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Irritable Bowel Syndrome. Dr Max Groome Consultant Gastroenterologist Ninewells Hospital, Dundee. Irritable Bowel: Outline. What is the best way to identify IBS patients? What are the minimum number of relevant Ix? What is the best management?. IBS: Background. Chronic, relapsing problem

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irritable bowel syndrome

Irritable Bowel Syndrome

Dr Max Groome

Consultant Gastroenterologist

Ninewells Hospital, Dundee

irritable bowel outline
Irritable Bowel: Outline
  • What is the best way to identify IBS patients?
  • What are the minimum number of relevant Ix?
  • What is the best management?
ibs background
IBS: Background
  • Chronic, relapsing problem

Abdo pain

Bloating

Change in bowel habit

  • 10-20% population
  • Peaks in 30’s – 40’s
  • Females >males (2:1)
pathophysiology of ibs
Pathophysiology of IBS
  • Genes + Environment
  • Disturbed GI motility; high-amplitude propagating contractions - exaggerated gastro-colic reflex, pain
  • Visceral hypersensitivity
visceral hypersensitivity
Visceral hypersensitivity

Seen in 2/3 patients (gut distension studies)

Mechanisms

  • Peripheral sensitisation:

Inflammatory mediators up-regulate sensitivity of nociceptor terminals

  • Central sensitisation:

Increased sensitivity of spinal neurones

evidence of hypersensitivity
Evidence of hypersensitivity?
  • Peripheral:

Up to 20% recall onset after infectious gastroenteritis

  • Central:

Increased pain radiation to somatic structures eg fibromyalgia

rome iii criteria
Rome III criteria
  • Recurrent abdo pain/discomfort for at least 3 days per month for 3 months

+ 2 or more of:

  • Improvement with defecation
  • Onset assoc. with ∆ stool frequency
  • Onset assoc. with ∆ stool form (appearance)
additional clues
Additional clues...
  • Bloating
  • Urgency
  • Sensation of incomplete emptying
  • Mucus per rectum
  • Nocturia (and poor sleep)
  • Aggravated by stress
association with other illnesses
Association with other illnesses
  • Fibromyalgia
  • Chronic fatigue syndrome
  • Temporomandibular joint dysfunction
  • Chronic pelvic pain

Overlap cases likely to have more severe IBS, psychiatric problems

psychological features
Psychological features
  • At least 50% are depressed/anxious/hypochondriacal
  • In tertiary centres, 2/3 have depression/anxiety
history
History
  • A good history will make the diagnosis:

Bowel habit

Bloating, nocturia

Diet (bread, fibre, meal times, bizarre exclusions)

Trigger factors (infection, menstruation, drugs)

Opiate use (codeine and Opiate/Narcotic bowel syndrome)

Psychosocial factors (stress)

Underlying fears (‘cancer’)

alarm features
Alarm features
  • Age > 50
  • Short duration of symptoms
  • Woken from sleep by altered bowel habit
  • Rectal bleeding
  • Weight loss
  • Anaemia
  • FH of colorectal cancer
  • Recent antibiotics
investigations
Investigations
  • FBC
  • ESR / plasma viscosity
  • CRP
  • Antibody testing for coeliac disease (TTG)
  • Lower GI tests if aged >50 or strong FH of CRC
treatment of ibs
Treatment of IBS
  • Diet

Regular meal times

Reduce fibre

  • Drugs:

Stop opiate analgesia

anti-diarrhoeals

Anti-spasmodics

Anti-depressants

fibre and ibs
Fibre and IBS
  • NICE guidance 2008:

Evidence for ‘weak’ , ‘inconclusive’, ‘may be detrimental’

Suggest:

‘review fibre intake, adjusting (usually reducing) while monitoring symptoms. If fibre is necessary – suggest oats’

stop opiates
Stop opiates

With prolonged use can lead to ‘opiate/narcotic bowel syndrome’:

  • Worsening pain control despite escalating dose
  • Reliance on opiates
  • Progression of frequency, duration and intensity of pain
  • No GI explanation for pain
anti spasmodics mebeverine hyoscine
Anti-spasmodics (Mebeverine, Hyoscine)

Poor quality studies

Metanalysis:*

Global benefit vs placebo (NNT 5.5)

Relief of pain vs placebo (NNT 8.8)

No benefit for diarrhoea / constipation

*Poynard T Alimentary Pharm & Ther 2001

laxatives
Laxatives
  • Fibre aggravates pain
  • Stimulant laxatives eg Senna not a long-term solution (tachyphylaxis)
  • Lactulose promotes flatulence
  • PEG-based laxatives > lactulose*

*Attar A Gut 1999

anti diarrhoeals
Anti-diarrhoeals
  • Loperamide (tablets or syrup)

Opiate analogue

inhibits peristalsis, gut secretions

Benefits diarrhoea. No effect on pain.

No dependency

Use PRN / prophylactic

Cann P 1984 Dig Dis Sci.

anti depressants
Anti-depressants

Tricyclics eg Amitriptyline

  • Reduce diarrhoea
  • Reduce afferent signals from gut (‘central analgesics’)
  • Helps restore sleep pattern
  • Fits with ‘neuroplasticity’ theories:

Loss of cortical neurones in psychiatric trauma

Brain-derived neurotrophic factor increases with Rx (pre-cursor of neurogenesis)

  • Low dose 10 – 75mg @ night (NNT 5.2)*

Side effects limit use (NNH 22)

*Drossman DA 2003 Gastroenterology

psychological treatment
Psychological treatment
  • If severe anxiety / depression
  • If no response to empiric anti-depressants

Options:

Relaxation therapy

Cognitive Behavioural therapy

Hypnosis

(moderate efficacy)

irritable bowel conclusions
Irritable Bowel: Conclusions
  • What is the best way to identify IBS patients?
  • What are the minimum number of relevant Ix?
  • What is the best management?
what does the patient want
What does the patient want?
  • Support and understanding
  • Clear explanation that IBS is an illness
  • Symptoms can be controlled by the patient
  • There is no miracle cure
  • There will be good days and bad
  • Explanation of treatment options

BSG IBS Guidelines 2007

summary of management
Summary of management
  • Careful history
  • Positive diagnosis of IBS
  • Simple management plan:

Diet

Symptom relief:

Loperamide / movicol / anti-spasmodic

Amitriptyline

further reading
Further reading
  • BSG IBS Guidelines 2007
  • NICE IBS Guidance 2008
  • AGA technical review 2002