Irritable Bowel Disease

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

Rakesh KumarAdiRakesh KumarAdi

MD(DM)MD(DM)

In GE OP gt 30 of patients have In GE OP gt 30 of patients have functional gastrointestinal disordersfunctional gastrointestinal disorders

IBS is the most common functional IBS is the most common functional bowel disorder bowel disorder

In 1966 DeLor coined the term to the irritable bowel syndrome (IBS) defining it as a functional enteropathy

IBS is defined as ldquoa functional bowel

disorder in which abdominal pain is

associated with defecation or a change in

bowel habitsrdquo Thompson et al Gut 19991143-1147

EPIDEMIOLOGYEPIDEMIOLOGY

IBS is a common disorder all over IBS is a common disorder all over the world the world

Prevalence 3 to 20 in the US Prevalence 3 to 20 in the US Younger people have a higher Younger people have a higher

prevalence of IBS prevalence of IBS Female predo-minance M F - Female predo-minance M F - 2 12 1

IBS Vs Other Imp DiseasesIBS Vs Other Imp Diseases

US prevalence of IBS up to 20US prevalence of IBS up to 20 US prevalence rates for other US prevalence rates for other

common diseasescommon diseases

ndash ndash Diabetes 3Diabetes 3

ndash ndash Asthma 4Asthma 4

ndash ndash Heart disease 8Heart disease 8

ndash ndash Hypertension 11Hypertension 11

Risk factorsRisk factors

Young ageYoung age Female genderFemale gender Affluent childhood Affluent childhood

environmentenvironment Recent antibiotic Recent antibiotic

useuse Food intolerance Food intolerance

Bacterial Bacterial gastroenteritis gastroenteritis (commonly(commonly CampylobacterCampylobacter))

DepressionDepression Adverse life Adverse life

events andevents and HypochondriasisHypochondriasis Extraintestinal Extraintestinal

somatic symptoms somatic symptoms

IBS SubtypesIBS Subtypes

1048698 Constipation predominant 1048698 Diarrhea predominant 1048698 Alternator (alternating bouts of diarrhea and constipation)

This classification was suboptimal because it was not evidence based

Revised subclassificationRevised subclassification

ROME IIIROME III proposed new subtyping proposed new subtyping based on stool consistency alone is based on stool consistency alone is

1 IBS with constipation (IBS-C)1 IBS with constipation (IBS-C)

2 IBS with diarrhea (IBS-D)2 IBS with diarrhea (IBS-D)

3 IBS mixed type (IBS-M)3 IBS mixed type (IBS-M)

4 IBS unsubtyped (IBS-U)4 IBS unsubtyped (IBS-U)

Pathophysiology of IBSPathophysiology of IBS

1 Abnormal Motility1 Abnormal Motility

Colonic and SI transit has been shown Colonic and SI transit has been shown to be delayed in IBS with constipation to be delayed in IBS with constipation and accelerated in IBS with diarrhea and accelerated in IBS with diarrhea but not all studies concur but not all studies concur

There is no consensus on the exact There is no consensus on the exact patterns of motor derangement that patterns of motor derangement that actually induce constipation or diarrhea actually induce constipation or diarrhea

Not sufficient to explain symptoms ofNot sufficient to explain symptoms of

abdominal painabdominal pain

2 Visceral 2 Visceral HypersenstivityHypersenstivity

Balloon distention in the rectum was Balloon distention in the rectum was shown to induce pain at lower vol in shown to induce pain at lower vol in pts with IBS pts with IBS

In IBS there is abnormal In IBS there is abnormal sensitization within the dorsal horn sensitization within the dorsal horn of the spinal cord or CNS of the spinal cord or CNS

But Visceral Hypersenstivity is found But Visceral Hypersenstivity is found only in 60 of patients only in 60 of patients

3 Brain Gut Axis3 Brain Gut Axis

The brain-gut axis is a system of integrated circuits that allows gut activity to influence the brain and brain activity to influence the gut

The symptoms in IBS are hypothesized to arise from dysregulation within the brain-gut axis

Numerous brain-gut neurotransmitters (ie enkephalins NO tachykinins CGRP CCK 5-HT)

It is now realized that the 1 Altered colonic motility 2 Visceral hypersensitivity in IBS

are determined by reciprocal interactions between gut and brain

4 Dysregulation of ChemicalSignaling

Serotonin (5-HT) is a chemical signal that plays an important role in IBS

It has been shown that 5-HT is It has been shown that 5-HT is involved at most levels in the involved at most levels in the bidirectional communication bidirectional communication occurring along the brain-gut axisoccurring along the brain-gut axis

The 5-HT released from EC cells causes 1) stimulate extrinsic afferent pathways

involved in pain perception by the CNS and 2) stimulate intrinsic afferent neurons

involved in triggering intestinal motor responses 5-HT present in both the (CNS) and (ENS)

is a key mediator of visceral hypersensitivity and heightened bowel motility in patients with

IBS

OthershellipOthershellip

Local inflammation Local inflammation Abnormal colonic flora amp Bacterial Abnormal colonic flora amp Bacterial

overgrowthovergrowth Abnormal gas propulsionAbnormal gas propulsion Food intoleranceFood intolerance Psychological factorsPsychological factors GeneticsGenetics

summarysummary

SymptomsSymptoms Chronic or recurrent GI symptoms ndash Lower abdominal paindiscomfort ndash Altered bowel function (urgency

altered stool consistency altered stool

frequency incomplete evacuation) ndash Bloating Not explained by identifiable structural or biochemical abnormalities

Diagnostic Approaches

1048698 1950s Increased gut motility 1048698 1980 to 1999 Symptom-based

criteria ndash Manning criteria ndash Rome criteria 1048698 1999 Rome II criteria 2006 Rome III criteria

Manning CriteriaManning Criteria

Abdominal pain that is relieved Abdominal pain that is relieved after a bowel movement after a bowel movement

Looser stool at pain onset Looser stool at pain onset More frequent stools at pain onset More frequent stools at pain onset Abdominal distention (visible)Abdominal distention (visible) Sensation of incomplete rectal Sensation of incomplete rectal

evacuationevacuation Passage of mucusPassage of mucus

ContdhellipContdhellip

Demerits Demerits Symptoms were specific Symptoms were specific but not sensitive for identifying IBS but not sensitive for identifying IBS

They were of greater diagnostic They were of greater diagnostic value in women value in women

MeritMerit The Manning criteria identify The Manning criteria identify additional patients with IBS-like additional patients with IBS-like symptoms who arguably also should symptoms who arguably also should be classified as true IBS be classified as true IBS

Rome I CriteriaRome I Criteria ge ge3 mo of continuous or recurrent abdominal 3 mo of continuous or recurrent abdominal

pain or discomfort relieved with defecation pain or discomfort relieved with defecation

andand Disturbed defecation (Disturbed defecation (ge 2ge 2 of the following) of the following)

1 Altered stool frequency 1 Altered stool frequency

2 Altered stool form (hard or loosewatery) 2 Altered stool form (hard or loosewatery)

3 Altered stool passage (straining or 3 Altered stool passage (straining or urgency urgency

feeling of incomplete evacuation) feeling of incomplete evacuation)

4 Passage of mucus 4 Passage of mucus

Rome II CriteriaRome II Criteria

Abdominal pain ge12wk which need Abdominal pain ge12wk which need not be consecutive in the preceding not be consecutive in the preceding 12 mon asso with least 2 of the 3 12 mon asso with least 2 of the 3 following features following features

1 Relieved with defecation 1 Relieved with defecation

2 Onset asso with a change in stool 2 Onset asso with a change in stool frequencyfrequency

3 Onset asso with a change in stool 3 Onset asso with a change in stool formform

Comparisons of the criteria have Comparisons of the criteria have shown that both identify similar shown that both identify similar patient populations patient populations

Although the Rome II criteria was Although the Rome II criteria was more restrictive in some studies more restrictive in some studies

Rome III CriteriaRome III Criteria Recurrent abdominal pain atleast Recurrent abdominal pain atleast 3 days3 days in in

a a

month in last month in last 3 mon3 mon asso with asso with ge 2ge 2 of the of the

followingfollowing 1 Improvement with defecation 1 Improvement with defecation 2 Onset asso with a change in stool 2 Onset asso with a change in stool frequencyfrequency 3 Onset asso with a change in stool form 3 Onset asso with a change in stool form

With onset of symptoms at least With onset of symptoms at least 6 months6 months

previously previously Drossman DA Rome III Drossman DA Rome III Digestive Disease Week May Digestive Disease Week May 20-25 200620-25 2006

Changes instituted from Rome II to Changes instituted from Rome II to Rome III criteria are Rome III criteria are

(1) frequency threshold of symptoms (1) frequency threshold of symptoms needed to meet criteria (ie 3 or more needed to meet criteria (ie 3 or more days per mon in the last 3 mons days per mon in the last 3 mons

(2) duration of symptoms (lt 6 months) (2) duration of symptoms (lt 6 months) before one can make a firm diagnosis before one can make a firm diagnosis

(3) refining the subtyping of IBS(3) refining the subtyping of IBS

Diagnosis

AGA Practice GuidelinesAGA Practice Guidelines

ndash ndash Symptom-based diagnostic Symptom-based diagnostic criteria (Rome II)criteria (Rome II)

with careful history and physical with careful history and physical examexam

ndash ndash Search for organic diseaseSearch for organic disease

RED FLAGSRED FLAGS

Anemia Fever Persistent

diarrhea Rectal bleeding Severe

constipation

Nocturnal symptoms

Family history of GI cancer

IBD or SPRUE New onset of sym

in pts 50+ yrs of age Weight loss

TreatmentTreatment

Treatment program is based on Treatment program is based on dominantdominant

symptoms and their severity symptoms and their severity 1048698 1048698 Education and supportEducation and support DietDiet 1048698 1048698 Medical managementMedical management 1048698 1048698 Psychological or behavioral optionsPsychological or behavioral options ndash ndash PsychotherapyPsychotherapy ndash ndash Stress managementStress management

Education and reassuranceEducation and reassurance Reassure Reassure patient that there is no serious organic patient that there is no serious organic disease or alarming symptoms disease or alarming symptoms

Diet Diet The standard of care for IBS The standard of care for IBS typically has been a high-fiber diet typically has been a high-fiber diet

Improves constipation with sufficientImproves constipation with sufficient supplementation (20-30 g per day)supplementation (20-30 g per day) May worsen some IBS symptoms (ie May worsen some IBS symptoms (ie

bloatingbloating and abdominal pain)and abdominal pain)

Medical managementMedical management

1 AntispasmodicsAnticholinergics 1 AntispasmodicsAnticholinergics Dicyclomine HClDicyclomine HCl Belladonna and phenobarbitalBelladonna and phenobarbital Clidinium bromideClidinium bromide with with

chlordiazepoxidechlordiazepoxide They seem most useful for those with They seem most useful for those with

postprandial pain when taken 30 postprandial pain when taken 30 minutes prior to eating minutes prior to eating

Non anticholinergic antispasmodics Non anticholinergic antispasmodics include include

1 1 MebeverineMebeverine (a smooth muscle (a smooth muscle relaxant)relaxant)

2 Selective calcium channel 2 Selective calcium channel blockers (eg blockers (eg

pinaveriumpinaverium) and ) and

3 Opiate agonists (eg 3 Opiate agonists (eg trimebutinetrimebutine) )

2 Laxatives 2 Laxatives Symptomatic treatment of C-IBSSymptomatic treatment of C-IBS Osmotic laxatives (MgSO4 Osmotic laxatives (MgSO4

lactulose)lactulose) Stimulant laxativesStimulant laxatives Some laxatives agents can Some laxatives agents can

exacerbate abdominal pain and exacerbate abdominal pain and bloatingbloating

3 Antidiarrheals 3 Antidiarrheals LoperamideLoperamide is efficacious in IBS is efficacious in IBS

with diarrhea with diarrhea Decreases frequency of bowel Decreases frequency of bowel

movementsmovements Improves stool consistency Improves stool consistency Does not affect abdominal pain or Does not affect abdominal pain or

distentiondistention

4 Tricyclic Antidepressants amp SSRIs Reserved for patients with sev or refractory

pain Improve global well-being more than

symptoms TCA tend to be constipating and therefore TCA tend to be constipating and therefore

may be of most benefit in IBS - Dmay be of most benefit in IBS - D SSRIs may be more beneficial in IBS-C SSRIs may be more beneficial in IBS-C

because they accelerate small bowel transit because they accelerate small bowel transit

5 Serotonergic5 Serotonergic AgentAgent

Treatment of C-IBS Treatment of C-IBS Tegaserod Tegaserod maleatemaleate

1048698 1048698 5-HT4 receptor partial agonist5-HT4 receptor partial agonist 1048698 1048698 Indicated for the short-term Indicated for the short-term

treatment of treatment of

women with IBS whose primary women with IBS whose primary bowelbowel

symptom is constipationsymptom is constipation

Treatment of D-IBS Alosetron 5-HT3 receptor antagonist Indicated only for women with sev

IBS- D who have ndash Chronic IBS symptoms (generally

lasting 6 months or longer) ndash Not responded adequately to

conventional therapy

IBS amp Ischemic ColitisIBS amp Ischemic Colitis

Patients with IBS are eight times Patients with IBS are eight times more likely than are other patients to more likely than are other patients to develop ischemic colitisdevelop ischemic colitis

Ischemic colitis occurs in 01 of pts on Alosetron but usually transient and without irreversible consequence

Annual Digestive Disease WeekAnnual Digestive Disease Week

Volume 36 Issue 16 (15 Aug 2006)

Psychological treatment Psychological treatment

PsychotherapyPsychotherapy

Hypnotherapy and Hypnotherapy and

Cognitive behavioral therapy (CBT)Cognitive behavioral therapy (CBT) IBS patients with abdominal pain IBS patients with abdominal pain

diarrhea and psychological distress diarrhea and psychological distress appear most likely to have a beneficial appear most likely to have a beneficial response to such intervention response to such intervention

PROGNOSIS PROGNOSIS

Once made diagnosis is maintained in Once made diagnosis is maintained in 9797 of IBS patients of IBS patients

Survival in IBS was not different from Survival in IBS was not different from expected expected

Some IBS patients have spontaneous Some IBS patients have spontaneous improvement over time but usually IBS improvement over time but usually IBS is a is a relapsing disorderrelapsing disorder

The presence of excessive psychological The presence of excessive psychological distress or anxiety as well as a long distress or anxiety as well as a long duration of complaints tends to indicate duration of complaints tends to indicate a poorer prognosisa poorer prognosis

In GE OP gt 30 of patients have In GE OP gt 30 of patients have functional gastrointestinal disordersfunctional gastrointestinal disorders

IBS is the most common functional IBS is the most common functional bowel disorder bowel disorder

In 1966 DeLor coined the term to the irritable bowel syndrome (IBS) defining it as a functional enteropathy
























































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Nocturnal symptoms




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Diagnosis





RED FLAGSRED FLAGS



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Nocturnal symptoms




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Diagnosis





RED FLAGSRED FLAGS



constipation

Nocturnal symptoms




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RED FLAGSRED FLAGS



constipation

Nocturnal symptoms




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PROGNOSIS PROGNOSIS









Diagnosis





RED FLAGSRED FLAGS



constipation

Nocturnal symptoms




TreatmentTreatment
















































PROGNOSIS PROGNOSIS





RED FLAGSRED FLAGS



constipation

Nocturnal symptoms




TreatmentTreatment
















































PROGNOSIS PROGNOSIS





TreatmentTreatment
















































PROGNOSIS PROGNOSIS


















































PROGNOSIS PROGNOSIS





Irritable Bowel Disease

Education

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