Irritable bowel syndrome
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IRRITABLE BOWEL SYNDROME. Kimberly M. Persley, MD. 1849 – W Cumming 1 “ 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 – History.

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IRRITABLE BOWEL SYNDROME

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Irritable bowel syndrome

IRRITABLE BOWEL SYNDROME

Kimberly M. Persley, MD


Earliest descriptions of symptoms defining ibs

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 – History

Earliest descriptions of symptoms defining IBS

  • Other historical terms

    – mucous colitis – colonic spasm – neurogenic mucous colitis – irritable colon – unstable colon– nervous colon– spastic colon– nervous colitis– spastic colitis

  • 1962 – Chaudhary & Truelove2

    Irritable colon syndrome

  • 1966 – CJ DeLor3

    Irritable bowel syndrome

References: 1. Cumming. Lond Med Gazette. 1849;NS9;969-973. 2. Chaudhary and Truelove. Q J Med. July 1962;31:307-322.

3. DeLor. Am J Gastroenterol. May 1967;47:427-434.


Historical perspective

IBS – History

Historical perspective

  • Long dismissed as a psychosomatic condition1

    – no clear etiology – affects predominantly women (~70%of sufferers are women)2– condition not fatal

  • Attitudes now changing

  • Incidence and prevalence not extensively monitored in past

References: 1. Maxwell et al.Lancet.December 1997;350:1691-1695. 2. Sandler. Gastroenterology. August 1990;99:409-415.


Hallmark symptoms of ibs

IBS – Signs and symptoms

Hallmark symptoms of IBS

  • 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

Reference: Thompson et al. Gut. 1999;45(suppl 2):1143-1147.


Key facts about ibs

IBS – Overview

Key facts about IBS

  • Up to 20% of the US population report symptoms consistent with IBS1

  • The most common GI diagnosis among gastroenterology practices in the US2

  • One of the top 10 reasons for PCP visits3

  • Affects predominantly females (~70% of sufferers)4

  • The most common functional bowel disorder5

References: 1. Camilleri and Choi. Aliment Pharmacol Ther. 1997;11:13-15. 2. Everhart and Renault. Gastroenterology. April 1991;100:998-1005. 3. Physician Drug & Diagnosis Audit (PDDA), April 1999, Scott-Levin. 4. Sandler. Gastroenterology. August 1990;99:409-415. 5. Thompson et al. Gastroenterol Int. 1992;5:75-91.


Key facts about ibs cont

IBS – Overview

Key facts about IBS (cont.)

  • Can cause great discomfort, sometimes intermittent or continuous, for many decades in a patient’s life1

  • Can significantly disrupt daily life2

  • Can have negative impact on quality of life2

  • Current treatment options3

    –dietary modification

    –fiber supplements

    –pharmacologic agents

    –psychotherapy

  • Success of current treatment options in addressing multiple symptoms of IBS has been limited4

References:1. Hahn et al. Dig Dis Sci. December 1998;43:2715-2718. 2. Hahn et al. Digestion. 1999;60:77-81. 3. Drossman. Aliment Pharmacol Ther. 1999;13(suppl 2):3-14. 4. Klein. Aliment Pharmacol Ther. 1999;13(suppl 2):15-30.


Irritable bowel syndrome

Specialists1

~25%

Consulters1

Primary care1

~75%

Nonconsulters1

~70%

Female2

~30%

Male2

IBS – Epidemiology

IBS consultation pattern

References:1. Drossman and Thompson. Ann Intern Med. June 1992;116(pt 1):1009-1016. 2. Sandler. Gastroenterology. August 1990;99:409-415.


Ibs vs other important disease states

IBS – Epidemiology

IBS vs other important disease states

  • US prevalence up to 20%1

  • US prevalence rates for other common diseases2:

    – diabetes 3%

    – asthma4%

    – heart disease 8%

    – hypertension11%

References:1.Camilleri and Choi. Aliment Pharmacol Ther. 1997;11:3-15. 2. Adams and Benson. Vital Health Stat 10. December 1991:83. DHHS publication no (PHS)92-1509.


Productivity burden

IBS – Burden of disease

Productivity burden

Absenteeism from work or school during the last 12 months

14

12

10

8

P=0.0001

Days per year

6

4

2

0

IBS

Non-IBS

Reference:Drossman et al. Dig Dis Sci. September 1993;38:1569-1580.


Irritable bowel syndrome1

Psychosocial

Factors

Vagal nuclei

Sympathetic

S2,3,4

Altered

Motility

Altered

Sensation

Irritable Bowel Syndrome

  • Biopsychosocial Disorder

    • Psychosocial

    • Motility

    • Sensory

    • ? Infectious

  • Prevalence 10%, Incidence 1-2% per Year

  • Disturbs QOL, Social Function, Healthcare Utilization


Ibs current thinking on pathophysiology

IBS – Pathophysiology

IBS: Current thinking on pathophysiology

Defects in the enteric nervous system may lead to the hallmark symptoms of IBS.

  • Visceral hypersensitivity1

    –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 tract2

    –Mediated by 5-HT, acetylcholine, ATP, motilin, nitric oxide, somatostatin, substance P, and VIP

References: 1. Bueno et al. Gastroenterology. May 1997;112:1714-1743. 2. Goyal and Hirano. N Engl J Med. April 1996;334:1106-1115.


Physiological distribution of 5 ht

IBS – Pathophysiology

Physiological distribution of 5-HT

CNS – 5%

GI tract – 95%

–enterochromaffin cells

–neuronal

Reference: Gershon. Aliment Pharmacol Ther. 1999;13(suppl 2):15-30.


5 ht receptor effects

IBS – Pathophysiology

5-HTreceptor effects

  • Mediate reflexes controlling gastrointestinal motility and secretion

  • Mediate perception of visceral pain

Reference: Gershon. Aliment Pharmacol Ther. 1999;13(suppl 2):15-30.


Comparison of pain thresholds of ibs patients and controls

IBS – Physiology

Comparison of pain thresholds of IBS patients and controls

Pain produced by rectosigmoid balloon distension

60

IBS

40

% Reporting Pain

20

Normal

0

20

60

100

140

180

Rectosigmoid balloon volume (mL)

Reference: From Whitehead et al. Dig Dis Sci. June 1980;25:404-413. With permission.


Comparison of pain thresholds

IBS – Physiology

Comparison of pain thresholds

IBS

Normal

Colonic Distension

Ice Water Immersion

Reference: Whitehead et al. Gastroenterology. May 1990;98:1187-1192.


Make a positive diagnosis 1 2

IBS – Diagnosis

Make a positive diagnosis1,2

Identify abdominal pain as dominant symptom with altered bowel function

Look for “red flags”

Perform diagnostic tests/physical exam to rule out organic disease

Make/confirm diagnosis

Initiate treatment program as part of diagnostic approach

Follow up in 3 to 6 weeks

References: 1. Paterson et al. Can Med Assoc J. July 1999;161:154-160. 2. American Gastroenterological Association. Gastroenterology. June 1997;112:2120-2137.


Ibs rome ii criteria

IBS ROME II CRITERIA

  • 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/or

    2. Onset Associated with a Change in Frequency of Stool; and/or

    3. Onset Associated with a Change in Form (Appearance) of Stool

Constipation

Diarrhea


Red flags may suggest an alternative or coexisting diagnosis

IBS – Diagnosis

“Red flags” may suggest an alternative or coexisting diagnosis

Additional diagnostic screening needed for atypical presentations such as

  • Anemia

  • Fever

  • Persistent diarrhea

  • Rectal bleeding

  • Severe constipation

  • Weight loss

  • Nocturnal symptoms of pain and abnormal bowel function

  • Family history of GI cancer, inflammatory bowel disease, or celiac disease

  • New onset of symptoms in patients 50+ years of age

Reference: Paterson et al. Can Med Assoc J. July 1999;161:154-160.


Diagnostic tests what when who

IBS – Diagnosis

Diagnostic tests—What? When? Who?

If patient has typical features of IBS:

  • If 50 years of age, order CBC, electrolytes, LFTs, screen stool for occult blood, and consider sigmoidoscopy.1

  • If 50 years of age, order CBC, electrolytes, LFTs, and perform a colonoscopy or air-contrast barium enema with sigmoidoscopy.1,2

References: 1. American Gastroenterological Association. Gastroenterology. June 1997;112:2120-2137. 2. Paterson et al. Can Med Assoc J. July 1999;161:154-160.


Differential diagnosis

IBS – Diagnosis

Differential diagnosis

  • Malabsorption1

  • Dietary factors1

  • Infection1

  • Inflammatory bowel disease1

  • Psychological disorders1

  • Gynecological disorders2

  • Miscellaneous1

References: 1. Drossman. Aliment Pharmacol Ther. 1999;13(suppl 2):3-14. 2. Moore et al. Br J Obstet Gynaecol. December 1998;105:1322-1325.


Curre nt management of ibs

IBS – Diagnosis

Current management of IBS

  • Establish a positive diagnosis1

  • Reassure patient that there is no serious organic disease or alarming symptoms1

  • Success of current treatment options in addressing multiple symptoms of IBS has been limited2

References: 1. Drossman. Aliment Pharmacol Ther. 1999;13(suppl 2):3-14. 2. Klein. Gastroenterology. July 1988;95:232-241.


Current management components of ibs

IBS – Management

Current management components of IBS

  • Education

  • Reassurance

  • Dietary modification

  • Fiber

  • Symptomatic treatment

  • Psychological/behavioral options

  • Realistic goals

Reference: Drossman. Aliment Pharmacol Ther. 1999;13(suppl 2):3-14.


Currently available rx treatments for ibs

IBS – Management

Currently available Rx treatments for IBS

  • Dicyclomine HCl1

  • Hyoscyamine sulfate (± other anticholinergics/sedatives)2

  • Belladonna and phenobarbital1

  • Clidinium bromide with chlordiazepoxide1

  • Tegaserod

  • Alosetron

References: 1.PDR®Generics™. 1998:314, 559-561, 873-875. 2.Physicians’ Desk Reference®.1999:2910-2911.


Antispasmodics anticholinergics

IBS – Management

Antispasmodics/anticholinergics

Symptomatic treatment—pain1

  • Smooth muscle relaxants via anticholinergic effects and/or direct action on smooth muscle2

References: 1. Drossman. Aliment Pharmacol Ther. 1999;13(suppl 2):3-14. 2.Drug Facts and Comparisons®. 1999:298-298c.


Antidiarrheals

IBS – Management

Antidiarrheals

Symptomatic treatment—diarrhea

  • Increase stool firmness

  • Decrease stool frequency

    • Examples: loperamide, diphenxylate-atropine

Reference:Drug Facts and Comparisons®. 1999:324b.


Laxatives and bulking agents

IBS – Management

Laxatives and bulking agents

Symptomatic treatment—constipation

  • Increased dietary fiber or psyllium1

  • Osmotic laxatives (MgSO4, lactulose)2

  • Stimulant laxatives3

  • Some laxatives and bulking agents can exacerbate abdominal pain and bloating3

References:1. American Gastroenterological Association. Gastroenterology. June 1997;112:2120-2132. 2. Camilleri and Choi. Aliment Pharmacol Ther. 1997;11:3-15. 3.Drug Facts and Comparisons®. 1999:316-317a.


Tricyclic antidepressants and ssris

IBS – Management

Tricyclic antidepressants and SSRIs

Symptomatic treatment—pain

  • Reserved for patients with severe or refractory pain

Reference: Drossman and Thompson. Ann Intern Med. 1992;116(pt 1):1009-1016.


Multiple medications needed to treat multiple symptoms

Lower abdominal pain

Bloating

Altered stool form

Altered stool passage

Urgency

Anticholinergics1XX

TricyclicantidepressantsX and SSRIs2

Antidiarrheals1XXX

Bulking agents1 X XX

Laxatives3XX

IBS – Management

Multiple medications needed to treat multiple symptoms

References:1. American Gastroenterological Association. Gastroenterology. June 1997;112:2120-2137. 2. Drossman and Thompson. Ann Intern Med. 1992;116(pt 1):1009-1016. 3.Drug Facts and Comparisons®. 1999:316.


Irritable bowel syndrome

INITIAL MANAGEMENT OF IBS

Symptom Features

Constipation

Diarrhea

Pain/Gas/Bloat

Review Diet History Re: Fiber Intake

Yes

Yes

Yes

Additional Tests

H2 Breath Test

Celiac panel

No

Abdominal X-ray (KUB During Pain)

Therapeutic Trial

Antidiarrheal

Increase Fiber (20g),

Osmotic Laxative

Antispasmodic

+ Antidepressant

Camilleri & Prather. 1992


Tegaserod zelnorm serotinin 4 receptor agonist

Tegaserod (Zelnorm)(serotinin 4 receptor agonist)

  • 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


Non traditional remedies

Non-Traditional Remedies

  • 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

Benoussan A. JAMA 1998

Pittler M. AJG 1998


Surgical therapy for ibs

Surgical Therapy for IBS

  • 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


Take home points

Take Home Points

  • 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”


Take home points1

Take Home Points

  • 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


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