irritable bowel syndrome
Download
Skip this Video
Download Presentation
IRRITABLE BOWEL SYNDROME

Loading in 2 Seconds...

play fullscreen
1 / 34

IRRITABLE BOWEL SYNDROME - PowerPoint PPT Presentation


  • 236 Views
  • Uploaded on

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.

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'IRRITABLE BOWEL SYNDROME' - dunne


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
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.

slide7

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%

– asthma 4%

– heart disease 8%

– hypertension 11%

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

Anticholinergics1 X X

Tricyclicantidepressants X and SSRIs2

Antidiarrheals1 X X X

Bulking agents1 X X X

Laxatives3 X X

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.

slide29

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
ad