1、Irritable Bowel Syndrome,Dr Intekhab Alam Department of Medicine Postgraduate Medical Institute Lady Reading Hospital, Peshawar.,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 consu
2、ltation Describe a reasonable therapeutic approach based on the patients predominant symptom.,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 (
3、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.,Definition (modified Romes Criteria),At least 12 weeks (not necessarily consecutive) in the
4、 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 as
5、sociated with a change in the form of the stool (loose, watery, or pellet-like).,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 Pas
6、sing 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,Symptoms of IBS,Abdominal discomfort and pain Bloating, muco
7、us 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,Pathophysiological Features,1. Altered Bowel Motility 2. Viscera
8、l Hypersensitivity 3. Psychosocial Factors 4. Neurotransmitter Imbalance 5. Infection and Inflammation,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 50. Nocturnal symptoms. Anemia.,D
9、iagnosis,Red Flags Cont:Persistent severe diarrhea or constipation. Hematochezia or melena. Weight Loss. Palpable rectal/abdominal mass.,Investigations:,Intensive and extensive investigations like flexible sigmoidoscopy, colonoscopy, EGD, barium enema, stool culture should not be recommended without
10、 red flags: However: Stools R/E, CBC with ESR, TSH, S Alb can be performed and should be normal.,Differential Diagnosis,IBD- Chrons, UC Medications- Laxatives, Constipating agents. Infection- Parasitic, Bacterial, Viral, Opportunistic. Malabsorption- Celiac, Ch:Pancreatitis, Lactose intolerance Endo
11、crine- Hypo/Hyperthyroidism, Diabetes, Addisons disease. Malignancy.,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 Pr
12、evious sexual or physical abuse,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,The emphasis should be shifted from
13、“finding the cause” of the symptoms to finding “a way to cope with them” .,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 funct
14、ion of serotonin is exerted upon its interaction with specific receptors. 7 distinct families of 5HTreceptors; 5HT1, 5HT2, 5HT3, 5HT4, 5HT5, 5HT6, and 5HT7,Therapeutic Approach,Diarrhea-Predominant Loperamide 2-4mg up to QID Can be used prophylactically with anticipated stressCholestyramine 4g 1-6x/
15、day Second line, Level C evidenceClinidine (0.1 mg bid).Alosetron.,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,Therapeutic Approach,Constipation-Predominant Fiber 20-30g/day Start slow and ti
16、trate 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,Tegaserod in IBS-C,The first selective serotonin 5HT4 receptor partial agonist approved by FDA for the
17、 treatment of abdominal pain and constipation predominent IBS patients Now available in Pakistan by different brand names.,Therapeutic Approach,Pain-Predominant Dicyclomine 10-20mg bid to qid PRN usage only Antispasmotichyoscyamine. Mebeverine, Trimebutineetc etc. Amitryptyline 10-25mg qhs TCA Stein
18、hart and colleagues showed in 1 RCT of 14 pts that amitriptyline showed global improvement in pts. with IBS Anticholinergic Side Effects limiting,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,Questions?,
