinal . is a functional gastrointestinal disorder with symptoms attributable disorder with symptoms attributable to the mid or lower gastrointestinal to the mid or lower gastrointestinal tract. The symptoms include tract. The symptoms include abdominal pain, bloating or abdominal pain, bloating or distension and various symptoms of distension and various symptoms of disordered defecation.disordered defecation.

Thompson Thompson et alet al, 1992, 1992

3

IBS: HistoryIBS: History ‘…‘….occasional pain in the intestines and derangement of their .occasional pain in the intestines and derangement of their

powers of digestion, powers of digestion, with flatulence and a sense of suffocation’with flatulence and a sense of suffocation’

Practical remarks on the discrimination and successful Practical remarks on the discrimination and successful treatment of spasmodic stricture treatment of spasmodic stricture of the colonof the colon

‘…‘…. the bowels are at one time constipated, at . the bowels are at one time constipated, at another lax, in the same person.…’another lax, in the same person.…’

Cumming, 1849Cumming, 1849

Howship, 1830Howship, 1830

Powell, 1820Powell, 1820

4

IBS: HistoryIBS: History

‘…‘…. a tenacious mucus, which may be . a tenacious mucus, which may be slimy and gelatinous, like frog-spawn….’slimy and gelatinous, like frog-spawn….’

Mucous colitisMucous colitis

Neurogenic mucous colitisNeurogenic mucous colitisBockus Bockus et alet al, 1928, 1928

Hurst, 1921Hurst, 1921

Osler, 1892Osler, 1892

5

IBS: 1992IBS: 1992

……. a functional bowel disorder in which . a functional bowel disorder in which abdominal pain is associated with abdominal pain is associated with defecation or a change in bowel habitdefecation or a change in bowel habit, and , and with disordered defecation and with with disordered defecation and with distensiondistension..


6

IBS: 1999IBS: 1999

……. comprises a group of functional bowel. comprises a group of functional boweldisorders in which abdominal discomfort or disorders in which abdominal discomfort or pain is associated with defecation or a pain is associated with defecation or a change in bowel habit, and with features of change in bowel habit, and with features of disordered defecation.disordered defecation.


8

The Epidemiology of The Epidemiology of Irritable Bowel Syndrome Irritable Bowel Syndrome

(IBS)(IBS)

9

World Prevalence of IBSWorld Prevalence of IBS

Adapted from Camilleri M, et al. Aliment Pharmacol Ther. 1997;11:3.

Muller-Lisners et al. Digestion. 2001;64:200.

Canada

13.5%

US 10-20%

Peru

18%

Nigeria 30%

France 9.4%

UK 22%

Australia 12%

New Zealand 17%

China 23%

Japan 25%

Germany 12%

10

14%14%

14%14%

20%20%

9%9%7-8%7-8%

13%13%

13%13%

25%25%

10%10%

13%13%22%22% 9%9%

12%12%15%15%12%12% 17%17%

IBS: PrevalenceIBS: Prevalence

11

Disease prevalenceDisease prevalence

25% of patients examined by a G.P. suffer from a 25% of patients examined by a G.P. suffer from a gastrointestinal disorder, IBS being the most gastrointestinal disorder, IBS being the most

frequentfrequent

Source: American Gastroenterological Association Patients Care Committee, 1997

12

Prevalence of IBS

13

The Diagnosis of The Diagnosis of Irritable Bowel Syndrome Irritable Bowel Syndrome

(IBS)(IBS)

14

The The PositivePositive Diagnosis of IBS: Diagnosis of IBS:A Symptom-Based ApproachA Symptom-Based Approach

Adapted from Paterson et al. Adapted from Paterson et al. Can Med Assoc J.Can Med Assoc J. 1999;161:154. 1999;161:154.American Gastroenterological Association. American Gastroenterological Association. Gastroenterology.Gastroenterology. 1997;112:2120. 1997;112:2120.

Identify Current Primary SymptomIdentify Current Primary SymptomssIdentify Current Primary SymptomIdentify Current Primary Symptomss

Look for ‘Red Flags’ Based on:Look for ‘Red Flags’ Based on: HistoryHistory Physical examPhysical exam Laboratory testsLaboratory tests

Perform Selected PPerform Selected Physical andhysical and Diagnostic DiagnosticTTests ests to Rule Out Organic Diseaseto Rule Out Organic Disease

MakeMake a Positive Diagnosisa Positive Diagnosis

Abdominal pain / discomfort Bloating Constipation/Diarrhea

Abdominal pain / discomfort Bloating Constipation/Diarrhea

15

Identify Identify RRed ed FFlagslags

HistorHistoryy Unintentional weight lossUnintentional weight loss Onset in older patient (>50 Onset in older patient (>50

years)years) Family Family history ofhistory of cancercancer or IBD or IBD

Initial Initial llabsabs HGBHGB WBCWBC ESRESR Abnormal chemistryAbnormal chemistry TSHTSH

PhysicalPhysical Abnormal examsAbnormal exams Rectal bleeding / obstructionRectal bleeding / obstruction Positive flexible Positive flexible

sigmoidoscopy or sigmoidoscopy or colonoscopy (>50 years)colonoscopy (>50 years)

Adapted from a technical review. Adapted from a technical review. Gastroenterology.Gastroenterology. 1997;112:2120. 1997;112:2120.Paterson et al. Paterson et al. Can Med Assoc J.Can Med Assoc J. 1999;161:154. 1999;161:154.Camilleri et al. Camilleri et al. Aliment Pharmacol Ther.Aliment Pharmacol Ther. 1997;11:3. 1997;11:3.

Red FlagsRed Flags

16

The balance of IBS diagnosis

17

IBS: Rome criteria (1992)IBS: Rome criteria (1992)At least 3 months continuous or recurrent symptoms of:

1. abdominal pain or discomfort which is: a. relieved with defecation, b. and/or associated with a change in frequency of stool, c. and/or associated with a change in consistency of stool; and 2. two or more of the following, at least a quarter of occasions or days: a. altered stool frequency, b. altered stool form (lumpy/hard or loose/watery), c. altered stool passage (straining or urgency, feeling of

incomplete evacuation), d. passage of mucus, e. bloating or feeling of abdominal distension.


18

IBS: Rome II criteria (1999)IBS: Rome II criteria (1999)

At least 12 weeks, which need not be consecutive, in the preceding 12 months of abdominal discomfortor pain that has two of three features:

relieved with defecation; and/or onset associated with a change in frequency of

stool; and/or onset associated with a change in form

(appearance) of stool.


19

IBS: Rome II criteria (1999)IBS: Rome II criteria (1999)

The following symptoms cumulatively support the diagnosis of IBS:

abnormal stool frequency; abnormal stool form (lumpy/hard or loose/watery

stool); abnormal stool passage (straining, urgency, or

feeling of incomplete evacuation); passage of mucus; bloating or feeling of abdominal distension.

Thompson et al, 1999

20

Rome III – Irritable Bowel Rome III – Irritable Bowel SyndromeSyndrome

Diagnostic Criteria* for Irritable Bowel SyndromeDiagnostic Criteria* for Irritable Bowel Syndrome

Recurrent abdominal pain or discomfort** at least 3 days Recurrent abdominal pain or discomfort** at least 3 days per month in the last 3 months associated with 2 or more of per month in the last 3 months associated with 2 or more of the following:the following: Improvement with defecationImprovement with defecation Onset associated with a change in frequency of stoolOnset associated with a change in frequency of stool Onset associated with a change in form (appearance) of stoolOnset associated with a change in form (appearance) of stool

*Criteria fulfilled for the last 3 months with symptom onset at least 6 months*Criteria fulfilled for the last 3 months with symptom onset at least 6 months

prior to diagnosis.prior to diagnosis.

**Discomfort means an uncomfortable sensation not described as pain.**Discomfort means an uncomfortable sensation not described as pain.

Gastroenterology 2006;130:1480-1491Gastroenterology 2006;130:1480-1491

21

Rome III – Irritable Bowel SyndromeRome III – Irritable Bowel Syndrome

http://www.medscape.com/viewarticle/533460http://www.medscape.com/viewarticle/533460

Subtyping Irritable Bowel Syndrome (IBS)Subtyping Irritable Bowel Syndrome (IBS)

The Rome II committee subclassified IBS on the basis of expert The Rome II committee subclassified IBS on the basis of expert opinion and attempted to incorporate stool frequency, stool opinion and attempted to incorporate stool frequency, stool form, and defecation symptoms. form, and defecation symptoms.

In the Rome III the subclassification was revised to be based In the Rome III the subclassification was revised to be based solely on solely on stool consistencystool consistency, which has been supported by , which has been supported by recent studies.recent studies.

Subclassification of IBS is important because it would likely be Subclassification of IBS is important because it would likely be associated with different treatment choices and associated with different treatment choices and pathophysiologic mechanisms.pathophysiologic mechanisms.

22

Rome III – Irritable Bowel SyndromeRome III – Irritable Bowel Syndrome

Sub typing IBS by Predominant Stool PatternSub typing IBS by Predominant Stool Pattern

Gastroenterology 2006;130:1480-1491Gastroenterology 2006;130:1480-1491

Patients with IBS-M have both hard and loose stools over periods of hours or days, whereas IBS patients with alternating bowel habits change subtype over periods of weeks and months.

23

IBS: Further evaluationIBS: Further evaluation

SigmoidoscopySigmoidoscopy Examination of stoolExamination of stool Blood studiesBlood studies Imaging studiesImaging studies

Drossman, 1997; 1999

24

The Pathophysiology of The Pathophysiology of Irritable Bowel Syndrome Irritable Bowel Syndrome

(IBS)(IBS)

25

IBS: Evolving understandingIBS: Evolving understanding

1950 1960 1970 1980 1990 2000

Abnormal motor function

Visceral hyperalgesia

Brain-gut interaction

5-HT mediated visceralsensitivity and gut motility

Drossman et al, 1999

26

IBS PathophysiologyIBS Pathophysiology

Adapted from Camilleri and Choi. Adapted from Camilleri and Choi. Aliment Pharmacol Ther.Aliment Pharmacol Ther. 1997;11:3. 1997;11:3.

EnhancedEnhancedPerceptionPerception

Sympathetic Sympathetic

VagalVagalNucleiNuclei

5-HT5-HT

AlteredAlteredMotilityMotility

VisceralVisceralHypersensitivityHypersensitivity

27

IBS: Quality of lifeIBS: Quality of lifeComparison with other diseasesComparison with other diseases

30

40

50

60

70

80

90

Physic

al fu

nctio

ning

Physic

al fu

nctio

ning

Role p

hysic

al

Role p

hysic

al

Body pai

n

Body pai

n

Gener

al h

ealth

Gener

al h

ealth

Vitalit

y

Vitalit

y

Social

funct

ionin

g

Social

funct

ionin

g

Role e

motio

nal

Role e

motio

nal

Men

tal h

ealth

Men

tal h

ealth

MeanMeanSF-36SF-36scorescore

National normativeNational normativevaluevalue

Diabetes type IIDiabetes type II

IBSIBS

Clinical depressionClinical depression

Wells Wells et alet al, 1997, 1997

28

IBS: Negative impact on IBS: Negative impact on quality of lifequality of life

Theoretical normative valueTheoretical normative value

Hahn Hahn et alet al, 1997, 1997

MeanMeanIBSQOLIBSQOL

scorescore

30

40

50

60

70

80

90

100

Emotio

nal

Emotio

nal

Men

tal h

ealth

Men

tal h

ealth

Sleep

Sleep

Energy

Energy

Physic

al fu

nctio

ning

Physic

al fu

nctio

ning

Diet

Diet

Social

role

Social

role

Physic

al ro

le

Physic

al ro

le

Sexual

rela

tions

Sexual

rela

tions

IBSIBS

29

The Management ofThe Management ofIrritable Bowel SyndromeIrritable Bowel Syndrome

(IBS)(IBS)

30

DOCTORDOCTOR

IBS: Patient's concernsIBS: Patient's concerns

What is IBS?What is IBS?

Do I haveDo I havecancer?cancer?

I can't lead I can't lead a normal lifea normal life

I can’t talk I can’t talk to anyoneto anyone about itabout it

Where is Where is the toilet?the toilet?

Can it be Can it be treated?treated?

31

TREATMENTTREATMENT

PATIENT EDUCATIONPATIENT EDUCATION DIETARY INTERVENTIONDIETARY INTERVENTION PHARMACOTHERAPYPHARMACOTHERAPY PSYCHOTHERAPY/COGNITIVE AND PSYCHOTHERAPY/COGNITIVE AND

BAHAVIOR THERAPYBAHAVIOR THERAPY HYPNOTHERAPYHYPNOTHERAPY

32

Drug Treatment of IBSDrug Treatment of IBSAbdominal pain/discomfortAbdominal pain/discomfort• Antispasmodics• Antidepressants

— TCAs/SSRIs

Bloating and distentionBloating and distention• Antiflatulents• Antispasmodics• Dietary modification

ConstipationConstipation• Fiber• Laxatives• PEG solutions

DiarrheaDiarrhea• Opioids—Loperamide

• Cholestyramine

AbdominalAbdominalpain/pain/

discomfortdiscomfort

Bloating/Bloating/distentiondistention

Altered bowelAltered bowelfunctionfunction

None of these medications effectively treat the multiple symptoms of IBS; they may exacerbate individual symptoms (eg, fiber and bloating, antispasmodic, constipation).

IBS Presentation

Health & Medicine

Transcript of IBS Presentation