Management of Irritable Bowel Syndrome (IBS) in Family Medicine Meera Kaur, PhD, RD, CDE

1. Management of Irritable Bowel Syndrome (IBS) in Family Medicine Meera Kaur, PhD, RD, CDE Assistant Professor, Family Medicine University of Manitoba, Canada http://home.cc.umanitoba.ca/~kaur/

2. What is IBS? IBS is defined as “abdominal pain or discomfort that occurs in association with altered bowel habits over a periods of at least three months.” 1 • Probably the most challenging of all functional GI disorders • 7-10% people worldwide have IBS • Prevalence in N. America is 3-20% with an average range of 10-15% • Peaks in the 3rd and 4th decades of life and declines in 6th and 7th decades • Patients with IBS consumes 50%more health care resources than those without it. 1 Brandt et al., Am. J.Gastro, 2009;104:SI-S-35 2

3. Pathophysiology • IBS is characterized by changes in motility in response to environmental or enteric stimuli • Visceral hypersensitivity is well documented in IBS patients • Serotonin, which has both motility and sensory modulating properties, could represent a common factor linking the symptoms of IBS • Mucosal inflammatory process 3

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5. Symptoms • Loose stool • Constipation • Alternating Diarrhea and Constipation • Urges to move bowel again immediately following a bowel movement • Mucus in stool 5

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7. Subtypes • Diarrhoea predominant (IBS-D) • Constipation predominant (IBS-C) • Pain predominant (IBS-P) 7

8. Diagnosis…. • Approach: Before doing any test… • Gain the confidence of the patient at the first consultation, let them talk and just listen • Remain aware that some IBS patients have a hidden agenda • Do not say to the patient what some FPs say, namely, “I don’t know what is wrong with you.” • Do not say what some Specialists say, namely: “There is nothing wrong with you” or “it is in your head.” 8

9. Diagnosis…. • Approach: Before doing any test • Get all the test reports from the other MDs files and • Show & discuss those test results with the patient • In those below 55 yrs. and in the absence of “alarm symptoms”, if “routine” blood tests + ESR/CRP are normal, diagnosis of IBS has: - 83% sensitivity - 97% specificity - 100% PPV Therefore, please consider doing these tests Tolliver et al (1994) Amer J Gast 89:176 9

10. Diagnostic Criteria • Manning • Kruls • Rome J Jailwala An Int Med 2000;133:136-147 10

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13. Differential Diagnoses • Dietary – e.g. lactose intolerance, ↑ caffeine etc. • Infections – Giardia, Bacterial Overgrowth Syndrome • Inflammatory Bowel Disease – UC, CD, • Microscopic Colitis • Malabsorption syndrome – Celiac Disease • Pancreatic Insufficiency • Psychological – Depression Anxiety, Somatization • Other - Neuroses 13

14. “Red Flags’” - Alarm Symptoms/Signs • Onset after 55 years • Persistent anorexia & weight loss > 10 lbs • Persistent “fever” in the evening • Pain – changing pattern or increasing after food and persisting for a few hours • Awakened by pain &/or diarrhea at night • Rectal bleeding, not just on wiping • Stools “like malabsorption syndrome” • P/E: palpable mass in the abdomen 14

15. Diagnosis Summary • IBS remains a clinical diagnosis • In those below 55 years and in the absence of alarm symptoms, Rome II Criteria (Clinical) has: - Sensitivity → 65% - Specificity → 100% • PPV → 100% Vanner et al (1999) Amer J Gast 94:2912 1 5

16. Traditional therapies focused on individual symptoms of IBS with constipation Bloating and distention • Dietary modifications • Antispasmodics • Antiflatulants • Digestive enzymes • Antibiotics Bloating /distention Abdominal pain / discomfort • Antispasmodics • Tricyclics • Analgesics Abdominal pain /discomfort Constipation or Diarrhea Irregular Bowel Habit • Fiber • Laxatives • Imodium • None of these medications effectively treat the multiple symptoms of IBS. May exacerbate individual symptoms e.g., fiber and bloating; antispasmodics and constipation 16

17. IBS: Symptomatic Therapy Smooth muscle relaxants 5-HT agonists/antagonists Antiflatulents Smooth muscle relaxants 5-HT agonists/antagonists TCAs, SSRIs Abdominal pain/discomfort Bloating Altered bowel function CONSTIPATION Fibres Osmotic agents 5-HT4 agonists Prokinetics DIARRHEA Loperamide Cholestyramine 5-HT3 antagonists 17

18. Alternative/Complementary Approach • Herbal • Peppermint oil capsule • Turmeric Extract • Artichoke leaf Extract 2. Mind-Body Therapies • Hypnotherapy • Cognitive-behavioral Therapy (CBT) • Relaxation Technique • Acupuncture and Moxibustion • Diet, lifestyle • Probiotics Yoon et al, Altern Med Rev, 2011; 16(2): 134-151 18

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20. Evidence-Based Position Statement on Management of IBS • Summary (Grades of Evidence) • IBS defined by abdominal discomfort plus altered bowel habits (C) • IBS significantly decrease quality of life (QOL) of most patients seeking care (C) • Treatment indicated when patient & physician believe QOL is diminished (C) • IBS therapies should improve global symptoms including discomfort, bloating, and altered bowel habits (C) Am J Gastro 2002; 97:S1-S5 20

21. Management - Summary • Lifestyle (poor data) • Diet (poor data) • Pain management (meta-analysis) • Antidiarrheals (db, pc trials) • Osmotic laxatives (poor data) • Psychotherapy (no good data) • Antidepressants (meta-analysis) • Probiotics (poor data) • Others - Alternative Medical Therapies (poor data) 21

22. Concluding Statements IBS is a benign condition without benign effects. We should keep an open mind while managing IBS. 22

23. References • Books • Journal articles published during 1990-2012 • International, National and Provincial governments’ relevant websites • Regulatory organizations’ websites and reports • Other relevant organizations’ publications/reports • Evidence-based Guidelines References are available on request 23

24. Questions? 24