FGIDs

3. FGIDs Dr. Mohammad Hassan Emami 15.12.1387 Tehran, IAGH

4. 28adult and 17 pediatric FGIDs are described in ROME III. • These are symptom-based diagnostic criteria that are not explained by other pathologically based disorders. • In recent years, however, histological findings have been identified that blur the distinction between “functional” and “organic. The Functional Gastrointestinal Disorders and the Rome III Process. DOUGLAS A. DROSSMAN, Guest Editor. GASTROENTEROLOGY 2006;130:1377–1390.

6. Rome III Functional Gastrointestinal Disorders of adults

7. Rome III Functional Gastrointestinal Disorders of pediatrics

8. IBS In Rome III FGID

9. Irritable Bowel Syndrome • Irritable bowel syndrome (IBS) tends to be an umbrella term for a variety of minor bowel disturbances of unknown origin • Sometimes called: • “irritable colon” • “spastic colon” • “Psychogenic colitis”

10. Symptoms of IBS • Symptoms include: • Change in bowel habit • often alternating constipation and diarrhea • Abdominal bloating and distension • Sometimes abdominal pain, frequently relieved by defecation ( rarely provoked with defecation) • Feeling of incomplete defecation

11. IBSCharacteristics • There is usually no sign of structural damage to the wall of the intestine (frequently indicated by blood in the stool) • No Alarming signs • All organic disease should be ruled out by appropriate medical tests • The Manning Criteria or the Rome II or Rome III questionnaires are often used for diagnosis

12. Rome II Criteria • 12 or more weeks of continuous or recurrent abdominal pain or discomfort with a duration of the disease for at least 12 months. • Plus at least two of the following: 1) relieved by defecation 2) associated with altered stool frequency 3) associated with altered stool form

13. Rome II Criteria Symptoms that cumulatively support the diagnosis of IBS : 1. Abnormal stool frequency ( >3 bowel movements/d or <3 bowel movements/wks) 2. Abnormal stool form (lumpy and hard or loose and watery) 3. Abnormal stool passage (straining, urgency, or feeling of incomplete evacuation) 4. Passage of mucus 5. Bloating or feeling of abdominal distension

14. Revised Rome III diagnostic criteria include the following: • Recurrent abd pain or discomfort at least 3 days per month in the last 3 months with a duration of the disease for at least 6 months;associated with 2 or more of the following: • -improvement with defecation • -Onset associated with a change in stool frequency • -Onset associated with a change in stool form

17. Population prevalence of IBS depending on the different Rome IBS definitions • According to Paul Enck’s investigations, the manning criteria were unable to distinguish between IBS and lactose malabsorption • Their sensitivity and specificity were around 67% and 70%, respectively, in one study it varied substantially between genders • The population prevalence of IBS varied between 5% and 25%, depending on the different Rome IBS definitions • Paul Enck’s. Irritable bowel syndrome: A single gastrointestinal disease or a general somatoform disorder? Journal of Psychosomatic Research 64 (2008) 561–565

18. Are IBS patients in primary care compatible with the definitions of Manning and Rome II criteria? • Of all patients (n=148) who matched the primary care definition of IBS, only 62% and 18% fulfilled the Manning and Rome II criteria, respectively, according to a Dutch investigation. Paul Enck’s. Irritable bowel syndrome: A single gastrointestinal disease or a general somatoform disorder? Journal of Psychosomatic Research 64 (2008) 561–565

19. IBS: Is not a single gastrointestinal disease, It is a general somatoform disorder • Most important step in the diagnosis is to listen, review symptoms in detail recognizing the key feature being the presence of abdominal pain or discomfort associated with bowel dysfunction and to detect alarming signs; • Separates IBS from functional constipation, functional diarrhea & FAPS Paul Enck’s. Irritable bowel syndrome: A single gastrointestinal disease or a general somatoform disorder? Journal of Psychosomatic Research 64 (2008) 561–565

20. IBS: A syndrome or many diseases? • Family studies provide strong evidence for a clustering of FGID in families & twin. This points towards the role of one or more hereditary factors. • Considering sensory and motor functionas well as the psychiatric comorbidity, polymorphisms of adrenergic, opioidergic or serotonergic receptors as well as G-protein b3 (GNB3) subunit gene polymorphism and polymorphisms of 5-HT transporter genes are suitable mechanisms for these abnormalities. • Hence acute GI infections with a mucosal inflammation appear to trigger a cascade of events that ultimately results in the manifestation of FGID, it is reasonable to assume that functionally relevant polymorphisms of genes with immunmodulating and/or neuromodulating features (OPRM1, IL-4, IL-4R, TNFa) play a role. • Bacterial Flora of the colon may play a role in IBS. Gerald Holtmann. IBS: A syndrome or many diseases? Best Practice & Research Clinical Gastroenterology Vol. 18, No. S, pp. 91–97, 2004

21. IBS: A syndrome or many diseases? • it is reasonable to anticipate that IBS will be dissected accordingly and our disease concepts will accept the irritable bowel syndrome as the clinical manifestation of a number of different disorders. Gerald Holtmann. IBS: A syndrome or many diseases? Best Practice & Research Clinical Gastroenterology Vol. 18, No. S, pp. 91–97, 2004

23. IBS Subtypes • IBS can be subdivided into: • Diarrhea-predominant (IBS-D) • Constipation-predominant (IBS-C) • Alternating diarrhea and constipation (IBS-MCD) • Pain-predominant (Unspecified functional bowel disorder; FAPS)

24. Clinical Presentation • Higher prevalence in Western societies • Many severe cases seen in Iranian LOR population* • Rarely ( if any ) cases seen in AFGANs* • Most prevalent digestive disease ( in West ) • Most present before age 45, although may begin in elderly • Women 2-3 times than men • 80% of severe cases of IBS are women

25. Clinical Presentation The predominant symptom is abdominal pain or discomfort accompanied by a change in stool frequency or consistency. • Abdominal pain: generalized or localized, usually in the lower abdomen, relieved by defecation (or flatus passage), exacerbated by stress, food, alcohol; no progressive deterioration • Altered bowel habits: the most common pattern is constipation alternating with diarrhea

26. Clinical Presentation • GI symptoms: bloating, distension, increased belching and flatulence, mucus in the stool • Upper GI symptoms (25-50%): dyspepsia, heartburn, nausea and vomiting • Extra intestinal symptoms: urinary frequency and urgency, sexual dysfunction, dyspareunia, menstrual difficulties, low back pain, headaches, chronic fatigue, insomnia……tend to increase in number with the severity IBS

27. Diagnostic strategy • Careful search for biological diseases and Red Flags • Careful search for psychosocial factors, stress, physical and sexual abuse • Establishing effective physician patient relationship • Sizing up the patient’s agenda

28. Abuse When pelvic pain is a predominant symptom, that's a huge red flag for a potential abuse history.

29. Red Flags • Anemia • Rectal bleeding • Heme-positive stools • Weight loss ( >3 kg) • Fever • New or recent onset in patient older than 50 years • Nocturnal symptoms • Persistent diarrhea or severe constipation • Family history of colon cancer, IBD, or celiac disease • Palpable abdominal or rectal mass • Recent antibiotic use

30. Why this patient referred now? • Always ask, “What is your concern?” • Explore further if necessary. • Possible reasons: • They may think that their diagnosis was missed. • May fear that they have an ominous disease. • The patient just wants her symptoms to be addressed more effectively. • Other times it’s a quality-of-life issue, where her symptoms are well controlled but she doesn’t like taking all these medicines. • It may be a psychological issue—the patient’s bowels are doing okay but she’s phobic about losing control

31. Fear Of Cancer • Many patients with abdominal pain and a change in bowel habits may think they have cancer and want to ask you about it. • Ask up front, “Are you concerned that you have cancer?” • You can see the relief on their face, because they want to make sure you’re thinking about that. • Then tell them “Frankly, this is not a sign of cancer; here’s what we look for when we think about cancer, and this is not that.” • Once you allay that fear, you create a much better landscape for proceeding.

32. Patient’s agenda • Will this Dr tell me what is wrong with me? • I have been told there is nothing wrong but I have symptoms • How can I control this symptom which has compromised my life? • Will I be told once again it is all in my head?

33. Patient’s agenda • Will the same uncomfortable tests be done again? • Will this physician also fail to diagnose the colitis, cancer,diverticulitis,adhesion that all other have missed? • Will this physician spend enough time and help me to change my life?

34. Physician’s agenda • Here is another IBS patient that I can not satisfy him anyway! • What has been done before ? • What might have been missed (Occult cancer ,CD ,Malabsorption)? • It is best just to do everything again!!!

35. Diagnostic Testing • CBC • Serum e- • ESR • TSH • Stool routine • < 50 y/o : consider flexible sigmoidoscopy • > 50 y/o : colonoscopy or air-contrast barium enema • EGD or UGI series • Ultrasound • Anti t-TG Ab ( IgA, IgG ) • In Cases with Severe or persistent Diarrhea ( or too much gas ): • Malabsorption screen (fecal fat, serum B12 , red cell folate, plasma ferritin, serologic tests for celiac sprue) • Especial S/E s (Stool cultures, Clostridium difficile toxin, ova and parasites, etc.) • Lactose and fructose tolerance test • In cases with Constipation , severe rectal urgency or fecal incontinence: • Colonic transit study • Anorectal function tests (e.g., manometry and electrophysiology) • Endoanal ultrasonography

38. Differential Diagnosis • Epigastric or periumbilical pain: biliary tract disease, peptic ulcer disease, intestinal ischemia, carcinoma of the stomach and pancreas, IHD • Lower abdomen pain: diverticular disease, inflammatory bowel disease, carcinoma of the colon, PID, Cyst ( or cyst rupture ), etc • Postprandial pain + bloating, nausea, vomiting: gastroparesis, partial intestinal obstruction, Giardia lamblia or other parasites, Crohn’s disease, Celiac disease • Diarrhea:lactase deficiency, laxative abuse, malabsorption, hyperthyroidism, inflammatory bowel disease, infectious diarrhea, Celiac disease , adenomatous polyp or colon CA • Constipation:drugs( anticholinergic, antihypertensive, antidepressant), hypothyroidism, hypoparathyroidism, acute intermittent porphyria, lead poisoning , colon CA

40. CASE 1 • A 20 years old lady presents with on & off abdominal pain, relieved by defecation from one year ago. • She has periods of loose stool which is simultaneous with periods of abdominal pain. • The frequency of symptoms are at least of once a week and in some periods daily during past 3 months. • She has no alarming sign, no positive familial history • Normal Ph. Exam • Normal CBC, ESR, CRP, TSH and anti t-Tg (IgA)

41. 1-Having this History and lab data what other investigation do you recommend? • Total colonoscopy • Sigmoidoscopy • Small bowel series • Abdominopelvic CT scan e) Non of the above

42. 2-which one of the IBS criteria is matched for this case? • Manning criteria • ROME criteria II • ROME criteria III d)All of the above

43. Case 2 • A 65 years old leady suffers from persistent generalized abdominal pain from 20 years ago. The pain is not related to diet intake or defecation but is usually during the day and rarely awakes her from sleep. • She does not have alarming sign but her regular activity and life is severely disturbed.

44. She asked repeatedly to do a diagnostic laparotomy. • She has had repeated visits. Hospital admission and extensive workups such as endoscopy, colonoscopy, small bowel barium study, abdominopelvic CT & Ultrasonogeraphy, CBC, Electrolytes, TSH, IgA anti t-TG, ESR, CRP, stool/exam, FBS were done.

45. She does not have any significant bowel habit change or deficatoryproblem. • PH.E: Abdominal pain in deep palpation, especially in both flanks. • No other remarkable findings.

46. According to this history please answer the fallowing questions. 1-what other evaluation is required? • Diagnostic laparoscopy • Genetic study for FMF • Urine pb • Protoporphirinmeasurement e) Non of the above

47. According to the ROME III classification which disorder can be labeled to this Patient? • A) IBS • B) Functional abdominal pain symdrome • C) Unspecified Functional bowel disorder • D) Functional Dyspepsia

48. Thank you