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IBS

IBS . Dr. Matt Johnson BSc MBBS MRCP MD. Specialty Areas of Interest. EofE Train the Trainers in Constipation Management Inflammatory Bowel Disease – including tertiary referral clinics at St. Mark’s and St. Thomas’s hospitals.

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IBS

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  1. IBS Dr. Matt Johnson BSc MBBS MRCP MD

  2. Specialty Areas of Interest • EofE Train the Trainers in Constipation Management • Inflammatory Bowel Disease – including tertiary referral clinics at St. Mark’s and St. Thomas’s hospitals. • Surgical Gastroenterology - National Referral Unit for ileoanal pouches, faecal incontinence, complex anorectal fistula disease at St. Mark’s • Small bowel pathology + Coeliac disease tertiary referral clinics for complicated and non-responsive cases. • Hepatology (General hepatopancreatobiliary medicine, Hepatitis clinics, Liver ITU, pre/post liver transplant medicine)

  3. St. Thomas’s Hospital

  4. St. Mark’s

  5. Research Fellowship • St. Marks’ and St. Thomas’ Hospital • The Bacterial Pathogenesis of Pouchitis and Development of Novel Probiotic Therapies • Prof PJ. Ciclitira, Prof RJ. Nicholls and Prof A. Forbes • MD

  6. 18 Publications Management of colonic diverticulosis. Coeliac disease in the elderly. Nat Clin Pract Gastroenterol Hepatol. 2008 Dec; 5(12): 697-706 Bacterial community diversity in cultures derived from healthy and inflamed ileal pouches after restorative proctocolectomy. IBD. 2009 Nov The bacteriology of pouchitis: A molecular phylogenetic analysis. GUT. 2009. Dec The prevalence of osteoporosis and osteopenia in ileal pouch patients post-restorative proctocolectomy. IBD. 2009. Sept Prolonged toxic megacolon secondary to Salmonella. [Submitted to Diseases of the Colon and Rectum] Coeliac disease in the older patient: Are we ageist in our practice. [Awaiting publication in Gastroenterolgy CME Journal] The medical management of patients with an ileal pouch anal anastomosis after restorative proctocolectomy. EJoGH. Faecal M2-pyruvate kinase; a novel, non-invasive marker of ileal pouch inflammation. EJoGH Faecal calprotectin: A non-invasive diagnostic tool and marker of severity in pouchitis. Eur J Gastroentero Hepatol. 2008 March; 20(3): 174-179 Hyperbaric oxygen as a treatment for malabsorption in a radiation damaged short bowel. June 2006; 18(6):685-688 Risk of dysplasia and adenocarcinoma following restorative procto-colectomy for ulcerative colitis. Colorectal Disease. CDI-00256-2005.R1. 03/05/06 Use of fecal lactoferrin to diagnose irritable pouch syndrome: A word of caution. Gastroenterology. 2004. 127(5):1647-8 Presentation, diagnosis and management of inflammatory bowel disease in older people. CME Geriatric Medicine, 2005; 7(3): 149-153 The pathogenesis of coeliac disease. Molecular Aspects of Medicine, Dec 2005: 26 (6); 421-458 11th International Symposium on Coeliac Disease: A report. Gastroenterology Today. Summer 2004; 14 (2): 46-7 Clinical toxicity of HMW glutenin subunits of wheat to patients with celiac disease. Proceedings of the 19th Meeting of the Working Group on the prolamin analysis and toxicity, 2004; III Symposium: 147-9 Malaria: The dilemmas of malarial diagnostics. J R Army Med Corps 2002; 148: 122-126

  7. L&D

  8. Graham Holland’s ‘the optimism and the frustration of living in a metropolis’

  9. IBS • Rome Criteria 3 • 3m of Abdominal Pain / Discomfort • Associated with 2 of 3 • Altered frequency • Altered consistency • Improves with defaecation

  10. IBS - Associated symptoms • Tiredness / lethargy • Poor sleep • Backpain • Fybromyalgia • Urinary urgency and frequency • Dysguesia - Unpleasant taste in mouth

  11. IBS • 9-12% of adult population • 40-60% of all Gastro OPA referrals • 1M : 2.5F • Aetiology • Psychological (Increased incidence of Psych Hx) • Stress (ppt in 50%) • Post infective (ppt in 10-20%) • Consulting behaviour / Abnormal illness behaviour • Gut motility (no consistent evidence) • Visceral hypersensitivity • Diet (lactose + wheat intolerance)

  12. IBS - Investigation • FBC + ESR (1%) • TFT (6%) • Coeliac (2-15%) • Ca + Albumin • Stool MCS + COP • Faecal elastase • US (incidental gallstones and fibroids 8%) • Lactose intolerance testing (21-25%) • Flexible sig / BaEnema / Colonoscopy • SeHCAT scan - Bile acid malabsorption (8%)

  13. IBS Management • Positive diagnosis • Listen • Lifestyle advice • Placebo (50%) • Dietary advice • (exclude lactulose,wheat, caffeine, CHO) • Psychological therapies • Diagnosis + Psych referral • Relaxation / Biofeedback, Hypnotherapy, Cognitive behavioural, Psychotherapy • Pharmacological Rx • PTO

  14. IBS Treatment • Pain • Anticholinergics • Antispasmodics • Tricyclic antidepressants • Urgency + Diarrhoea • Loperamide • Codeine • Constipation • Increased fibre • Ispaghula • Others = Placebo

  15. Gastro Psychiatrist

  16. Give me a Gastro patient that doesn’t fit these criteria ! • Rome Criteria 3 - Surely we can all relate ! 3m of Abdominal Pain / Discomfort Associated with 2 of 3 • Altered frequency • Altered consistency • Improves with defaecation

  17. IBS - What does it mean to me? • Non-organic disorder • Functional bowel symptoms (FBS) • Talk to your patients about their life and their bowel habits “Don’t treat the symptoms Treat the cause” • Anyone with chronic diarrhoea need full Ix

  18. FBS - What are the main symptoms • Chronic Diarrhoea (rare) • Pain • Faecal loading (Left Vs Right or Pan-colonic) • Bloating / Aerophagia • Bloating • Constipation • Constipation Cycle functional bowel symptoms • Diverticulosis, Coeliac • Right sided faecal loading

  19. Chronic Diarrhoea

  20. Chronic Diarrhoea • Lactose Intolerance • Infection eg Giardia • Bile acid malabsorption • Coeliac disease • Small bowel bacterial overgrowth (SBBO) • Inflammatory bowel disease (UC / Crohn’s) • All patients need to be actively investigated • All should be referred in to a gastroenterologist

  21. Left sided Constipation • 1) RIF pain (exclude DD) • 2) Reduced frequency • 3) Harder consistency with Straining +/- Haemorrhoids or Fissure • Mx • 1) Increase fluid intake >2L/day • 2) High fibre diet (not if DD present) • 3) Laxatives • 4) Stimulants

  22. Right sided faecal loading

  23. Right sided faecal loading • 1) Altered bowel habits = Hard pellets + episodic loose • 2) Bloating / Flatulence / Borborygmi • 3) Sense on incomplete emptying • 4) Straining +/- Haemorrhoids • Mx • 1) Increase fluid intake >2L/day • 2) Low residue (high soluble fibre) diet • 3) Osmotic agents (Movicol) +/- Laxatives • 4) Stimulants +/- 5HT4 agonists (Prucalopride)

  24. Osmotic agents: polyethylene glycol Attar et al. Gut. 1999.44.226-30 Andorsky & Goldner. Am J Gastroenterol. 1990;85(3):261-5 Corazziari et al. Dig Dis Sci. 1996;41(8):1636-42 Di Palma et al. Am J Gastroenterol. 2007;102(9):1964-71 Higher stool frequency with PEG vs lactulose after 1 month1 Less straining with PEG vs lactulose after 1 month1 P<0.005 P<0.0001 25

  25. Idiopathic Slow Transit Constipation Day 5 after taking markers

  26. Abdominal Pain

  27. Abdominal Pain • Faecal Loading • Left sided • Right sided • Pan-colonic • Diverticulosis • Bloating • Aerophagia

  28. Bloating

  29. 3 Main Causes • 1) Air swallowed = Aerophagia • 2) Gas production = SBBO • 3) Air trapped = Faecal Loading • Mx • 1) Awareness / Exercise / Positional deflation /Anti-anxiety agents • 2) H2 Lactulose breath test + Abs • 3) Rx to soften and shift the bowel

  30. Aerophagia

  31. Low FODMAP Diet • FODMAPs = • Fermentable Oligo-, Di-, and Mono-saccharides, And Polyols. • Typical symptoms would include • abdominal bloating • excessive gas • chronic diarrhea or constipation • Strict FODMAP avoidance

  32. Low FODMAP Diet

  33. One remedy

  34. COELIAC DISEASE Matt Johnson + David Dewar Professor Paul Ciclitira St Thomas’s Hospital, London

  35. AD and age at diagnosis: GroupPrevalence AD A1 – age<2yrs 5.1% A2 – age 2-10yrs 17% A3 – age>10yrs 23.6% • Prevalence of autoimmune disease is related to duration of gluten exposure Ventura A (1999) Gastroenterology 117:297-303

  36. Osteoporosis • 47% women < 50% men on GFD have osteopenia / osteoporosisa • Improvement 1 year post treatmentb aMcFarlane (1995) Gut 36:710-14 bValdimarsson (1996) Gut 38:322-7

  37. Diverticulosis

  38. Physiology and Anatomy • Terminal arterial branches • Penetrate circular muscle • Often lie adjacent to taenia

  39. Complications • Bleeding (15%) • 40% of all LGIBleeds • Assoc colitis • Stricture Obstruction • Diverticulitis inflammation “itis” • Fistula • Sepsis • Perforation

  40. DD Re-Bleeding Rates Year Percentage 1 9% 2 10% 3 19% 4 25% 1 Longstreth Am J Gastro 1997

  41. Use of surrogate markers of inflammation and Rome criteria to distinguish organic from non-organic intestinal diseaseTibble J. Gastro. 2002; (123): 450-460 • 602 new referrals with bowel symptoms • All patients had FC, intestinal permeability studies and either Ba enema or colonoscopy • 263 had organic disease, 339 diagnosed with IBS • FC OR=27.8 p<0.0001

  42. BMJ Meta-analysisRheenen P.F. BMJ. 2010;341:c3369 • 13 studies = 670 adults + 371 children • Sensitivity = 0.93 (0.85-0.97) in adults • Specificity = 0.96 (0.79-0.99) similar in kids • Screening potential IBD patients would reduce 67% of colonoscopy • 6% false negative = delayed diagnosis • 9% may have a non-IBD pathology

  43. Can FCalp reduce unnecessary colonoscopy in IBSWhitehead SJ. GUT. 2010; (59): A36 • 2419 patients • 1750 -ives • 669 +ives (FC > 50mcg/g) = 58% pathology • Cheaper + more effective at differentiating between IBS and IBD • Same price as doing a ESR + CRP

  44. Faecal Calprotectin • Business Case as a QUIPP Project • 1 year = 2600 colonoscopies • Cost = 2600 x £394 = £1,020,240 • Normals = 40% • Cost of FC in those 40% = £13,000 • Cost of colonoscopy in those 40% = £409,760 • +/- the additional complications • Ease pressure on our colon lists + BCS lists • Increase OGD capacity, when Community Endo Unit closes

  45. Graham Holland’s Vision of Luton

  46. Further Information • www.drmattwjohnson.com • Oesophageal Laboratory • Small bowel capsule enteroscopy • Faecal calprotectin • IBD-SSHAMP • Spire - 07889 219806 • L&D - 01582 497242

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