by Dr TRẦN NGỌC ÁNH Hà Nội Medical University
Objectives
1.Recognize the typical
clinical presentation for IBS
2.Describe an appropriate
diagnostic plan and ROME III
3.Prescribe an appropriate therapeutic regimens
IBS- Dr Trần Ngọc Ánh
GENERAL CONSIDERATIONS
IBS- a functional bowel disorder : abdominal pain,
IBS-other functional disordes: fibromyalgia, headech,
discomfort, altered bowel habits, absence of detectable structural abnormalities
backache, genitourinary symptoms
IBS- Dr Trần Ngọc Ánh
GENERAL CONSIDERATIONS
Diagnosis: Clinical presentation 10-20% adult, adolescents: symptoms of IBS W/M:2-3; 80% Severe in women
IBS- Dr Trần Ngọc Ánh
IBS- Dr Trần Ngọc Ánh
PATHOPHYSIOLOGY
Abnormal GUT motility
Genetics
Visceral hypersensitivity
IBS
IBS- Dr Trần Ngọc Ánh
PATHOPHYSIOLOGY
IBS- Dr Trần Ngọc Ánh
PATHOPHYSIOLOGY
Psychosocial factor Heightened pain sensitivity to visceral
stimulation of the brain gut axis
Fibromyalgia (49% have IBS) Chronic fatigues syndrome (51%) Chronic pelvic pain (50%) JMTs (64%) Post infections causes: luminal irritation small bowel bacteries over growth, gas, food allergy
IBS- Dr Trần Ngọc Ánh
CLINICAL FEATURES
1.Abdominal pain -Localition: 25% hypogastrium, 20% rightside, 20%
left side, 10% epigastric
-Episodic and crampy -Exacerbated by eating or emotional stress Improved by passage of flatus or stools Worsening during the premenstrual and menstrual
phases
IBS- Dr Trần Ngọc Ánh
CLINICAL FEATURES
2.Altered Bowel Habit -Most consistent clinical feature -Constipation alternaty with diarrhea, usually with
onve of these symptoms predominantly
-Constipations: episodic, continous and
increasingly intractable to laxative . Interrupted with brief periods of diarrhea
-Diarrhea Smll volumes of loose stools (<200mL). Not
IBS- Dr Trần Ngọc Ánh
bleeding. Maybe: passage of large amount mucus
CLINICAL FEATURES
Aggraved by emotional stress or eating Malabsortion or weight loss: not occur 3,Gas and Flatulence -Abdominal distension, increased belching or
flatulence (Increased gas)-Quantitative measurement reveal: no more than a normal amount of intestinal gas
-Impaired transit and tolerance of intestinal gas
loads
-Reflux gas from the distal to the more proximal
IBS- Dr Trần Ngọc Ánh
intestine belching
CLINICAL FEATURES
4,Upper Gastrointestinla symptoms -Dyspepsia, heartburn, nausea, vomiting: 31.7%
IBS 55.6% have dyspepsia
IBS- Dr Trần Ngọc Ánh
Dyspepsia have IBS (7.9% Non dyspepsia have IBS)
CLINICAL FEATURES
Typ of IBS
Typ of IBS
IBS- Dr Trần Ngọc Ánh
75% change subtyps, 29% swith between IBS-C, IBS-D over 1 years
IBS- constipationm34%
IBS diarhea 27%
IBS alternating 39%
IBS- Dr Trần Ngọc Ánh
CLINICAL FEATURES
IBS- Dr Trần Ngọc Ánh
Spectrum of severity in IBS
Mild
Moderate
Severe
Clinical features
Prevalence
70%
25%
55
+++
++
+
Correlation with Physiology
Symptoms
0
+
+++
0
+
+++
Psychosocial difficulties
++
+++
Health care issues
+
IBS- Dr Trần Ngọc Ánh
LABORATORY FINDINGS
Complete blood count Sigmoidoscopy Stool specimens Air contrast barium enema Colonoscopy Exclude lactase deficiency Hydrogen breath test Evaluation after 3 weeks lactase free diet Exclude celiac sprue (Serology test) GI radiography, Gastroscopy, Ultrasonography
IBS- Dr Trần Ngọc Ánh
APPROACH TO THE PATIENT
Careful history, physical examination, establish
the diagnosis
Recurrence of lowel abdominal pain with altered
bowel habits over a period of time without progressive deterioration
Exclude -Disorder for the first time in old age -Persistent diarhea after a 48 h -Nocturnal diarrhea, steatose
IBS- Dr Trần Ngọc Ánh
APPROACH TO THE PATIENT
Young patients
>40 years
If patient have
• Complete blood
• Air contrast barium
count
enema
• Sedimentation rate • Leucocyte or blood
• Colonoscopy
in stool
• Sigmoidoscopy • Stool specimens
• Stool volume
>200ml • OTHER
DIAGNOSTIC
IBS- Dr Trần Ngọc Ánh
APPROACH TO THE PATIENT
Diagnostic criteria for irritable bowel syndrome
ROME
Recurrent abdominal pain or discomfort at least 3 days per month in the last 3 months asscociated with 2 or 3 mor of the following
Improvement with defecation
Onset asscociated with a change in frequency of stool
Onset asscociated with a change in form (appearance of stool)
IBS- Dr Trần Ngọc Ánh
TREATMENT
DIETARY ALTERATIONS
ANTIFLATULENCE THERAPY
SEROTONIN RECEPTION AGONIST, ANTAGONISTS
STOOL BULKING AGENTS
ANTIDEPRESSANT DRUG
CHLORIDE CHANNEL ACTIVATION
ANTISPASMODIC
ANTIDIARRHEAL
IBS- Dr Trần Ngọc Ánh
TREATEMENT
1.Patient counseling and dietary alterations -Chronic and benign -Avoid obvious food precipatant -A meticulous dietary history may reveal substances
(Coffe, disaccharides, legumes, carbbage) aggravate symptoms
-Excessive fructose, artificiel sweteners (sorbitol,
manitol) may cause diarrhea, bloating, crampy, or flatulence
IBS- Dr Trần Ngọc Ánh
TREATEMENT
Good food for IBS IBS-D: low fiber exclusion diet IBS-C: Low fiber plus or minus laxtive IBS-C no bloating: high fiber diet plus or minus laxative
IBS- Dr Trần Ngọc Ánh
TREATEMENT
Avoid food in IBS -Alcohol, caffein related drink Non citrus drink, herbalte -Avoid all: milk butter, yoghurt →soya subtitutes
IBS- Dr Trần Ngọc Ánh
TREATEMENT
Avoid food in IBS: Processed meats, burges, sausages
IBS- Dr Trần Ngọc Ánh
TREATEMENT
Avoid food : Spicy food
Curries, pelpers, chillies, onions, garlic, acidic vinegar, Potatoes
-Spicy
IBS- Dr Trần Ngọc Ánh
TREATEMENT
2.Stool bulking agents High fiber diets, bulking agents (brand, hydrophilic
colloid)
Dietary fiber -Increased stool bulk (the ability of fiber to increased
fecal output of bacteria) -Speeds up colonic transit In diarrhea prone: Can delay transit Fiber suppl with psyllium has been shown to reduce
perception of rectal distension have positive affect on visceral afferent function
IBS- Dr Trần Ngọc Ánh
TREATEMENT
No respons an e in patients with diarrhea or pain Different fiber preparations may have dissimilar effect on selected symptom in IBS. Psyllium : greater improvement in stool pattern and abdominal pain less bloating and distension Stool bulking agents: prevent both excessive
IBS- Dr Trần Ngọc Ánh
hydratation or dehydratation of stool
TREATEMENT
3.Antispasmodic Anticholinergic drugs: relief for symptoms : painful
Synthetic anticholinergics: Dicyclomine(Have less
cramps related to intestinal spasm
effect on mucous membrane secretion and produce fewer undesirable side effects)
4.Antidiarrheal agents -Peripheral actif opiate base agents; Loperamide 2-4mg
Bile acid binder cholestyramine resin
IBS- Dr Trần Ngọc Ánh
every 4-6h up to 12 mg/day
TREATMENT
Symptom
Drug
Dose
Diarrhea
Loperamid Cholestyramine resin Alosetron
2-4g max 12g/d 4g with meals 0.5-1mg bid (for severe, women)
Constipation
Psylium husk Methylcellulose Calcium polycarbophil Lactulose syrup 70% sorbitol Polyethylen glycol Lubiprostone Magnesium hydroxide
3-4g bid with meals 2g bid with meals 1g qd 10-20g bid 15ml bid 17g/250ml water qd 24mg bid 30-60mL qd
Abdominal pain
Qd to qid Start 25-50mg hs Begin small dose, incerease
Smooth muscle hydroxid Tricyclic antidepressant Selective serotonin reuptake inhibitors
IBS- Dr Trần Ngọc Ánh
TREATEMENT
5.Antidepressant drug Desipramine (TCA): most empiric, less
Citalopram (SSRI) ↓se/drug interactions Fluoextine (SSRI) Fewer withdrawal effects Paroxetine (SSRI) Greatest anticholinergic effects of
sedation/constipation than amitriptyline
Buspirone (Azapirone): antianxiety, Bowel relaxation IBS-D; Tricyclic antidepressant IBS –C:Tricylic agent, the selective serotonin reuptake
SSRI
IBS- Dr Trần Ngọc Ánh
inhibitor-SSRP, paroxetic
TREATEMENT
6.Antiflatulant therapy Eat slowly, not chew gum, not drink carbonated
beverages
Avoid flatogenic foods, exercising, losing excess weight, tacking activated charcoat ar safe but unproven remedies
Simethicone, Antibiotic, probiotic? Pancreatic enzymes reduce bloating, gas Tegaserod improves bloating
IBS- Dr Trần Ngọc Ánh
IBS- Dr Trần Ngọc Ánh
TREATEMENT
7.Serotonin reception agonist and antagonists 5HT1agonists (Sumatriptan, Buspirone) ↓early satiety,
5HT3 antagonists(Alosetron, Cilansetra, Ondansetron)
↓antral motility, ↓gastric accomodation
anti diarrhea, antinociceptive, antiemetics
5HT4 antagonists(Tegaserod, Cisapride) prokinetic Alosetron: ↓painful (limiteds its usage) Tegaserod: ↑intestinal and ascending colon transit→↓constipation, bloating (se: diarrhea, Cardiovascular events)
IBS- Dr Trần Ngọc Ánh
TREATEMENT
IBS- Dr Trần Ngọc Ánh
8.Chloride channel activators Lubiprostone: chronic constipation
TREATEMENT
Constipation predominant
Diarrhea predominant
IBS
Pain predominant
Bloating predominant
IBS- Dr Trần Ngọc Ánh
TREATEMENT
1.IBS-Constipations 1.Fiber >20g/day 2.Antidepressants effective for pain, diarrheas,
tend make constipation
3.SSRI improved pain and side effects of diarrhea 4.Tegaserod is intended primarily for the relief of
constipation-predominant IBS
IBS- Dr Trần Ngọc Ánh
TREATEMENT
Alosetron(Lotronex) Antidepressants-Amiltriptyline Probiotics
IBS- Dr Trần Ngọc Ánh
2.IBS –Diarrhea Loperamide 2-4mg/day-4 times daily: ↓loose stools, urgency, fecal soiling,↓ stool frequency, but not- pain, bloating
TREATEMENT
3.IBS Pain predominant Antispasmodic Antimuscarinics (Dicyclomine, Hyoscyfamine) Smooth muscle relaxants (Mebeverine,
Calcium channel blocker(Nifedipine, Pepermint
Pinaverine)
oil)
Antidepressants-Amiltriptyline Probiotics
IBS- Dr Trần Ngọc Ánh
TREATEMENT
Probiotics Recommendation: Antibiotics and probiotics
IBS- Dr Trần Ngọc Ánh
4.IBS Bloating predominant The non absorbed agent Rifaxamin(Xifaxa)↓ global IBS symptoms especially bloating
