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By Dr. Zahoor 1 Slide 2 Irritable bowel syndrome or spastic colon, is functional bowel disorder and symptom based diagnosis It is commonest Functional Gastrointestinal Disorder (FGID) Why we say functional? Because symptoms occur in the absence of any demonstrable abnormalities in the digestion, absorption of nutrients, fluid and electrolyte. There is no structural abnormality in GIT. IBS has no known organic cause 2 Slide 3 Symptoms Chronic abdominal pain Abdominal discomfort, blotting Alteration of Bowel habits Rectal mucus Diarrhea or constipation may predominate or they may alternate (IBS-D, IBS-C or IBS-A) Nocturnal symptoms are rare 3 Slide 4 Onset of IBS Symptoms Symptoms usually occurs after infection post infection bile salt mal absorption Use of antibiotic Alteration in immune system Emotions, depression, anxiety can effect GIT function Psychological stress can increase GIT symptoms 4 Slide 5 5 Slide 6 Biopsychosocial Concept of GIT disorders 6 Slide 7 In western world, 1 in 5 people report symptoms consistent with IBS Up to 40% of all patient seen in specialist gastroenterology clinic will have IBS Female patients out number male patient 7 Slide 8 IBS is multi system disorder IBS patient suffer from many non intestinal symptoms 8 Slide 9 Diagnostic Criteria In preceding 3 months, there should be at least 3 days per month of recurrent abdominal pain or discomfort associated with 1. Improvement with defecation 2. On set associated with a change in frequency of stool 3. Change in form (appearance) of stool Note Rule out other condition that produce IBS like symptoms e.g. parasitic infection, celiac disease, lactose intolerance, inflammatory bowel disease 9 Slide 10 Investigation Investigations are done to exclude other conditions Stool microscopy and culture (to exclude infectious conditions) Blood test full blood examination, ESR, LFT Abdominal ultrasound (to exclude Biliary tract disease) Endoscopy and biopsy (to exclude celiac disease, inflammatory bowel disease) 10 Slide 11 IBS Treatment Therapies target central and end organ pathways End organ treatment ( GIT ) - Diet - High fiber diet - Anti diarrheal drugs e.g. Loperamide - Treat constipation 5HT 4 receptor agonist e.g. prucalopride - Smooth muscle relaxant for pain e.g. mebeverine hydrochloride 11 Slide 12 Central Treatment - Psychotherapy - Anti depressant e.g. Amitriptylline, Clomipramine 12 Slide 13 13 Management of Irritable Bowel Syndrome Slide 14 14 Slide 15 In this form of functional bowel disease, symptoms occur in the absence of abdominal pain Symptoms commonly are - Passage of several stools in rapid succession usually first thing in the morning - No further motion may occur that day or defecation occurs after meals 15 Slide 16 Symptoms (cont) - The first stool of the day is usually formed, later ones are mushy, loose or watery - Urgency of defecation - Anxiety - Exhaustion after defecation 16 Slide 17 Treatment Loperamide Tricyclic antidepressant at night e.g. Clomipramine 10- 30 mg Note If there are atypical features e.g. large volume stool, rectal bleeding, weight loss, nutritional deficiency then more investigations should be done 17 Slide 18 18 Slide 19 The colon and rectum Structure (important points) The large intestine starts at caecum Colon is made up of ascending, transverse, descending and sigmoid colon which join the rectum 19 Slide 20 Structure of Large Intestine 20 Slide 21 The mucosa of colon is lined by epithelial cells with crypts but no villi, so that surface is flat Mucosa is full of goblet cells Colon is innervated by enteric nervous system with input from parasympathetic and sympathetic pathways 21 Slide 22 Physiology of colon Main role of colon is absorption of water and electrolytes Propulsion of contents from caecum to the anorectal region Peristalsis is induced by release of serotonin (5-HT) from neuroendocrine cells in response to luminal distension Normal colonic transit time is 24 to 48 hours with normal stool weight up to 250 g/day 22 Slide 23 Physiology of defecation Role of rectum and anus Rectum is normally empty Stool is propelled into the rectum by colonic contraction Desire to defecate and urgency to defecate are experienced with increasing volume of rectal content (threshold 100ml) 23 Slide 24 Physiology of defecation ( cont) These sensation are associated with rectal contraction and relaxation of internal anal sphincter, both of which push the stool down in to the proximal anal canal This increases the defecation urge, which can be suppressed by vigorous contraction of external sphincter and Puborectalis muscle 24 Slide 25 Constipation is very common symptom, particularly in women and elderly Constipation is defined as - infrequent passage of stool - less than 3 times per week - passage of hard stools straining more than 25% of time - incomplete evacuation 25 Slide 26 Constipation may affect more than 1 in 5 of the population Patient may attribute many symptoms to constipation e.g. headache, malaise, nausea, bad taste in mouth Other symptoms abdominal blotting or discomfort, perianal pain 26 Slide 27 27 Causes of Constipation Slide 28 Assessment of Constipation Constipation can be classified into Three broad categories: 1. Normal transit through colon (59%) 2. Defecatory Disorder (25%) 3. Slow transit (13%) 28 Slide 29 1- Normal Transit Constipation Stool traverses the colon at normal rate but there is passage of hard stool 2. Defecatory Disorder They are mainly due to dysfunction of anal sphincter and pelvic floor e.g. mucosa of anterior rectal wall prolapses downward during straining 3. Slow Transit Occurs predominantly in young women who have infrequent bowel movement 29 Slide 30 Treatment Treat the underlying cause In Normal and Slow transit constipation, the main focus should be on increasing fiber content of the diet and increase fluid intake 30 Slide 31 Treatment ( cont ) Laxative and Enemas 1. Bulk forming laxative - Dietary fiber - Methyl cellulose - Ispaghula husk 2. Stimulant laxative (stimulate gut motility) - Bisacodyl - Phenolphthalein 3. Osmotive Laxative - Lactulose 31 Slide 32 Treatment ( cont) Suppositories Bisacodyl Glycerol Enemas Arachis oil 32 Slide 33 33