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IBS

IBS . Dr. Matt W. Johnson BSc MBBS MRCP MD. L&D. Graham Holland’s ‘the optimism and the frustration of living in a metropolis’. IBS is a Diagnosis of Exclusion ......or is it ? If in doubt go see your local Shamen……..occasionally they come to see you.

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IBS

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  1. IBS Dr. Matt W. Johnson BSc MBBS MRCP MD

  2. L&D

  3. Graham Holland’s ‘the optimism and the frustration of living in a metropolis’

  4. IBS is a Diagnosis of Exclusion......or is it ?If in doubt go see your local Shamen……..occasionally they come to see you

  5. British Society of Gastroenterology Guidelines 2000

  6. IBS • 9-12% of adult population • 40-60% of all Gastro OPA referrals • 1M : 2.5F • Aetiology • Psychological (Increased incidence of Psych Hx) • Stress (ppt in 50%) • Post infective(ppt in 10-20%) • Consulting behaviour / Abnormal illness behaviour • Gut motility(no consistent evidence) • Visceral hypersensitivity • Diet (lactose + wheat intolerance)

  7. IBS • Rome Criteria 3 • 3m of Abdominal Pain / Discomfort • Associated with 2 of 3 • Altered frequency • Altered consistency • Improves with defaecation

  8. IBS - Associated symptoms • Tiredness / lethargy • Poor sleep • Backpain • Fybromyalgia • Urinary urgency and frequency • Dysguesia - Unpleasant taste in mouth

  9. IBS - Investigation • FBC + ESR (1%) • TFT (6%) • Coeliac (2-15%) • Ca + Albumin • Stool MCS + COP • Faecal elastase • US (incidental gallstones and fibroids 8%) • Lactose intolerance testing (21-25%) • Flexible sig / BaEnema / Colonoscopy • SeHCAT scan - Bile acid malabsorption (8%)

  10. Gastro Psychiatrist

  11. IBS Management • Positive diagnosis • Listen • Lifestyle advice • Placebo (50%) • Dietary advice • (exclude lactulose, wheat, caffeine, CHO) • Psychological therapies • Diagnosis + Psych referral • Relaxation, Biofeedback, Hypnotherapy, Cognitive behavioural, Psychotherapy • Pharmacological Rx • PTO

  12. Give me a Gastro patient that doesn’t fit these criteria ! • Pancreatic Ca, Crohn’s stricture, Colonic Ca • Rome Criteria 3 - Surely we can all relate personally to these 3m of Abdominal Pain / Discomfort Associated with 2 of 3 • Altered frequency • Altered consistency • Improves with defaecation • But what about “bloaty” woman, I hear you cry ?????

  13. Warning - Before you diagnose someone with IBS - be aware • Ford AC. ArchIntMed 2009 • 4.1% of all IBS = Coeliac disease • Garcia-Rodriguez LA. ScanJGastro. 2000: 35; 306 • IBS patients have a 6x risk of Ca in 1st year • IBS patients after 5y have >20x risk of CrD • Hamilton W. BMJ. 2009: 339 • 2.5% Ovarian Ca present with bloating

  14. IBS Facts • Google = 6.5 million entries for IBS • Heaton. GUT. 1992 • Only 58% of normal pop conformed to producing normal stool on Bristol Stool Chart • Piessevaux. DDW. 2009 • 80% of Belgiums have lower GI symptoms • 10% reach IBS criteria

  15. New IBS referralWhat does it mean to me? • Could be anything gastroenterological, that hasn’t yet been given a label

  16. IBS - Is there better terminology to explain what we mean? • Non-organic disorder or • Functional bowel symptoms (FBS) • My preference

  17. The Secret of Treating IBS / Functional Bowel Syndrome “Don’t treat the symptoms - Treat the root cause”

  18. Functional Bowel Syndrome What are the main symptoms • 1) Chronic Diarrhoea (rare) • 2) Classic Constipation • 3) Constipation Cycle Functional Bowel Syndrome (C-IBS) • Diverticulosis, Coeliac • Right sided faecal loading • 4) Pain • Faecal loading (Left Vs Right or Pan-colonic) • Bloating / Aerophagia • 5) Bloating

  19. 1) Chronic Diarrhoea

  20. Probably not the healthiest curry house in town 21

  21. D-IBS > 3x/d • Fernandez-Banares F. AmJGastro. 2007: 102; 2520 • 62 Colonoscopy -ive patients • 82% had an underlying diagnosis • Coeliac + sb Crohn’s • Lactose + Fructose intolerance • Small bowel bacterial overgrowth • Bile acid malabsorption • Pancreatic insufficiency • 18% had functional IBS (?psych / PI-IBS)

  22. Post-Infectious IBS • Meta-analysis = 5-10% develop PI-IBS • Halvarson AmJG. 2006; 101: 1994 • Campylobacter - 27% • Parry S. AmJGastro 2003:98;1970 • Salmonella - 18% • Mearin F. Gastro. 2005: 129; 98 • E.coli - (63% with ETEC/EATC) 18% of these suffered IBS after 6m • Okhuysen PC AmJGastro. 2004:99;1774

  23. Chronic Diarrhoea • All patients need to be actively investigated • All patients should be referred to a gastroenterologist • NB- IBS symptoms can still be experienced in patients with organic disease • 60% of UC patients • 39% of CrD patients • Keohane J. AmJGastro. 2010: 105; 1788

  24. 2) Left sided Constipation • 1) LIF pain (exclude DD) • 2) Reduced frequency • 3) Harder consistency with Straining +/- Haemorrhoids or Fissure • Mx • 1) Increase fluid intake >2L/day • 2) High fibre diet (not if DD present) • 3) Laxatives • 4) Stimulants

  25. Some slides have be borrowed with kind regards to;- Dr. Anton Emmanuel of and also to the SHIRE Team and the Advanced Constipation Training Course Date of preparation: September 2011 UK/BU/RES/11/0051n

  26. 3) Constipation cycle functional bowel syndrome- Proximal / Right sided faecal loading • 1) Altered bowel habits = Hard pellets + episodic loose • 2) Bloating / Flatulence / Borborygmi • 3) Sense on incomplete emptying • 4) Straining +/- Haemorrhoids • Mx • 1) Increase fluid intake >2L/day • 2) Low residue (high soluble fibre) diet • 3) Osmotic agents (Movicol) +/- Laxatives • 4) Stimulants +/- 5HT4 agonists (Prucalopride)

  27. Right sided faecal loading

  28. 4) Abdominal Pain

  29. Abdominal Pain • a) Faecal Loading • Left sided • Right sided • Pan-colonic • b) Diverticulosis • c) Bloating • Aerophagia

  30. Bloating

  31. 3 Main Causes • 1) Air swallowed = Aerophagia • 2) Gas production = SBBO • 3) Air trapped = Faecal Loading • Mx • 1) Awareness / Exercise / Positional deflation /Anti-anxiety agents • 2) H2 Lactulose breath test + Abs • 3) Rx to soften and shift the bowel

  32. Aerophagia

  33. One remedy

  34. Low FODMAP Diet • FODMAPs = • Fermentable Oligo-, Di-, and Mono-saccharides, And Polyols. • Typical symptoms would include • abdominal bloating • excessive gas • chronic diarrhea or constipation • Strict FODMAP avoidance

  35. Low FODMAP Diet

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