1、Irritable Bowel Syndrome,Dr Bruce Davieswww.bradfordvts.co.uk,Sept 2001,Bruce Davies,2,Introduction,First described in 1771. 50% of patients present 35 years old. 70% of sufferers are symptom free after 5 years. GPs will diagnose one new case per week. GPs will see 4-5 patients a week with IBS. Poin
2、t prevalence of 40-50 patients per 2000 patients.,Sept 2001,Bruce Davies,3,What Is IBS?,A syndrome. One mans constipation is another mans normality. Cause unknown. 20% seem to start after an episode of gastroenteritis.,Sept 2001,Bruce Davies,4,Diagnostic Criteria,Rome 11 Diagnostic criteria.Mannings
3、 Criteria.,Sept 2001,Bruce Davies,5,Rome 11 Diagnostic Criteria.,At least 12 weeks history, which need not be consecutive in the last 12 months of abdominal discomfort or pain that has 2 or more of the following: Relieved by defecation. Onset associated with change in stool frequency. Onset associat
4、ed with change in form of the stool.,Sept 2001,Bruce Davies,6,Rome 11 Diagnostic Criteria.,Supportive symptoms. Constipation predominant: one or more of: BO less than 3 times a week. Hard or lumpy stools. Straining during a bowel movement. Diarrhoea predominant: one or more of: More than 3 bowel mov
5、ements per day. Loose mushy or watery stools. Urgency.,Sept 2001,Bruce Davies,7,Rome 11 Diagnostic Criteria.,General: Feeling of incomplete evacuation. Passing mucus per rectum. Abdominal fullness, bloating or swelling.,Sept 2001,Bruce Davies,8,Mannings Criteria.,Three or more features should have b
6、een present for at least 6 months: Pain relieved by defecation. Pain onset associated with more frequent stools. Looser stools with pain onset. Abdominal distension. Mucus in the stool. A feeling of incomplete evacuation after defecation.,Sept 2001,Bruce Davies,9,Associated Symptoms,In people with I
7、BS in hospital OPD. 25% have depression. 25% have anxiety. Patients with IBS symptoms who do not consult doctors population surveys have identical psychological health to general population. In one study 70% of women IBS sufferers have dyspareunia.,Sept 2001,Bruce Davies,10,Associated Symptoms,Stres
8、sful life events are associated. Compared with controls people with IBS are less well educated and have poorer general health. Women:Men = 3:1.,Sept 2001,Bruce Davies,11,Reasons to Refer,Age 45 years at onset. Family history of bowel cancer. Failure of primary care management. Uncertainty of diagnos
9、is. Abnormality on examination or investigation.,Sept 2001,Bruce Davies,12,Urgent Referral,Constant abdominal pain. Constant diarrhoea. Constant distension. Rectal bleeding. Weight loss or malaise.,Sept 2001,Bruce Davies,13,Subtypes,Diarrhoea predominant. Constipation predominant. Pain predominant.,
10、Sept 2001,Bruce Davies,14,Differential Diagnosis,Inflammatory bowel disease. Cancer. Diverticulosis. Endometriosis.A positive diagnosis, based on Mannings criteria may provoke less anxiety than extensive tests.,Sept 2001,Bruce Davies,15,Examination,Results should be normal or non-specific. Abdomen a
11、nd rectal examination. FBC, CRP. No consensus as to whether FOBs or sigmoidoscopy is needed.,Sept 2001,Bruce Davies,16,Treatment,Patients concerns. Explanation. Treatment approaches.,Sept 2001,Bruce Davies,17,Patients Concerns.,Usually very concerned about a serious cause for their symptoms. Take ti
12、me to explore the patients agenda. Remember that investigations may heighten anxiety.,Sept 2001,Bruce Davies,18,Explanation.,Must offer a plausible reason for symptoms. Even if cause is unknown, patients require some explanation. Drawing a parallel with baby colic may help. Stress is currently a soc
13、ially acceptable explanation for many symptoms in life.,Sept 2001,Bruce Davies,19,Treatment Approaches.,Placebo effect of up to 70% in all IBS treatments. Treatment should depend on symptom sub-type. Often considerable overlap between sub-groups.,Sept 2001,Bruce Davies,20,Antidepressants,Poor eviden
14、ce for efficacy. Better evidence for tricyclics. Very little evidence for SSRIs.,Sept 2001,Bruce Davies,21,Diarrhoea Predominant.,Increasing dietary fibre is sensible advice. Fibre varies, 55% of patients will get worse with bran. “Medical fibre” adds to placebo effect. Loperamide may help.,Sept 200
15、1,Bruce Davies,22,Constipation Predominant.,Increased fibre. Osmotic laxatives helpful. Ispaghula husk is one. Stimulant laxatives make symptoms worse. Lactulose may aggravate distension and flatulence.,Sept 2001,Bruce Davies,23,Pain Predominant.,Antispasmodics will help 66%. Mebeverine is probably
16、first choice. Hyoscine 10mg qid can be added. Bloating may be helped by peppermint oil. Nausea may require metoclopramide.,Sept 2001,Bruce Davies,24,Diet,Dietary manipulation may help. Food intolerance is common food allergy is rare. Relaxation therapies may be useful adjunct.,Sept 2001,Bruce Davies
17、,25,Referral,About 15% of patients seen by GPs with IBS are referred. Gastroenterology Mainly upper GI symptoms. General Surgical Lower GI symptoms.,Sept 2001,Bruce Davies,26,Self-help,IBS network, St Johns House, Hither Green Hospital, Hither Green Lane, London SE13 6RU,Sept 2001,Bruce Davies,27,Au
18、dit?,Numbers on repeat prescription for anti-spasmodics. Do they use their drugs as prescribed? What other medications do they use? Referral rates? What investigations are done? Protocol? Formulary?,Sept 2001,Bruce Davies,28,Psychological Thoughts,Should a mental health assessment always be done? Should all therapy be directed at psychological causes? Is IBS a physical or a somatisation disorder?,
