Irritable Bowel Syndrome

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Irritable Bowel Syndrome

• Dr Intekhab Alam
• Department of Medicine
• Postgraduate Medical Institute
• Lady Reading Hospital, Peshawar.

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Objectives

• Describe diagnostic criteria for IBS
• Understand a cost-effective approach to
  diagnosing IBS
• Identify red flags that should alert you to
  further testing or consultation
• Describe a reasonable therapeutic approach based
  on the patients predominant symptom.

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What is Irritable Bowel Syndrome(IBS)?

• A group of functional bowel disorders
• Chronic abdominal complaints without a structural
  or biochemical cause
• Constitutes a major health problem with
  gastrointestinal (GI) symptoms
• The cause of IBS is unknown.
• Affects up to 20 adults in the industrialized
  world
• The condition is more frequent in women.
• The direct medical costs of IBS are US 8
  billion in the US each year.

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Definition (modified Romes Criteria)

• At least 12 weeks (not necessarily consecutive)
  in the preceding 12 months of abd. discomfort or
  pain that cannot be explained by structural or
  biochemical abnormalities and that has at least 2
  of the following 3 features
• 1. Pain is relieved with defecation.
• 2. Its onset is associated with a change in the
  frequency of bowel movements
• 3. Its onset is associated with a change in the
  form of the stool (loose, watery, or
  pellet-like).

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Subclassification of patients

• Supportive symptoms of IBS
• Fewer than 3 bowel movements a week
• More than 3 bowel movements a day
• Hard or lumpy stools
• Loose or watery stools
• Urgency
• Feeling of incomplete bowel movement
• Passing mucus during a bowel movement
• Abdominal fullness, bloating or swelling
• Diarrhea-predominant IBS (IBS-D)
• One or more of 2, 4 or 6 and none of 1, 3 or 5
• Constipation-predominant IBS (IBS-C)
• One or more of 1, 3 or 5 and none of 2, 4 or 6

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Symptoms of IBS

• Abdominal discomfort and pain
• Bloating, mucous in stools, diarrhea,
  constipation, or alternating diarrhea and
  constipation
• Depression, anxiety or stress
• IBS can be subdivided into
• Diarrhea-predominant (IBS-D)
• Constipation-predominant (IBS-C)
• Alternating diarrhea and constipation

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Pathophysiological Features

• 1. Altered Bowel Motility
• 2. Visceral Hypersensitivity
• 3. Psychosocial Factors
• 4. Neurotransmitter Imbalance
• 5. Infection and Inflammation

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Diagnosis

• If there are Red Flags, strongly consider
  investigations to exclude any underlying sinister
  pathology
• Family h/o colonic cancer or IBD.
• Fever.
• Onset age gt50.
• Nocturnal symptoms.
• Anemia.

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Diagnosis

• Red Flags Cont
• Persistent severe diarrhea or constipation.
• Hematochezia or melena.
• Weight Loss.
• Palpable rectal/abdominal mass.

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Investigations

• Intensive and extensive investigations like
  flexible sigmoidoscopy, colonoscopy, EGD, barium
  enema, stool culture should not be recommended
  without red flags
• However
• Stools R/E, CBC with ESR, TSH, S Alb can be
  performed and should be normal.

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Differential Diagnosis

• IBD- Chrons, UC
• Medications- Laxatives, Constipating agents.
• Infection- Parasitic, Bacterial, Viral,
  Opportunistic.
• Malabsorption- Celiac, ChPancreatitis,
• Lactose intolerance
• Endocrine- Hypo/Hyperthyroidism, Diabetes,
  Addisons disease.
• Malignancy.

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Therapeutic Approach

• Establish an empathetic physician-patient
  relationship Reassurance, education, Support
• Identify associated factors and treat
• Anxiety
• Stress
• Social Phobias
• Depression/Dysthymia
• Panic Disorder
• Substance Abuse
• Previous sexual or physical abuse

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Therapeutic Approach

• Dietary Recommendations
• No specific advice has been shown to be
  efficacious in trials
• Expert opinion recommends limiting
• Raw onions, Cucumber, water melon.
• Caffeine..
• Fat.
• Exacerbating items known to the patient

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• The emphasis should be shifted from finding the
  cause of the symptoms to finding a way to cope
  with them .

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Serotonin (5-hydroxytryptamine, 5HT)

• A monoamine neurotransmitter
• Found in cardiovascular tissue, the peripheral
  nervous system, blood cells, and the CNS
• 95 resides in the GI tract
• Serotonergic neurons secrete 5HT
• The function of serotonin is exerted upon its
  interaction with specific receptors.
• 7 distinct families of 5HTreceptors 5HT1, 5HT2,
  5HT3, 5HT4, 5HT5, 5HT6, and 5HT7

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Therapeutic Approach

• Diarrhea-Predominant
• Loperamide 2-4mg up to QID
• Can be used prophylactically with anticipated
  stress
• Cholestyramine 4g 1-6x/day
• Second line, Level C evidence
• Clinidine (0.1 mg bid).
• Alosetron.

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Alosetron in IBS-D

• The first 5HT3 antagonist, approved only for
  female patients by FDA.
• Ischemic Colitis has been reported.
• Not yet available in Pakistan

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Therapeutic Approach

• Constipation-Predominant
• Fiber 20-30g/day
• Start slow and titrate up/may worsen bloating
• Osmotic Laxatives
• Magnesium Citrate
• Lactulose
• Polyethelyne Gylcol
• Tegaserod 6mg bid.
• FDA approved in women for short term use (6
  weeks)
• Diarrhea most common side effect

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Tegaserod in IBS-C

• The first selective serotonin 5HT4 receptor
  partial agonist approved by FDA for the treatment
  of abdominal pain and constipation predominent
  IBS patients
• Now available in Pakistan by different brand
  names.

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Therapeutic Approach

• Pain-Predominant
• Dicyclomine 10-20mg bid to qid
• PRN usage only
• Antispasmotic
• hyoscyamine.
• Mebeverine, Trimebutine..etc etc.
• Amitryptyline 10-25mg qhs
• TCA
• Steinhart and colleagues showed in 1 RCT of 14
  pts that amitriptyline showed global improvement
  in pts. with IBS
• Anticholinergic Side Effects limiting

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Summary

• Use a symptom based approach and reasonable lab
  approach to diagnose IBS
• Identify red flags that may signal an alternative
  diagnosis
• Tailor your treatment to the patients predominant
  symptom
• Treat coexisting factors such as depression and
  anxiety

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Questions?