Irritable Bowel Syndrome

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Irritable Bowel Syndrome

• Jennifer E. Guss, MD
• Baylor College of Medicine
• Med-Peds Continuity Clinic

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IBSDefinition

• Syndrome characterized by chronic abdominal pain
  and altered bowel habits in absence of any
  organic cause
• Most commonly diagnosed GI condition and has a
  worldwide prevalence of 10-15

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IBSEpidemiology

• All genders affected
• All ages affected
• Most commonly seen in young women
• 21 female to male predominance

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IBSEpidemiology

• Second most common cause of work absenteeism
  (after common cold)
• Only 15 affected individuals seek medical help
• Accounts for 25-50 of all visits to
  gastroenterologist
• Costs 1.7billion/year in US(2000)

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IBSClinical Manifestations

• Varied!
• Gastrointestinal and extraintestinal
• Chronic abdominal pain and altered bowel habits

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IBSAbdominal Pain

• Crampy, variable intensity, periodic
  exacerbations
• Locationlower abdomen, esp. left
• Severitymildly annoying?disabling
• Exacerbating factorseating, emotional stress
• Reliefdefacation

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IBSAltered Bowel Habits

• Diarrhea, constipation, diarrhea and
  constipation, normal alternating with diarrhea
  and/or constipation
• normal varies person to person, therefore
  establish normal for each individual when taking
  history

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IBSDiarrhea

• Frequent, loose stools, small?mod volume
• Timingwhile awake, esp. AM after eating
• BM preceded by extreme urgency
• May have feeling of incomplete evacuation
• ½ of all pts also c/o mucus d/c with stools

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IBSDiarrhea

• NOT associated with large volume stools
  blood
• nocturnal diarrhea greasy
  stools

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IBSConstipation

• Durationdays?months with interludes of normal
  stooling or diarrhea
• quality of stoolshard, pellet shaped
• Feeling of incomplete evacuation even when rectum
  is empty
• Can result in inappropriate straining, enema and
  laxative use

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IBSOther GI Symptoms

• GERD
• Dysphagia
• Early satiety
• Dyspepsia
• Nausea
• Non-cardiac chest pain
• Abdominal bloating

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IBSSymptoms

• Increased gas as flatulence or belching(though
  normal volume of gas in GI tract and no signs of
  colonic distention)
• exaggerated visceral hyperalgesia response to
  gasperception of a lot of pain with normal
  amount of gas

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IBSExtra-Intestinal Symptoms

• Broad range
• Impaired sexual function
• Dysmenohrrea
• increased urinary freq and urgency
• Increased likelihood of HTN, RAD, rheumatic
  syndromes incl FM

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IBSDiagnosis

• History 2 sets of diagnostic criteria
• Manning Criteria(1978)
• Rome Criteria(1992 revised 1999)
• American Gastroenterological Assoc recs using
  combination and focusing on the positive symptoms

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IBSDiagnosis

• Manning Criteria
• pain relief after BM
• loose,freq stools at onset
• passage of mucus
• sense of incomplete emptying

• Rome Criteria
• functional group of discomfort or bowel d/os
  with abd pain assoc with defecation, or a change
  in bowel habits, and disordered defecation
• continuous or recur abd pain for 3 months

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IBSDiagnosis

• Make diagnosis based on constellation of symptoms
  and ABSENCE of alarm symptoms
• hematochesia
• wt loss gt 10 lbs
• fhx colon cancer
• recurrent fever
• anemia
• chronic severe diarrhea

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IBSWork-up

• For pt without red flags in history
• Take a good history-exp find out why pt is
  seeking medical assistance
• cancer phobia
• disability
• interpersonal distress
• sx exacerbation
• Understanding pts motivation will help MD
  address the individuals needs and will result in
  superior outcome.

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IBSWorkup

• Look for dietary and medical causes
• Caffiene, antacids with Mg, anticholinergics,
  CCBD, lactose, sorbitol
• Rule out physical, sexual, emotional abuse-known
  correlation b/t certain GI illnesses and abuse

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IBSWork-up recs by AGA

• Diagnositic studiesCBC and Chem 7-normal in IBS
• If diarrhea predominantTSH, stool studies (3
  separate, fresh samples for op), consider celiac
  dx if of northern european ancestry, fhx, DM I
• Flex sigconsider if gt40yo to exclude malig, or
  young pt to exclude IBD
• This conservative approach misses lt5 of pts
  with other organic dz

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IBSTreatment

• After r/o other dz and rule in IBS, do a 3-6 week
  treatment trial based on symptoms and then
  follow-up
• Treatment Options
• Education
• Dietary Modification
• psycho-social therapy
• pharmacologic medical tx

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IBS TreatmentEducation

• Three Prongedvalidate,reassure,inform
• 1.Validateyes, your dz is uncomfortable and
  inconvenient
• 2.ReassureIBS is a benign dz with a good
  prognosis and you will have a normal life span
• 3.InformIBS is a chronic condition and the
  diagnosis will not change

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IBS TreatmentEducation

• The therapeutic relationship is the most
  important part in pt compliance with IBS. Often
  takes multiple visits to accomplish the trust
  needed for a good outcome.

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IBS TreatmentEducation

• Patients who feel understood(validate), are more
  compliant with their often life-long
  therapy(inform), and feel less anxious therefore
  do better(reassure).
• These pts respond better to limits set by MD and
  have more realistic expectations for results

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IBS TXdietary modification

• Trial of lactose free diet
• For pts c/o gas, exclude foods that increase
  flatulence (beans, onions, celery, carrots, dried
  fruit, wheat germ, simple carbs, bananas)
• Increase fiber-diet and/or commercial bulking
  agents-works by increasing stool bulk and drawing
  in water for better lubrication. Start with
  1/2Tbsp daily

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IBS TXdietary modification

• 2 week food/symptom diary helps to identify
  specific foods that may exacerbate symptoms

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IBS TXPsycho-Social Therapy

• If symptoms are assoc with anxiety, depression,
  identifiable stressors
• Hypnosis, biofeedback, behavioral thearapy-useful
  when IBS sxs assoc with stressors
• Psychotherapy-decrease anxiety and increase
  health promoting behaviors, helps pt tolerate IBS
  sxs

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IBS TXMedications

• Drug therapy is adjunctive tx ONLY, not primary
  mode of tx
• Drug choice depends on sx constellation(diarrhea
  v constipation)
• Minimize chronic use of meds since dz is lifelong

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IBS TXMedications

• Antispasmotics
• Antidepressants
• Antidiarrheals
• Zelnorm
• Lotronex
• Integrative medical choices

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IBS MedsAntispasmotics

• Most frequently used
• Works by selective inhibition of GI smooth muscle
  to decrease colonic activity
• Useful for those with post prandial abd pain,
  gas, bloating, fecal urgency

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IBS MedsAntispasmotics

• Bentyl(dicyclomine)-20mg po qid prn
• Levsin(hyoscyamine)-0.125-0.25mg po or SL tid-qid
  prn
• These act via anticholinergic /antimuscarinic
  properties
• Best use is PRN and prohylactically in
  anticipation of known stressors and exacerbating
  factors

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IBS MedsAntidepressants

• work via analgesic properties which are
  independent of antidepressant properties
• TCAs and SSRIs useful for those with
  neuropathic pain
• TCAs-anticholinergic effects?slow transit time,
  good for diarrhea. Low dose only needed, lower
  than for antidepressant effect
• Amitriptyline, imipramine, nortriptyline-10-25mg
  po qhs, and increase for desired effect. Need
  4-6 weeks to see results

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IBS TXAntidepressants

• SSRIs-Paxil and Prozac 20mg po daily, Zoloft
  100mg po daily
• Useful esp if depression is a cofactor
• Studies showing good results with Zoloft, rec
  continuing for 6-12 months.

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IBS TXantidiarrheal

• Loperamide-PRN only

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IBS TXZelnorm

• GenericTegaserod
• 5-hydroxytryptamine 4 receptor agonist
• Best for women with constipation
• Stimulates colonic motility

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IBS TXLotronex

• Alosetron is generic
• 5-hydroxytryptamine(SRT)3 receptor antagonist
• Was pulled off marked by FDA for association with
  ischemic colitis secondary to severe constipation
• Reinstated but under tight control based on high
  patient demand
• Best for women with diarrhea

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IBS TXIntegrative

• Not well researched
• Options include certain herbal medications,
  probiotics, enzymes, and psychotherapy

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IBSSummary

• Diagnose based on positive sxs and absence of
  red flags, minimal but normal lab work-up
• Take a good history to elicit dietary/drug/ abuse
  as controllable factors
• Treat for 3-6 weeks and reevaluate
• Cornerstone of tx is therapeutic
  relationship-validate, reassure, inform

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IBSSummary

• Use dietary modification for all
  patients-elimination of aggravating foods,
  increasing fiber in diet
• Use psychosocial therapy and medications when
  needed for pts specific syndrome