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Irritable Bowel Syndrome

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

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  1. Irritable Bowel Syndrome Dr Max Groome Consultant Gastroenterologist Ninewells Hospital, Dundee

  2. 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?

  3. 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)

  4. Pathophysiology of IBS • Genes + Environment • Disturbed GI motility; high-amplitude propagating contractions - exaggerated gastro-colic reflex, pain • Visceral hypersensitivity

  5. Visceral pain sensation

  6. Descending inhibitory pathways

  7. 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

  8. Evidence of hypersensitivity? • Peripheral: Up to 20% recall onset after infectious gastroenteritis • Central: Increased pain radiation to somatic structures eg fibromyalgia

  9. 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)

  10. Additional clues... • Bloating • Urgency • Sensation of incomplete emptying • Mucus per rectum • Nocturia (and poor sleep) • Aggravated by stress

  11. Association with other illnesses • Fibromyalgia • Chronic fatigue syndrome • Temporomandibular joint dysfunction • Chronic pelvic pain Overlap cases likely to have more severe IBS, psychiatric problems

  12. Psychological features • At least 50% are depressed/anxious/hypochondriacal • In tertiary centres, 2/3 have depression/anxiety

  13. Irritable Bowel Concept

  14. What is best way to identify IBS patients?

  15. 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’)

  16. 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

  17. What are the minimum number of relevent investigations?

  18. Investigations • FBC • ESR / plasma viscosity • CRP • Antibody testing for coeliac disease (TTG) • Lower GI tests if aged >50 or strong FH of CRC

  19. What is the best management plan?

  20. Treatment of IBS • Diet Regular meal times Reduce fibre • Drugs: Stop opiate analgesia anti-diarrhoeals Anti-spasmodics Anti-depressants

  21. 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’

  22. 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

  23. 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

  24. 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

  25. 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.

  26. 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

  27. Psychological treatment • If severe anxiety / depression • If no response to empiric anti-depressants Options: Relaxation therapy Cognitive Behavioural therapy Hypnosis (moderate efficacy)

  28. 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?

  29. 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

  30. Summary of management • Careful history • Positive diagnosis of IBS • Simple management plan: Diet Symptom relief: Loperamide / movicol / anti-spasmodic Amitriptyline

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

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