Management

1

• Management
• of irritable bowel syndrome (IBS)
• WORKSHOP
• Dimitris Karanasios

2
Content

• Knowledge about pathogenesis and diagnosing IBS
• Strategies for achieving symptoms control
• Patients involvement in IBS self-management

3
PATHOGENESIS GUIDELINES

• Pathogenesis of IBS
• Guidelines for IBS management
  (NICE, American Gastrenterology Society, ECPCG)

4
A 43-year-old woman attends your practice

• She complains about pain and discomfort in
  the abdomen as well as a change in the frequency
  of her stools. Defecation improved for the last
  three years but now its not tolerable as she
  says.
• History
• Smoking for 20 years (2p/d)
• Does not consume alcohol
• A history of major depression on her mothers
  side
• Physical examination
• BP 126/84 mmHg
• Weight 68 kg, Height 170 cm, WC 74 cm
• No abdominal or rectal masses, bowels sound
  normal
• Additional examinations
• Abdominal x-rays, abdomen ultrasound (2 months
  ago) both normal

5
INDIVIDUAL EXERCISE

• Establish the patients bowel habit.
• Assess the patients risk for malignancy, paying
  attention to possible red flags.
• Think of other conditions that could be excluded.
• Establish the diagnosis if possible.
• Use IBS guidelines (NICE, American
  Gastrenterology Society, ECPCG),
  Rome III diagnostic criteria, Bristol
  Stool Chart

6
EXAMINATIONS

• The patients condition and common problems
• Necessary additional examinations when IBS
  criteria are met
• Aimless additional examinations

7
IBS EXAMINATIONS (Roma III criteria)
RECOMMENDED NOT RECOMMENDED
1. Full blood count (FBC) 1. Ultrasound
2. Erythrocyte sedimentation rate (ESR) or plasma viscosity 2. Rigid/flexible sigmoidoscopy
3. C-reactive protein (CRP) 3. Colonoscopy Barium enema
4. Antibody testing for coeliac disease (endomysial antibodies EMA or tissue transglutaminase TTG) 4. Hydrogen breath test (for lactose intolerance and bacterial overgrowth)
5. Thyroid function test (TSH)
6. Faecal ova and parasite test
7. Faecal occult blood test
8
GROUP WORK (3 GROUPS)

• PREPARE A PROGRAM FOR
• Giving information that explains the importance
  of self-help in effectively managing the
  patients IBS (information on general lifestyle,
  physical activity, diet and symptom-targeted
  medication)
• Pharmacological therapies (antispasmodic or/and
  laxatives, tricyclics, SSRIs)
• Behavioural and alternative therapies

9
PRESENTATION OF THE PROGRAMS AND DISCUSSION
10
SUMMARY
11
The self-management of IBS

• People with IBS should be given information
  that explains the importance of self-help in
  effectively managing their IBS.
• This should include information on
• general lifestyle
• physical activity
• diet and
• symptom-targeted medication.
• Diagnosis and management of irritable bowel
  syndrome in primary care. National Institute for
  Health and Clinical Excellence (NICE) 2008

12
Pharmacological treatment of IBS

• Decisions about pharmacological management
  should be based on the nature and severity of
  symptoms. The recommendations made below assume
  that the choice of single or combination
  medication is determined by the predominant
  symptom(s).
• Antispasmodic agents
• Laxatives
• Tricyclic antidepressants
• Selective serotonin reuptake inhibitors (SSRIs)
• Diagnosis and management of irritable bowel
  syndrome in primary care. National Institute for
  Health and Clinical Excellence (NICE) 2008

13
Behavioural and alternative therapies in IBS

• Psychological interventions
• Referral for cognitive behavioural therapy CBT,
  hypnotherapy and/or psychological therapy should
  be considered for people with IBS who do not
  respond to pharmacological treatments after 12
  months and who develop a continuing symptom
  profile (described as refractory IBS).
• Complementary and alternative medicine
• The use of acupuncture should not be encouraged
  for the treatment of IBS.
• The use of reflexology should not be encouraged
  for the treatment of IBS.
• Diagnosis and management of irritable bowel
  syndrome in primary care. National Institute for
  Health and Clinical Excellence (NICE) 2008

14
The Rome III Diagnostic Criteria

• A SYSTEM FOR DIAGNOSING FUNCTIONAL
  GASTROINTESTINAL DISORDERS BASED ON SYMPTOMS FOR
  IBS
• Recurrent abdominal pain or discomfort
  at least 3 days per month over the last 3 months
  associated with 2 or more of the following
• Improvement with defecation
• Onset associated with a change in frequency of
  stool
• Onset associated with a change in form
  (appearance) of stool
• Criteria fulfilled for the last 3 months
  with symptom onset at least 6 months prior to
  diagnosis. "Discomfort" means an
  uncomfortable sensation not described as pain.