“Functional” Bowel Disorders

1. “Functional” Bowel Disorders Eamonn M M Quigley MD November 2010

2. “Functional” Bowel Disorders • Refer to disorders of gut function where there is no obvious abnormality of structure or morphology • Cause symptoms • Impair Quality of Life • Do NOT imply/equate to psychological/psychogenic!!

3. A Sub-Classification • Defined disorders of function; i.e. motility disorders • Putative disorders of function; “functional disorders”

4. Well-Defined Motility Disorders Symptoms Dysfunction Pathology Pathophysiology

5. Motility Disorders • Primary • Achalasia • Diffuse Oesophageal Spasm • Gastroparesis • Acute/Chronic Intestinal Pseudo-obstruction • Megacolon • Hirschsprung’s disease

6. Achalasia • Non-relaxing LOS • Drop-out of Inhibitory neurons (NO, VIP) • Aperistalsis in the oesophageal body • Causes: • Chagas’ disease • Pseudo-achalasia • Cancers • Idiopathic

8. Chagas’ Disease Symptoms Dysfunction Pathology Pathophysiology

9. Achalasia - Management • Muscle relaxants • Ca++ - blockers • Nitrates • Dilatation • Bougie; transient benefit only • Balloon forced dilatation • Surgery • Heller myotomy • Botox Ineffective

10. Diffuse Oesophageal Spasm • True idiopathic spasm rare; usually secondary to GORD • Non-cardiac chest pain • Treat: • Muscle relaxants • Dilatation • ? Surgery

11. Pseudoobstruction • Rare disorders resulting in diffuse motor dysfunction: • Oesophageal dysmotility • Gastroparesis • Small bowel pseudobstruction • Colonic pseudobstruction • Myopathy or Neuropathy • Congenital or Acquired • Primary or Secondary • Connective tissue diseases • Muscle disease • Neurologic disorders • Metabolic disorders e.g. Diabetes

12. Pseudoobstruction

13. Presents as acute or recurrent “obstruction”: • Small intestine • Colon • Acute e.g acute colonic pseudo- • obstruction (acute megacolon) • post-op (Ogilvie’s syndrome) • Chronic • results in intestinal failure • small intestinal bacterial overgrowth • inability to tolerate p.o. nutrition

14. Scleroderma Symptoms Dysfunction Pathology Genetics Immunology Pathophysiology

15. Neurological Disease:1. Brain Stem Tumor Neurological Disease:2. Parkinson’s Disease Symptoms Dysfunction Pathology Dysphagia Nausea Ileus Constipation Incontinence Dysphagia Nausea Ileus Constipation Incontinence Pathophysiology

16. Hirschsprung’s Disease • Children; rarely presents in adulthood • Loss of inhibitory neurons • Genetics understood • Svenson’s pull-through procedure

17. Hirschsprung’s Disease Symptoms Dysfunction Pathology Pathophysiology

18. “Functional” Disorders • Functional Heartburn • Globus Sensation • Functional Dyspepsia • Irritable Bowel Syndrome • Functional Abdominal pain • Functional Diarrhoea/Constipation Often overlap; one disorder or a number of discrete disorders

19. Functional GI Disorders • Responsible for over 50% of all G.I. Complaints seen by a G.P.!

20. How do you make a diagnosis? • Symptoms • No pathology • No abnormal blood tests • No abnormal X Ray’s

21. Diagnosis • By exclusion • Definitive, based on symptoms ( a consensus approach)

22. Rome • Functional Dyspepsia “ A chronic pain or discomfort centred in the upper abdomen; may be additional symptoms such as fullness, bloating, early satiety, nausea, vomiting”

23. Rome • IBS • “ chronic abdominal pain or discomfort associated with bowel movement; may be additional symptoms such as bloating, distension, constipation, diarrhoea”

24. IBS • Abdo Pain + • Urge to b.m. • Relief by b.m. • Alternating diarrhoea and constipation • Bloating, distension • Difficult defaecation

25. Functional Bowel DisordersCause(s) • Motor Dysfunction • Visceral Hypersensitivity • Low-grade inflammation • Central Perception • Psyche

26. FD – Pathophysiology; motility • Gastroparesis • Impaired Fundic Accommodation • Antral Dilatation • Gastric Hypersensitivity • Abnormal Cerebral Perception • Helicobacter Pylori

27. IBS - Pathophysiology • Motility • Visceral Hypersensitivity • Central Perception • Inflammation • Post-infective • Immune activation • Microbiota different • Psyche

28. Case History • 24 year-old female graduate student, volunteers in Africa • 2000 presented with a 2 year history of abdominal cramps and constipation • Went on wheat-free diet • Substituted soya for cows milk • Lived in: • Malawi age 3-10 • Malaysia age 14-16 • December 2003 • Every 2 weeks: diarrhoea, nausea lasting 2-3 days • Loperamide helped • April 2004 • Anticholinergic, antispasmodic and antidiarrhoeal: some help • July 2004

29. Case History • July 2004 • Despite 6 diphenoxylate/day • Every 3-4 days borborygmi and cramps followed by diarrhoea (b.o. X 5 in a.m.) and urgency • Took tinidazole for 4 days – no effect • Family history of pernicious anaemia, coeliac disease and Crohn’s disease

30. Case History • April 2009 • Intermittent symptoms • Worse after meals and when stressed • Has had a number of anti-biotic and anti-parasitic regimes • No weight loss • Extensive and repeated investigations • Blood work, gastroscopy, colonoscopy, small bowel x-rays, abdominal imaging • All negative

31. Management • Listen and appreciate • Understand aggravating factors and modify • Symptomatic • Anti-diarrhoeals • Laxatives • Anti-spasmodics • Tricyclic anti-depressants (low dose); SSRI’s • Behavioral and psychological therapies

32. Summary • Motility disorders • Not common • May cause considerable disability • Based on disorders of intestinal nerve or muscle or their central connections • “Functional” disorders • Common • May cause considerable impairment in quality of life • Pathophysiology not fully understood