Irritable Bowel Syndrome (IBS)

1. Irritable Bowel Syndrome (IBS) Chapter 43

2. Description of IBS • Common chronic functional disorder • Characterized by intermittent abdominal pain or discomfort and stool pattern irregularities • Symptoms may occur for years • More frequent diagnosis in women

3. Clinical Manifestations • GI symptoms • Abdominal pain • Diarrhea or constipation • Abdominal distention • Excessive flatulence • Bloating • Urgency • Sensation of incomplete evacuation

4. Clinical Manifestations • Non-GI symptoms • Fatigue • Sleep disturbances

5. Psychosocial Factors in IBS • Psychologic stressors associated with development and exacerbation of IBS • Common in patients with IBS • Anxiety, panic disorder • Depression • Posttraumatic stress disorder • Abuse history

6. Psychosocial Factors in IBS • Stress can exacerbate stress symptoms • May influence health care–seeking behavior

7. Case Study • D.V. is a 31-year-old woman who presents to your clinic with abdominal pain, discomfort, and bloating. • She has had intermittent abdominal pain for approximately 6 months. • She often misses work, where she is an administrative assistant, because of her GI symptoms, as well as fatigue. Stockbyte/Thinkstock

8. Problems Not Associated with IBS • Anemia • Fever • Persistent diarrhea • Rectal bleeding • Severe constipation • Weight loss

9. Etiology and Pathophysiology • No organic cause is known • Patients often report history of GI infections and food intolerances • The role of food allergies is unclear • Other dietary factors such as fermentable saccharides and polyols may contribute to symptoms

10. Differential Diagnoses • Malabsorption • Gluten intolerance • Lactose intolerance • Dietary factors • Infection • Colorectal cancer • Inflammatory bowel disease

11. Differential Diagnoses • Endometriosis • Psychologic disorders • Gynecologic disorders • Peptic ulcer disease • Celiac disease

12. Case Study • D.V. eats irregularly and often in a hurry. • She is anxious about her symptoms and worried that she may have colon cancer because her grandmother died of cancer. Stockbyte/Thinkstock

13. Case Study • She has a very stressful lifestyle. • She denies any blood in stool or diarrhea. • There is no change in body weight, and appetite is good. Stockbyte/Thinkstock

14. Diagnostic Studies • No specific physical findings • Diagnosis determined by • Symptoms • Ruling out other conditions

15. Diagnostic Studies • Physical examination • Past health history • Psychosocial factors • Stress • Anxiety • Family history • Drug/diet history

16. Diagnostic Studies • Impact on activities of daily living • Determine if and how IBS symptoms interfere with • School • Work • Recreational activities

17. Diagnostic Studies • Symptom-based criteria for IBS have been standardized • Referred to as the Rome criteria III

18. Collaborative Care • Treatment is directed at • Psychologic factors • Dietary factors • Medications that • Regulate output • Reduce pain/discomfort

19. Collaborative Care • Patients do better with therapy if • They have a trusting relationship with the care provider • They have coping mechanisms • Symptoms are less severe/frequent

20. Collaborative Care • Encourage patient to verbalize concerns • Suggest patient keep a diary to help identify factors that trigger IBS • Symptoms • Diet • Episodes of stress

21. Case Study • D.V. states that abdominal pain and bloating are relieved by having a bowel movement. • She is often constipated, for which she takes laxatives. Stockbyte/Thinkstock

22. Case Study • On examination, bowel sounds are present. • Vital signs and WBC count are normal. Stockbyte/Thinkstock

23. Collaborative Care • Consider predominant symptom pattern • Diarrhea • Constipation • Pain

24. Collaborative Care • Gradually increase fiber intake • Aim for a minimum of 20 g/day • Use a stool bulking agent • Monitor tolerance to increased fiber • Suggest gradual changes to avoid bloating and abdominal discomfort due to gas

25. Nutritional Therapy • Eliminate gas-producing foods • Brown beans • Brussels sprouts, cabbage, cauliflower, raw onions • Grapes, plums, raisins

26. Nutritional Therapy • Eliminate fructose and sorbitol • Yogurt may be better tolerated than milk products • Probiotics may be used • Alterations in intestinal bacteria are believed to exacerbate symptoms

27. Case Study • What problems do D.V.’s history and symptoms suggest? • What important teaching topics should you discuss with her? Stockbyte/Thinkstock

28. Drug Therapy • Loperamide (Imodium) • Used to treat incidences of diarrhea • Synthetic opioid • Decreases intestinal transit

29. Drug Therapy • Alosetron (Lotronex) • Serotonergic antagonist • Used to treat severe pain and diarrhea • Available only in a restricted access program for women who have not responded to other IBS therapies, because of serious side effects: • Severe constipation • Ischemic colitis

30. Drug Therapy • Lubiprostone (Amitiza) • Approved for the treatment of women with IBS-related constipation • Linaclotide (Linzess) • Approved for the treatment of men and women with IBS-related constipation

31. Drug Therapy • Antidepressants • Low doses of tricyclic antidepressants seem to provide benefit • Possibly work by decreasing peripheral nerve sensitivity

32. Psychologic Therapies • Cognitive-behavioral therapy • Stress management techniques • Acupuncture • Hypnosis

33. Nonpharmacologic Treatments • Teaching and reassurance • Relaxation • Stress management techniques • Complementary and alternative therapies

34. Irritable Bowel Syndrome • No single therapy has been found to be effective for all patients with IBS

35. Case Study • What nutritional recommendation could you make to D.V.? • How should you address her concerns about cancer? Stockbyte/Thinkstock