Diagnosis And Treatment Of Ibs

Front 1

Iritable Bowel Syndrome- why it is important

Back 1

IBS is one of the most frequently diagnosed gastrointestinal disorders in primary care and gastroenterology offices
Negative impact on patients quality of life
Increasing direct and indirect costs associated with this illness

Front 2

27 year old secretary presents for routine screening.
Symptoms of abdominal pain, bloating and diarrhea, worsened by large high fat meals, stress, menses
Symptoms are relieved with defecation
Symptoms are 2-3x per month, no interference with daily activity.

Back 2

Mild IBS

Front 3

34 year old truck driver reports abdominal discomfort, urgency, diarrhea and sometimes fecal soiling worsened by large meals and fatty foods
Symptoms occur 2-3 times per week
Associated with loss of work (need for frequent stops to fully evacuate)‏
Psychological distress and impairment

Back 3

Moderate IBS

Front 4

45 year old women with a long term history of crampy lower abdominal pain, loose stools, incomplete relief of pain after the bowel movement
Unable to work, financial difficulties
History of abuse, denies role in illness
Frequent physician visits; multiple operations

Back 4

Severe IBS

Front 5

Epidemiology of IBS

Back 5

5-10% of the population are affected

3:1 F:M
most have mild IBS
IBS- usu under 50 y/o
most are 15-34

Front 6

How does IBS affect quality of life?

Back 6

Physical functioning, bodily pain, general health, mental health, emotions, social functioning, vitality
Several studies report that IBS increases the rate of absenteeism
Impairs patients functioning when they continue work with symptoms
One survey showed that patients missed a mean of 13.4 days from work or school compared with 4.9 of non-IBS patients

Front 7

IBS- definition

Back 7

A group of symptoms:
-abdominal pain
-constipation and or diarrhea
-bloating/distension

A "functional" bowel disorder

Front 8

Dx of IBS

Back 8

Rome III Criteria
Abdominal pain 3 days/month in the last 12 weeks that is continuous or recurrent
Associated with >2 of the following: Improvement with defecation, change in stool frequency, change in stool form
Onset >6 months prior to diagnosis

Front 9

Supportive Sx of IBS

Back 9

Abnormal stool frequency (<3bm/week; > 3bm/day)‏
Abnormal stool form (lumpy, hard, loose, watery)‏
Straining with defecation
Urgency, incomplete evacuation
Bloating, passing mucous

Front 10

Bristol Stool Scale

Back 10

Type 1 - Separate hard lumps like nuts (difficult to pass)‏
Type 2 - Sausage shaped but lumpy
Type 3 - Like a sausage but with cracks on surface
Type 4 - Like a sausage or snake, smooth and soft
Type 5 - Soft blobs with clear-cut edges (passed easily)‏
Type 6 - Fluffy pieces with ragged edges, a mushy stool
Type 7 - Watery, no solid pieces (entirely liquid)‏

Front 11

IBS pathophysiology

Back 11

Neuromuscular dysfunction
Abnormal colonic motility
Visceral Hypersensitivity

Abnormal Brain- GI tract interactions
Immune activations
Genetic Influence
Psychological Distress
Intestinal Flora Disturbances

Front 12

Increased Pain Sensitivity in IBS

Back 12

pain out of proportion to motility changes, discomfort even during normal events (like having a full rectum)
Pain in areas other than bowels.

Front 13

WHAT NEUROTRANSMITTERS CAUSE NEUROGENIC DEFECTS IN IBS?

Back 13

Serotonin (5-hydroxytryptamine, 5-HT) as possible mediator:
Released by mucosal enterochromaffin cells with noxious stimulation
Activates peristalsis—abnormalities cause increased/decreased transit
Activates sensory pathways that mediate pain

Front 14

CNS modulation: Brain-gut axis

Back 14

Neuronal control of the GI tract occurs at several different levels
Enteric nervous system, sympathetic & parasympathetic nervous system, higher brain centers
Chemical mediators play a role in sensation and GI motility (dopamine, norepinephrine, serotonin, acetylcholine)‏

Front 15

Immune System Activation Post Inffectious IBS

Back 15

1/3 pts say their IBS started after acute enteric infection
10-30% of pts presenting with an acute enteric infection fo on to develop IBS like Sx
6-27% develop PI IBS after e.coli or c. jejuni

Front 16

T cell activation in IBS

Back 16

Blood samples from 100 IBS, 44 controls
Colonic biopsies: 11 IBS, 10 controls
*(three different cohorts)*
Blood and colonic mononuclear cells stimulated with anti CD3/CD28 Antibodies
Proliferation
Cytokine secretion
T-cell phenotype
IBS symptom severity was assessed
IBS pts have incr IL-1B
they also display and activated phenotype

Front 17

Psychological distress and IBS

Back 17

Psychological stress exacerbates gastrointestinal symptoms
Psychosocial disturbance affects illness experience and behavior (sexual and physical abuse)
IBS can lead impaired health related quality of life.

Front 18

Evidence of heredity in IBS

Back 18

incr freq with first degree relatives, monozygotic twins

Front 19

Small Bowel Bacterial Overgrowth

Back 19

Abdominal pain, bloating are also found in SBBO
Of 202 IBS pts (Rome II), 158(78%) had SBBO.
47 with follow up testing
25 pts eradication of SBBO &improved abdominal pain, diarrhea. (p<0.05)
48% eradicated patients no longer met Rome criteria

Front 20

Evolving model of IBS

Back 20

brain-gut. psycho social, visceral hypersensitivity, gut immune interactions, altered motility and secretion

Front 21

DX of IBS

Back 21

Symptom based criteria are useful for clinical research and clinical practice.
Extensive diagnostic testing is not required unless there are red flag symptoms (weight loss, fevers, blood in stool, anemia, etc.)‏
Red flag symptoms require more extensive evaluation
Consider:
CBC, ESR, CRP, Metabolic profile, stool cx, stool O&P, WBC and c-difficile toxin
Celiac antibodies (total serum IgA and tissue transglutaminase antibodies)‏
Flexible sigmoidoscopy or colonoscopy

Front 22

Tx of IBS

Back 22

Provide reassurance/education
Treat according to predominant symptom
Assess response to therapy in 4-6 weeks.

Front 23

Tx of IBS: mild Sx

Back 23

cut out Coffee/caffeine, alcohol, fatty foods, dairy

Front 24

Tx of IBS Moderate Sx

Back 24

keep track of foods, drinks and stressors, keep track of timing and severity of Sx

Front 25

Behavioral Tx

Back 25

Relaxation Therapy, hypnosis, biofeedback, cognitive behavioral therapy

Front 26

Bulking Agents

Back 26

(psyllium, wheat bran, corn fiber) increase stool frequency ease stool passage through acceleration of colonic transit.
Side effects include gas, bloating

Front 27

Laxatives

Back 27

Stimulant laxatives: (bisacodyl, senna)-
Stimulate motility
Increase intestinal secretion
Side effect: cramps

Front 28

Osmotic Laxatives

Back 28

increases water retention
Magnesium Salts
Sodium phosphate
Lactulose
Sorbitol
Polyethylene Glycol

Front 29

Lubiprostone

Back 29

Approved for chronic functional constipation (January 2006); IBS-C
Bicyclic fatty acid metabolite of prostaglandin E1.
Increases intestinal fluid secretion by stimulating a specific intestinal chloride channel (ClC2) in apical membrane
No change in electrolyte concentrations in the serum

Front 30

Loperamide

Back 30

Slows transit time through colon
Increasing resorption of intestinal water

Front 31

Diphenoxylate w/ atropine

Back 31

Reduces transit time
Reduces intestinal muscle spasms
Anticholinergic activity

Front 32

Tx of IBS: severe Sx

Back 32

antidepressants

Front 33

Treatment of Pain and bloating

Back 33

Antispasmodics (dicyclomine, hyoscyamine) relieve abdominal pain by inhibiting smooth muscle contraction
5HT3 antagonists
5HT4 agonists
Anti-depressants: TCA and SSRI's
Antibiotics
Probiotics

Front 34

Alosetron

Back 34

5 HT3 antagonist- targets serotonin receptors in the gut. reduced visceral pain, slowed colonic transit
Originally approved for women with IBS-D
Side Effect: constipation; ischemic colitis
Recently reintroduced after 12 week multicenter, randomized placebo study
Lowest dose most effective (0.5-1.0mg) with less risk of severe constipation
Approved only for women with severe IBS-D.

Front 35

Tegaserod Maleate

Back 35

now totally off the market
Stimulate intestinal motility via cholinergic transmission (5HT4 agonist)‏
Augment the peristaltic reflex
Enhance intestinal secretion
Reduce visceral hypersensitivity
Short-term treatment of women with IBS-C (2002).
Chronic constipation in men and women younger than 65 years (2004).
Removed from the U.S. market Increased risk of serious cardiovascular adverse effects

Front 36

Tricyclic Antidepressants and IBS

Back 36

IBS
Migraines
Fibromyalgia
Interstitial cystitis
Neuropathic pain
Extensively studied
Used at low does
Diarrheal predominant IBS
(Desipramine, amitriptyline,)‏

Front 37

SSRIs and IBS

Back 37

Fewer placebo controlled trials
Improvement of health related quality of life, symptom frequency and abdominal pain
Role in treating depressed and non-depressed IBS patients

Front 38

Role of ABX and IBS

Back 38

Treatment of patients with bacterial overgrowth (diagnosed often with hydrogen breath testing)

Rifaxamin, Metronidazole, Quinolones

Front 39

probiotics and IBS

Back 39

Systemic Review of RCTs
Evaluate the efficacy, safety and tolerability of probiotics in treatment of IBS
16 RCT met criteria
(11 studies suboptimal)

Limited data on tolerability and adverse events
Bifidobacterium infantis 35624 showed improved pain/discomfort, bloating/distention bowel difficulty

Front 40

Comprehensive Approach to Tx

Back 40

Education/ Reassurance
Dietary Modification
Pharmacotherapy of gut symptoms
Psychological therapy
Antidepressants (low dose)‏
Referral to pain management