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IRRITABLE BOWEL SYDNROME

IRRITABLE BOWEL SYDNROME. IBS - Definition. Altered bowel habit and/or Abdominal discomfort or pain No demonstrable organic disease As no marker exists for IBS, diagnosis is based on clinical features. Summary of H ypotheses on the Pathophysiology of IBS.

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IRRITABLE BOWEL SYDNROME

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  1. IRRITABLE BOWEL SYDNROME

  2. IBS - Definition Altered bowel habit and/or Abdominal discomfort or pain No demonstrable organic disease As no marker exists for IBS, diagnosis is based on clinical features

  3. Summary of Hypotheses on the Pathophysiology of IBS • IBS is characterized by changes in motility in response to environmental or enteric stimuli1 • Visceral hypersensitivity is well documented in IBS patients2 • Serotonin, which has both motility and sensory modulating properties, could represent a common factor linking the symptoms of IBS3

  4. 6-22% of the North America population have seen a physician for IBS symptoms Most cases diagnosed before age 45 but IBS is sometimes diagnosed in those above 65 years Women are 3 times more frequently affected than men Less common in Asians & Hispanic than Caucasians Epidemiology - 1

  5. Epidemiology - 2 6-22% of population report symptoms but only about 1/5 to 1/3 of these seek medical care Factors associated with physician consultations: Personality disorders or depression Long duration of symptoms

  6. Impact on Society - 1 Visits to the doctor: 12% primary care 28% gastroenterologist Health care costs: Twice that of an asymptomatic person More appendectomies, cholecystectomies and hysterectomies in those with IBS

  7. IBS: Current thinking on pathophysiology IBS – 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

  8. 5-HTreceptor effects IBS – Pathophysiology • Mediate reflexes controlling gastrointestinal motility and secretion • Mediate perception of visceral pain

  9. Impairment of QOL: worse than in patients with DM or CRF Time off work: 3 times more often than that for an asymptomatic person Restriction of activities: by 145 days per year Impact on Society - 2

  10. Symptoms for at least 12 weeks (which need not be consecutive), in the preceding 12 months: Abdominal pain or discomfort, which has 2 of the 3 following features: Rome II Criteria for Diagnosis

  11. Rome II Criteria - continued Pain relieved with defecation; or Altered bowel habit associated with a change in the frequency of stools; or Altered bowel habit associated with a change in the form(appearance) of the stools

  12. Rome II Criteria - continued Other symptoms that cumulatively support the diagnosis of IBS include the following: Abnormal stool frequency (>3BMx/d or <3BMs/wk) Abnormal stool form (lumpy and hard or loose and watery) Abnormal stool passage (straining, urgency, feeling of incomplete evacuation) Passage of mucus Bloating or feeling of distention.

  13. Frequency of Symptoms In 154 consecutative patients diagnosed as IBS in a GI unit, there was Abdominal discomfort or pain 33% of days Bloating 28% of days Altered stool form 25% of days Altered stool frequency 18% of days Passage of mucus 7% of days

  14. Abdominal Pain Intensity, location and characteristic of pain is highly variable epigastric 10% right side 20% left sided 20% hypogastric 25% too variable 25% Cramping or an ache Post-prandial worsening of pain for 1-3 hours Stress or emotional turmoil worsens condition Worse before and/or during menstruation

  15. Altered Bowel Habit Constipation-predominant –hard pellet-like stools, infrequent (<1/day) Diarrhea-predominant frequent loose stools post prandial urgency straining incomplete evacuation mucoid discharge – 50%, no blood

  16. Symptom Associations UGI – dyspepsia, heartburn, early satiety, nausea, all are more frequent in constipation- predominant IBS LGI – abdominal distention, bloating – more in women GUS – pelvic pain, dysmenorrhea, dyspareunia, urinary frequency, nocturia, incomplete bladder evacuation MSK – fibromyalgia, back pain, head & neck pain

  17. Other Associations Increased risk of PUD, HBP, sicca syndrome & vague rashes Triad of IBS, GERD & Asthma is 3-times more frequent than expected

  18. 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 ‘Red Flags’ - Alarm Symptoms/Signs

  19. Differential Diagnosis Dietary – e.g. lactose intolerance. Infections – Giardia, Bacterial Overgrowth Syndrome Inflammatory Bowel Disease – UC, CD Malabsorption syndrome – Celiac Disease, Pancreatic Insufficiency Psychological – Depression Anxiety Other - Neuroses

  20. Diagnosis - 1 Approach: before doing any tests: 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 3. Do not say to the patient what some FPs say, namely, “I don’t know what is wrong with you” 4. Do not say what some Specialists say, namely: “There is nothing wrong with you” or “it is in your head”

  21. Diagnosis - 2 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 do these tests

  22. Diagnosis - 3 I ask the patient; “which single GI disease do you think you may have?” and I do one test first to exclude that and review the patient after the test: In my experience: PainDiarrheaConstipation <50 yrs PUD, CD LI, MAS, “obstruction” >50 yrs GBD, CRC CRC are the commonest cause of anxiety for the patient

  23. Diagnosis - 4 Two multicentre trials have found the following associations: Lactose Intolerance 23% “Structural abnormality” 2% Abnormal thyroid tests 6% Stools O&P 2%

  24. 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% No diagnosis revision during 2 yr follow up Vanner etal (1999) Amer J Gast 94:2912

  25. Traditional therapies focused on individual symptoms of IBS with constipation • Abdominal pain / discomfort • Antispasmodics • Tricyclics • Analgesics Bloating and distention • Dietary modifications • Antispasmodics • Antiflatulants • Digestive enzymes • Antibiotics Abdominal pain /discomfort Bloating /distention 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

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