COMMON OPD PATIENT

29 y.o. lady 18 month history loose stool

2-3 per dayBegins just soft, then looser –”explosive”Night okNo blood, occasional mucusCan have a week or 2 when all is ok

Abdominal discomfort Occasional pain relief needed Generally across lower abdomen Relieved in part by going to the toilet

Weight stable No significant family history Abdominal exam and rigid sigmoidoscopy

normal

What next?

Rome 3 Criteria for IBS

Recurrent abdominal pain or discomfort at least 3 days/month in the last 3 months associated with 2 or more of:

Improvement with defaecation Onset associated with change in frequency of stool Onset associated with change in form (appearance) of stool

Diarrhoea/constipation predominant subtypes

Historical advice Increase fibre

Adequate fluid intake

Regular physical activity

Avoid triggers e.g. spicy/fatty foods, “windy vegetables, caffine

What are FODMAPS?

Poorly absorbed, short chain carbohydrates

F ermentable

O ligo-saccharides

D i-saccharides

M ono-saccharides

A nd

P olyols

Indications- why?

IBS – unresponsive to traditional advice

IBD with IBS symptoms during controlled periods (33% UC and 57% Crohn’s report functional symptoms)

Coeliac disease without complete resolution of symptoms on strict GF diet

Indications – when?

Waking without symptoms but develop over the day

Symptoms improved with poor intake

Gluten avoidance with partial improvement

Already trialling self imposed food exclusion

Contraindications

IBS associated with eating disorders

Uncontrolled IBD

Caution with low body weight (unless symptoms cause of this)

Other symptoms such as headache, rash, asthma, eczema, allergies

How do FODMAPS work?

When malabsorbed ↑water secretion into bowel leading to diarrhoea

Sugars reach large intestine → fermented by bacteria = ↑gas

Gas in small / large intestine = wind, bloating, discomfort, nausea, abdo cramps

Can slow movement through bowel = constipation

Other factors = bacterial overgrowth in small intestine and gut hypersensitivity to gas

Sources

Fructose-Apple-Pear-Mango-Honey-High fructose syrup-Tinned fruit in juice- Concentrated sources:

wine/ dried fruit/ excess juice/tomato paste

Fructans- Wheat- Rye- Onion- Spring onion- Shallots- Leek- Artichokes- Asparagus- Inulin

Sources

Galactans- Broccoli- Brussel sprouts- Cabbage- Legumes:- Baked beans- Red kidney beans- Chickpeas- Lentils- Soy lentils

Polyols- Apricots- Plums- Cherries- Watermelon- Avocado- Mushrooms- Cauliflower- Articial sweeteners:

mannitol, sorbitol, xylitol, isomalt

Sources

Lactose- Cow’s milk- Yoghurt (2tblspns tolerated)- Soft cheese- Ice cream- Condensed milk- Custard- Evaporated milk

Fructose Malabsorption

Those who incompletely absorb fructose leading to GI symptoms

30-40% of population malabsorb excess fructose - ? Reason

> 1/3 adults with IBS unable to absorb fructose load of 25-50g

FM causes symptoms due to delivery to colonic lumen where fermented to produce H2, CO2 and short chain FAs → luminal distention

Fructose Malabsorption

Increased fructose malabsorption when taken without other food

Foods problematic if have high fructose load or more fructose than glucose

Prescence of glucose = improved tolerance

Sucrose well tolerated

Should have breath test to diagnose fructose and lactose intolerance

Nutritional management

Prior to referral check for coeliac disease, other pathology

2-6 week low FODMAP diet + food and symptom diary45-60 minute appointment

If improvementChallenge fructose and lactose

Liberalisation and maintenance: establish tolerance to FODMAPS

Nutritional Management

Education needed Gluten vs low FODMAP Appropriate substitutes Allergy vs intolerance Avoiding constipation

Summary

Low FODMAP diet worth trialling under dietetic supervsion

Many patients will attempt to manipulate their own diet, therefore need structure and sound advice

Clear explanation needed: reduced load not total avoidance

Questions?