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IRRITABLE BOWEL SYDNROME

IRRITABLE BOWEL SYDNROME. Provash C. Ganguli MBBS, FRCPE, FRCPC Clinical Professor of Medicine University of Saskatchewan Saskatoon, SK. IBS - Plan of Presentation. Today I will talk about the:

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IRRITABLE BOWEL SYDNROME

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  1. IRRITABLE BOWEL SYDNROME Provash C. Ganguli MBBS, FRCPE, FRCPC Clinical Professor of Medicine University of Saskatchewan Saskatoon, SK

  2. IBS - Plan of Presentation Today I will talk about the: Definition, epidemiology, pathophysiology, clinical features, differential diagnosis, investigations and clinical trial data on various treatments and end with a practical approach to management for IBS

  3. 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

  4. 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 1AGA Patient Care Committee Gastroenterology 1997;112:2120-2137 2 Adapted from Camilleri and Choi et al., Aliment Pharmacol Ther 1997; 11: 3 3Kim and Camilleri et al., Am J Gastroenterol 2000; 95(10): 2698

  5. FRAP in childhood may herald IBS in adulthood 6-22% of the NA 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

  6. 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 Patient’s opinion re: cause of symptoms Drossman etal (1992)Dig Dis Sci 38:1569 Taltey etal (1997) Gut 41:394

  7. Impact on Society - 1 Visits to the doctor: 12% primary care 28% gastroenterologist Mitchell & Drossman (1987) Gastroent.92:1282 Health care costs: Twice that of an asymptomatic person More appendectomies, cholecystectomies and hysterectomies in those with IBS

  8. Impairment of QOL: worse than in patients with DM or CRF Gralneck etal (2000) Gastroent 119:654 Time off work: 3 times more often than that for an asymptomatic person Restriction of activities: by 145 days per year Creed etal (2001) Ann Int Med 134:860 Impact on Society - 2

  9. 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

  10. 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

  11. 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.

  12. 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 Hahn etal (1978) Dig Dis Sci 43:2715

  13. 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

  14. 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

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

  16. Other Associations Increased risk of PUD, HBP, sicca syndrome & vague rashes Triad of IBS, GERD & Asthma is 3-times more frequent than expected Kennedy etal (1998) Gut 43:770 Fass etal (1998) Digestion 59:79 Sperker etal (1999) Amer J Gast 94:3541

  17. 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

  18. Differential Diagnosis Dietary – e.g. lactose intolerance, Xs 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

  19. 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”

  20. 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 Tolliver etal (1994) Amer J Gast 89:176

  21. 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

  22. Diagnosis - 4 Two multicentre trials have found the following associations: Lactose Intolerance 23% “Structural abnormality” 2% Abnormal thyroid tests 6% Stools O&P 2% Hamm etal (1999) Amer J Gast 94:1279

  23. 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

  24. 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

  25. Placebo-Response Rate in GI Clinical Trials Placebo Author Drug Response (%) Piai Prifinium 50 Milo Domperidone 34 Page Dicyclomine54 Heefner Desipramine60 Myren Trimipramine 67 Longstreth Psyllium 40 Fielding Timolol59 Fielding Trimebutine58

  26. Ganguli 2003 Meta-Analysis of Antidepressants in IBS JL Jackson Am J Med 2000;108:65-72

  27. Ganguli 2003 Dicetel and Colonic Transit in IBS-D Colonic Transit time (Hrs) RCT of 91 pts with IBS-D randomized to a) Dicetel 50 mg TID \ x 2 wks b) Mebeverine 100 mg TID / Improvement in global well being in both groups of patients (73% and 72% respectively) Meta-analyses has shown Dicetel OR of global improvement of 2.15 with NNT =6, P<0.05 P<0.01 J Gast and Hepatol 2000;15:925-30 J Jailwala An Int Med 2000;133:136-147

  28. Ganguli 2003 Treatment of IBS-Diarrhea A recent systematic review found that 4 of 4 studies of loperamide (Imodium) showed an improvement in diarrhea, and 2 of 2 showed global improvement. One trail had enough data to calculate ARR of 0.28 for global improvement yielding a NNT of 3.6 J Jailwala An Int Med 2000;133:136-147

  29. 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 DIARRHEA Loperamide Cholestyramine 5-HT3 antagonists CONSTIPATION Fibres Osmotic agents 5-HT4 agonists Prokinetics Dr. Marc Bradette

  30. Ganguli 2003 Evidence-Based Position Statement on Management of IBS Summary (Grades of Evidence) 1) IBS defined by abdominal discomfort plus altered bowel habits (C) 2) IBS significantly decrease quality of life (QOL) of most patients seeking care (C). 3) Treatment indicated when patient & physician believe QOL is diminished (C) 4) IBS therapies should improve global symptoms including discomfort, bloating, and altered bowel habits (C). Am J Gastro 2002;97:S1-S5

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

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