irritable bowel sydnrome
DESCRIPTION
IRRITABLE BOWEL SYDNROME. IBS - Definition. Altered bowel habit and/or Abdominal discomfort or pain No demonstrable organic disease As no marker exists for IBS, diagnosis is based on clinical features. Summary of H ypotheses on the Pathophysiology of IBS. - PowerPoint PPT PresentationTRANSCRIPT
IRRITABLE BOWEL IRRITABLE BOWEL SYDNROMESYDNROME
IBS - DefinitionIBS - Definition
• Altered bowel habit and/orAltered bowel habit and/or• Abdominal discomfort or painAbdominal discomfort or pain• No No demonstrabledemonstrable organic disease organic disease
As no marker exists for IBS, As no marker exists for IBS, diagnosis is based on clinical featuresdiagnosis is based on clinical features
Summary of Hypotheses on the Pathophysiology
of IBS• IBS is characterized by changes in motility in
response to environmental or enteric stimuli1
• Visceral hypersensitivity is well documented in IBS patients2
• Serotonin, which has both motility and sensory modulating properties, could represent a common factor linking the symptoms of IBS3
Epidemiology - 1Epidemiology - 1
• 6-22% of the North America population have 6-22% of the North America population have seen a physician for IBS symptomsseen a physician for IBS symptoms
• Most cases diagnosed before age 45 but IBS Most cases diagnosed before age 45 but IBS is is sometimes diagnosed in those above sometimes diagnosed in those above 65 years65 years
• Women are 3 times more frequently affected Women are 3 times more frequently affected than than menmen
• Less common in Asians & Hispanic than Less common in Asians & Hispanic than CaucasiansCaucasians
Epidemiology - 2Epidemiology - 2
• 6-22% of population report symptoms but only 6-22% of population report symptoms but only about about 1/5 to 1/3 of these seek medical care1/5 to 1/3 of these seek medical care
• Factors associated with physician Factors associated with physician consultations:consultations:
–Personality disorders or depressionPersonality disorders or depression–Long duration of symptomsLong duration of symptoms
Impact on Society - 1Impact on Society - 1
• Visits to the doctor:Visits to the doctor:– 12% primary care12% primary care– 28% gastroenterologist28% gastroenterologist
• Health care costs:Health care costs:– Twice that of an asymptomatic Twice that of an asymptomatic
personperson– More appendectomies, More appendectomies,
cholecystectomies and cholecystectomies and hysterectomies in those with IBShysterectomies in those with IBS
IBS: Current thinking on IBS: Current thinking on pathophysiologypathophysiology
• Visceral hypersensitivityVisceral hypersensitivity11
–– Increased visceral afferent response to normal as Increased visceral afferent response to normal as well as well as
noxious stimulinoxious stimuli
–– Mediators include 5-HT, bradykinin, tachykinins, Mediators include 5-HT, bradykinin, tachykinins, CGRP, and CGRP, and
neurotropinsneurotropins
• Primary motility disorder of GI tractPrimary motility disorder of GI tract22
–– Mediated by 5-HT, acetylcholine, ATP, motilin, Mediated by 5-HT, acetylcholine, ATP, motilin, nitric oxide, nitric oxide,
somatostatin, somatostatin, substance P, and VIP substance P, and VIP
IBS IBS –– Pathophysiology Pathophysiology
Defects in the enteric nervous system may lead Defects in the enteric nervous system may lead to the hallmark symptoms of IBS.to the hallmark symptoms of IBS.
5-HT5-HT receptor effectsreceptor effects
• Mediate reflexes controlling Mediate reflexes controlling
gastrointestinal motility and secretiongastrointestinal motility and secretion
• Mediate perception of visceral painMediate perception of visceral pain
IBS IBS –– Pathophysiology Pathophysiology
Impact on Society - 2Impact on Society - 2
• Impairment of QOL: worse than in patients Impairment of QOL: worse than in patients with DM with DM or CRFor CRF
• Time off work: 3 times more often than that Time off work: 3 times more often than that for an for an asymptomatic personasymptomatic person
• Restriction of activities: by 145 days per yearRestriction of activities: by 145 days per year
Rome II Criteria for DiagnosisRome II Criteria for Diagnosis
• Symptoms for at least 12 weeks (which need Symptoms for at least 12 weeks (which need not be not be consecutive), in the preceding 12 consecutive), in the preceding 12 months:months:
• Abdominal pain or discomfort, which has 2 of Abdominal pain or discomfort, which has 2 of the 3 the 3 following features:following features:
Rome II Criteria - continuedRome II Criteria - continued
1.1. Pain relievedPain relieved with defecation; or with defecation; or
2.2. Altered bowel habit associated with a change Altered bowel habit associated with a change in the in the frequencyfrequency of stools; or of stools; or
3.3. Altered bowel habit associated with a change Altered bowel habit associated with a change in the in the formform (appearance)(appearance) of the stools of the stools
Rome II Criteria - continuedRome II Criteria - continued
Other symptoms that cumulatively support Other symptoms that cumulatively support the diagnosis of IBS include the following:the diagnosis of IBS include the following:
1.1. Abnormal stool Abnormal stool frequencyfrequency (>3BMx/d or (>3BMx/d or <3BMs/wk)<3BMs/wk)
2.2. Abnormal stool Abnormal stool formform (lumpy and hard or loose (lumpy and hard or loose and watery)and watery)
3.3. Abnormal stool Abnormal stool passagepassage (straining, urgency, (straining, urgency, feeling of incomplete evacuation)feeling of incomplete evacuation)
4.4. Passage of Passage of mucusmucus
5.5. BloatingBloating or feeling of distention. or feeling of distention.
Frequency of SymptomsFrequency of Symptoms
In 154 consecutative patients In 154 consecutative patients diagnosed as diagnosed as IBS in a GI unit, there was IBS in a GI unit, there was
• Abdominal discomfort or pain 33% of Abdominal discomfort or pain 33% of daysdays
• Bloating 28% of daysBloating 28% of days
• Altered stool form 25% of daysAltered stool form 25% of days
• Altered stool frequency 18% of daysAltered stool frequency 18% of days
• Passage of mucus 7% of daysPassage of mucus 7% of days
Abdominal PainAbdominal Pain
Intensity, location and characteristic of pain is Intensity, location and characteristic of pain is highly variablehighly variable
– epigastric 10%epigastric 10%– right side 20%right side 20%– left sided 20%left sided 20%– hypogastric 25%hypogastric 25%– too variable 25%too variable 25%
• Cramping or an acheCramping or an ache
• Post-prandial worsening of pain for 1-3 hoursPost-prandial worsening of pain for 1-3 hours
• Stress or emotional turmoil worsens conditionStress or emotional turmoil worsens condition
• Worse before and/or during menstruationWorse before and/or during menstruation
Altered Bowel HabitAltered Bowel Habit
• Constipation-predominantConstipation-predominant –––hard pellet-like stools, infrequent (<1/day)hard pellet-like stools, infrequent (<1/day)
• Diarrhea-predominantDiarrhea-predominant– frequent loose stoolsfrequent loose stools– post prandialpost prandial– urgencyurgency– strainingstraining– incomplete evacuationincomplete evacuation– mucoid discharge – 50%, no bloodmucoid discharge – 50%, no blood
Symptom Associations Symptom Associations
• UGIUGI – dyspepsia, heartburn, early satiety, – dyspepsia, heartburn, early satiety, nausea, nausea, all are more frequent in all are more frequent in constipation-constipation- predominant IBSpredominant IBS
• LGILGI – abdominal distention, bloating – more in – abdominal distention, bloating – more in womenwomen
• GUSGUS – pelvic pain, dysmenorrhea, – pelvic pain, dysmenorrhea, dyspareunia, dyspareunia, urinary frequency, urinary frequency, nocturia, incomplete nocturia, incomplete bladder bladder evacuationevacuation
• MSKMSK – fibromyalgia, back pain, head & neck – fibromyalgia, back pain, head & neck painpain
Other AssociationsOther Associations
• Increased risk of PUD, HBP, sicca syndrome & Increased risk of PUD, HBP, sicca syndrome & vague rashesvague rashes
• Triad of IBS, GERD & Asthma is 3-times more Triad of IBS, GERD & Asthma is 3-times more frequent than expectedfrequent than expected
‘‘Red Flags’ - Alarm Symptoms/SignsRed Flags’ - Alarm Symptoms/Signs
• Onset after 55 yearsOnset after 55 years• Persistent anorexia & weight loss > 10 Persistent anorexia & weight loss > 10 lbslbs• Persistent “fever” in the eveningPersistent “fever” in the evening• Pain – changing pattern or increasing Pain – changing pattern or increasing after after food and persisting for a few hoursfood and persisting for a few hours• Awakened by pain &/or diarrhea at nightAwakened by pain &/or diarrhea at night• Rectal bleeding, not just on wipingRectal bleeding, not just on wiping• Stools “like malabsorption syndrome”Stools “like malabsorption syndrome”• P/E: palpable mass in the abdomenP/E: palpable mass in the abdomen
Differential DiagnosisDifferential Diagnosis
1.1. Dietary – e.g. lactose intolerance.Dietary – e.g. lactose intolerance.
2.2. Infections – Giardia, Bacterial Overgrowth Infections – Giardia, Bacterial Overgrowth SyndromeSyndrome
3.3. Inflammatory Bowel Disease – UC, CDInflammatory Bowel Disease – UC, CD
4.4. Malabsorption syndrome – Celiac Disease, Malabsorption syndrome – Celiac Disease, Pancreatic InsufficiencyPancreatic Insufficiency
5.5. Psychological – Depression AnxietyPsychological – Depression Anxiety
6.6. Other - NeurosesOther - Neuroses
Diagnosis - 1Diagnosis - 1
ApproachApproach: before doing any tests: before doing any tests::
1.1. Gain the confidence of the patient at the first Gain the confidence of the patient at the first consultation, let them talk and just listenconsultation, let them talk and just listen
2.2. Remain aware that some IBS patients have a Remain aware that some IBS patients have a
hidden agendahidden agenda
3.3. Do not say to the patient what Do not say to the patient what somesome FPs say, FPs say, namely, “I don’t know what is wrong with you”namely, “I don’t know what is wrong with you”
4.4. Do not say what Do not say what somesome Specialists say, Specialists say, namely: “There is nothing wrong with you” or namely: “There is nothing wrong with you” or “it is in your head”“it is in your head”
Diagnosis - 2Diagnosis - 2
5.5. Get Get allall the test reports from the other MDs the test reports from the other MDs files and files and
6.6. Show & discuss those test results with the Show & discuss those test results with the patientpatient
7.7. In those below 55 yrs and in the absence of In those below 55 yrs and in the absence of “alarm symptoms”, if “routine” blood tests + “alarm symptoms”, if “routine” blood tests + ESR/CRP are normal, diagnosis of IBS has:ESR/CRP are normal, diagnosis of IBS has:
8.8. - 83% sensitivity- 83% sensitivity- 97% specificity- 97% specificity
- 100% PPV- 100% PPV
Therefore, please do these testsTherefore, please do these tests
Diagnosis - 3Diagnosis - 3
• I ask the patient; “which I ask the patient; “which singlesingle GI disease do GI disease do you think you may have?” and I do you think you may have?” and I do one testone test first to exclude that and review the patient first to exclude that and review the patient after the test:after the test:
• In my experience:In my experience:
PainPain DiarrheaDiarrhea ConstipationConstipation
<50 yrs<50 yrs PUD, CDPUD, CD LI, MAS, LI, MAS, “obstruction”“obstruction”
>50 yrs>50 yrs GBD, CRCGBD, CRC CRCCRC
are the commonest cause of anxiety for the are the commonest cause of anxiety for the patientpatient
Diagnosis - 4Diagnosis - 4
Two multicentre trials have found the following Two multicentre trials have found the following associations:associations:
• Lactose IntoleranceLactose Intolerance 23%23%
• “ “Structural abnormality”Structural abnormality” 2%2%
• Abnormal thyroid testsAbnormal thyroid tests 6%6%
• Stools O&P Stools O&P 2%2%
Diagnosis - SummaryDiagnosis - Summary
• IBS remains a clinical diagnosis.IBS remains a clinical diagnosis.
• In those below 55 years and in the absence of In those below 55 years and in the absence of alarm symptoms, Rome II Criteria alarm symptoms, Rome II Criteria
(Clinical) has:(Clinical) has:
- Sensitivity 65% - Sensitivity 65%
- Specificity 100%- Specificity 100%
- PPV PPV 100% 100%
-No diagnosis revision during 2 yr follow No diagnosis revision during 2 yr follow upup
Vanner etal (1999) Amer J Gast Vanner etal (1999) Amer J Gast 9494:2912:2912
Traditional therapies focused on individual symptoms of IBS with
constipation Bloating and distention Dietary modifications Antispasmodics Antiflatulants Digestive enzymes Antibiotics
Abdominal pain / discomfort Antispasmodics Tricyclics Analgesics
Irregular Bowel Habit
Fiber Laxatives Imodium
AbdominalAbdominalpain /pain /
discomfortdiscomfortBloating /Bloating /distentiondistention
Constipation Constipation or Diarrheaor Diarrhea
None of these medications effectively treat the multiple symptoms of IBS. May exacerbate individual symptoms e.g., fiber and bloating; antispasmodics and constipation