IBS Presentation

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A presentation on IBS, from P.S.F.P.

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  • The first international categorisation of functional gastrointestinal disorders was presented at the 13th International Congress of Gastroenterology in Rome in 1988. Here, a multinational committee defined functional gastrointestinal disorders as a variable combination of chronic or recurrent gastrointestinal symptoms not explained by structural or biochemical abnormalities (Drossman et al, 1990). Based on epidemiological and clinical data the committee of clinician-investigators identified sub-groups of functional gastrointestinal disorders attributed to the oesophagus, gastroduodenum, intestines, biliary tree, and anorectum.
    The ‘Working Team’ further developed a classification of the functional bowel disorders. Their definition of a functional bowel disorder is shown here.
    References:
    Drossman DA, Thompson WG, Talley NJ, et al. Identification of sub-groups of functional gastrointestinal disorders. Gastroenterology Int 1990; 3: 159-72.
    Thompson WG, Creed F, Drossman DA, et al. Functional bowel disease and functional abdominal pain. Gastroenterology Int 1992; 5: 75-91.
  • This and the following two slides provide historical descriptions and the earliest known uses of various terms that have been used to describe IBS.
    The first reports in medical journals of patients with functional abdominal symptoms appeared in the early nineteenth century. Howship suggested that the disorder was due to ‘a spasmodic stricture in the sigmoide flexure of the colon’.
    During Howship’s time, treatment of ‘spasmodic stricture of the colon’ involved the use of enemas containing turpentine, castor oil, and gruel. Later, Cumming would advocate use of the ‘mustard blister’ and ‘electrogalvanism’.
    References:
    Powell R. On certain painful afflictions of the intestinal canal. Medical Transactions of the Royal College of Physicians 1820; 6: 106-17.
    Howship J. Practical remarks on the discrimination and successful treatment of spasmodic stricture in the colon. Published by Burgess & Hill, London, 1830.
    Cumming W. Electro-galvanism in a peculiar affliction of the mucous membrane of the bowels. London Medical Gazette 1849, NS9: 969-73.
  • In 1892, Sir William Osler first described ‘mucous colitis’ stating that the colonic epithelium was normal and that many patients were hysterical, hypochondriac, self-centred, neurasthenic and suffered from colicky abdominal pains. Osler’s description of mucous colitis included ‘…. a tenacious mucus, which may be slimy and gelatinous, like frog-spawn….’ passed in strings, strips or as a continuous tubular cast of the colon. The casts were made of mucus with cell remnants and concretions called intestinal sand. Osler also reported that some patients were constipated, whilst others had diarrhoea. The abdomen, rarely distended, often contained a tender spot in the left upper quadrant.
    Sir Arthur Hurst also described a mucous colitis in 1921, and later, in 1935, agreed with Osler’s description. He suggested it was a common disorder before 1914 but exceedingly rare since then. Hurst also reported that patients often brought mucus casts to the clinic and passed up to two ounces (50 grams) of intestinal sand in a day. Although frequently referred to, such casts are now rarely seen by physicians.
    In the late 1920’s, Bockus et al referred to a neurogenic mucous colitis, the features of which contrasted with those described by Osler. In 50 patients, Bockus found a characteristically clear mucus. Most patients were constipated, dyspeptic, depressed, introspective, exhausted, emotionally unstable, or asthenic and many had a palpable and tender colon.
    References:
    Osler W. The principles and practice of medicine: designed for the use of practitioners and students of medicine. Published by D Appleton, New York, 1892.
    Hurst AF. Constipation and allied intestinal disorderes. Published by Oxford University Press, Oxford, 1921.
    Hurst AF. The unhappy colon. Lancet 1935; i: 1483-7.
    Bockus HL, Bank J, Wilkinson SA. Neurogenic mucous colitis. Am J Med Sci 1928; 176: 813-29.
  • The ‘Working Team’ also further developed a classification of all functional gastrointestinal disorders, and characterised IBS under the category ‘functional bowel disorders’. They also refined their definition of IBS and this is shown here.
    The principal difference from the definition given by the ‘Working Team’ in Rome in 1988 is that abdominal pain and disordered bowel habit must both be present. It was noted that some may consider this definition too restrictive and would include people without pain if other criteria were sufficiently present.
    Reference:
    Thompson WG, Creed F, Drossman DA, et al. Functional bowel disease and functional abdominal pain. Gastroenterology Int 1992; 5: 75-91.
  • The ‘1998 Working Team’ was sponsored by the pharmaceutical industry. Using a committee consensus approach, the team assessed the terminology and results of clinical research in order to revise the diagnostic criteria, comment further on diagnosis, and summarise treatment recommendations for the functional bowel disorders and functional abdominal pain.
    The committee defined a functional bowel disorder as a functional gastrointestinal disorder with symptoms attributable to the mid or lower gastrointestinal tract, including the IBS, functional abdominal bloating, functional constipation, functional diarrhoea, and unspecified functional bowel disorder.
    Their revised definition of IBS is shown here. The revisions to the definition included the change from ‘disorder’ to ‘disorders’ to acknowledge the multiple pathophysiologic possibilities. In addition, for IBS, ‘discomfort’ was added to ‘pain’ to broaden symptom description, and ‘distension’ was deleted.
    Reference:
    Thompson WG, Longstreth GF, Drossman DA, et al. Functional bowel disorders and functional abdominal pain. Gut 1999; 45 (Suppl. 2): 1143-7.
  • Historically, studies have suggested that the prevalence of IBS is similar world-wide and is probably therefore independent of genetic, environmental or dietary factors in different populations. Estimates of the prevalence of the condition in a number of countries do however range widely, from 5-25%.
    It is uniformly recognised that IBS symptoms are very common in the Western community. More recently it has however been found that the prevalence of IBS may be considerably lower among Eastern populations. Ho et al reported a prevalence of only 2.3% amongst a Singaporean community. IBS was equally uncommon amongst Chinese, Malays and Indians. The reason for the low prevalence of IBS among Asians is unknown.
    References:
    Caballero-Plascencia AM, Sofos-Kontoyannis S, Valenzuela-Barranco M, et al. Irritable bowel syndrome in patients with dyspepsia: a community based study in Southern Europe. Eur J Gastroenterol Hepatol 1999; 11: 517-22.
    Ho KY, Kang JY, Seow A. Prevalence of gastrointestinal symptoms in a multiracial Asian population, with particular reference to reflux-type symptoms. Am J Gastroenterol 1998; 93: 1816-22.
  • The first international guidelines for the diagnosis of IBS were presented by a ‘Working Team’ at the 13th International Congress of Gastroenterology in Rome in 1988. Later, the ’Working Team’ also further developed the classification of functional gastrointestinal disorders and at the same time proposed revised criteria for the diagnosis of IBS.
    The revised guidelines included the proviso that the diagnostic criteria apply only if:
    1. Symptoms are persistent or recurrent for at least three months; and
    2. The symptoms are not attributable to other gastrointestinal disease based on reasonable medical evaluation. The group also defined altered stool frequency which for research purposes they suggested as being >3 bowel movements/day or <3 bowel movements/week.
    These diagnostic criteria, which enabled the physician to make a more confident diagnosis of IBS in most cases have become known as the ‘Rome’ criteria.
    Reference:
    Thompson WG, Creed F, Drossman DA, et al. Functional bowel disease and functional abdominal pain. Gastroenterology Int 1992; 5: 75-91.
  • The ‘1998 Working Team’ was sponsored by the pharmaceutical industry. Using a committee consensus approach, the ‘1998 Working Team’ assessed the terminology and results of clinical research in order to revise the diagnostic criteria, comment further on diagnosis and summarise treatment recommendations for functional bowel disorders and abdominal pain.
    It was determined that a functional bowel disorder is diagnosed by characteristic symptoms for at least 12 weeks during the preceding 12 months and this is reflected by changes to the diagnostic criteria for IBS, referred to as the Rome II criteria. In addition, it was noted that the diagnosis always presumes the absence of a structural or biochemical explanation for the symptoms. The Working Team also revised the description of features in the Rome criteria to clarify how discomfort and pain are temporally related to a change in frequency and form of stool. This they did by adding ‘onset’ to the relevant symptom features.
    In addition to the features shown here, the Working Team listed a number of symptoms cumulatively supporting the diagnosis of IBS and these are shown in the following slide.
    Reference:
    Thompson WG, Longstreth GF, Drossman DA, et al. Functional bowel disorders and functional abdominal pain. Gut 1999; 45 (Suppl. 2): 1143-7.
  • The symptoms shown here were those the Working Team considered cumulatively support the diagnosis of IBS.
    The Team considered these non-pain related symptoms (the second part of the previous Rome criteria) as non-essential due to their poor clustering in factor analyses, their lesser prevalence in men, and the partial duplication in the retained pain related criteria shown in the previous slide.
    The nature of the symptoms was further clarified by replacing the term ‘altered’ with ‘abnormal’.
    Reference:
    Thompson WG, Longstreth GF, Drossman DA, et al. Functional bowel disorders and functional abdominal pain. Gut 1999; 45 (Suppl. 2): 1143-7.
  • The diagnosis of IBS involves identifying certain symptoms consistent with the disorder and excluding other medical conditions having a similar presentation. For this reason a sequential diagnostic strategy is usually recommended that includes the use of symptom-based criteria and a further, conservative evaluation based on the predominant symptom(s).
    Further evaluation may include sigmoidoscopy (or colonoscopy for older patients), examination of the stool for ova and parasites, occult blood or laxatives, and blood studies including full blood picture, sedimentation rate and serum chemistries. In some cases, imaging studies e.g. endoscopy, barium X-ray, computed tomography and scan may be carried out when findings are not typical for IBS (e.g. anaemia, weight loss, blood in stool, fever, abnormal physical findings or blood chemistries).
    Other factors that may influence the diagnostic approach include: the duration and severity of the symptoms; their change or course over previous weeks or months; demographic factors (e.g. older or younger, male or female): the referral status of the patient; findings from previous studies; family history of colon cancer or inflammatory bowel disease; and the presence and degree of psychosocial factors affecting the presentation of the illness.
    References:
    Drossman DA, Whitehead WE, Camilleri M. Irritable bowel syndrome: A technical review for practice guideline development. Gastroenterology 1997; 112: 2120-37.
    Drossman DA. Review article: an integrated approach to the irritable bowel syndrome. Aliment Pharmacol Ther 1999; 13 (Suppl. 2): 3-14.
  • Despite there being a physiological basis for the symptoms of IBS, a clear pathophysiological mechanism has yet to be identified. Research for a mechanism has now been carried out for over half a century. This was initially focused on abnormal motor function, as it was believed that the basis for the symptoms of IBS lie in enhanced gut motility. Investigators studied abnormal motor responses of the colon after, for example, experimental stress, meals or pain. Research to date suggests that quantitative differences in motor reactivity of the gut and increased sensitivity to stimuli (e.g. distension) or spontaneous contractions generate the symptoms of IBS.
    However, abnormalities in motility fail to explain the pain experienced by patients with IBS. This observation led to studies of visceral perception where it was found that IBS patients have excessive sensitivity to distension of the gut. Studies in which the gut was distended by a balloon showed that some patients with IBS experience awareness of distension and pain at balloon pressures and volumes that are significantly lower than those which elicit the same sensations in healthy subjects.
    Further progress resulted in the generation of the hypothesis of a brain-gut interaction, inasmuch as centres in the central nervous system (CNS) are recognised to modulate intestinal motor and sensory activity. It is suggested that normal gastrointestinal function results from a combination of intestinal motor, sensory, autonomic, and CNS activity. Gastrointestinal symptoms in IBS may therefore be a consequence of a disruption in the co-ordination of these systems.
    While there are numerous neurotransmitters found both in the CNS and in the gut, it is 5-hydroxytryptamine (5-HT) that has been the focus of recent attention. Current research into the underlying pathophysiology of IBS is centred on the role of 5-HT as a mediator of gut motility and of visceral sensitivity.
    Reference:
    Drossman DA. Review article: an integrated approach to the irritable bowel syndrome. Aliment Pharmacol Ther 1999; 13 (Suppl. 2): 3-14.
  • It is increasingly being recognised by physicians and healthcare workers that IBS has a significant impact on patients’ quality of life. Patient well-being is a critical component of health and encompasses factors such as physical functioning, mental health and social interaction. Studies have shown that IBS can affect sleep, employment, sexual functioning, leisure, travel, diet, and can cause depression and anxiety (Hahn et al, 1999).
    The decreased health status in patients with IBS has been measured using quality of life questionnaires such as generic Short-Form 36 (SF-36). The SF-36 has been used to compare the impact of IBS on the quality of life relative to other diseases.
    This slide shows that patients with IBS have a poor health-related quality of life, the reduction in which is similar to that seen in patients with other chronic diseases such as diabetes or clinical depression.
    References:
    Hahn BA, Yan S, Strassels S. Impact of irritable bowel syndrome on quality of life and resource use in the United States and United Kingdom. Digestion 1999; 60: 77-81.
    Wells NEJ, Hahn BA, Whorwell PJ. Clinical economics review: irritable bowel syndrome. Aliment Pharmacol Ther 1997; 11: 1019-30.
  • Modern medicine is heading towards a greater emphasis on collection of patient health information and outcome measures. One of the tools created to accomplish this goal is the health-related quality of life questionnaire which adds the dimension of the patient’s own experience with illness and the ramifications of treatment beyond those of traditional clinical markers.
    Hahn et al have described the development and evaluation of the Irritable Bowel Quality of Life Questionnaire (IBSQOL) which was designed specifically for use in patients with IBS. Evaluation of the IBSQOL included testing in over 500 patients which resulted in a measure of quality of life that was both valid and reliable.
    This slide shows quality of life assessed by the IBSQOL in a group of patients with IBS. The theoretical national normative value for individuals without IBS is shown for comparison.
    Reference:
    Hahn BA, Kirchdoerfer LJ, Fullerton S, et al. Evaluation of a new quality of life questionnaire for patients with irritable bowel syndrome. Aliment Pharmacol Ther 1997; 11: 547-52.
  • A questionnaire was sent to people suffering from IBS (Dancey & Backhouse, 1993). They were asked how having IBS affected their lives. These are some of the findings.
    The vast majority of sufferers complained that IBS was not explained fully enough to them - in some instances the sufferers did not even know what IBS meant. At the time of diagnosis, most had not heard of IBS. People wanted information about the condition and how to cope with it.
    Some people were afraid that their symptoms were due to other more serious disease such as cancer or severe ulcerative colitis.
    Sufferers reported that IBS affected their work - three-quarters said they had been absent from work due to IBS. Nearly half of sufferers said that having IBS affected their sex lives.
    IBS sufferers felt isolated, over half knew no one else with IBS. Most said they did not talk about IBS to other people and some made great efforts not to let anyone know about their problems. Even when in pain, sufferers tried to hide their distress.
    Nearly 70% of sufferers said that travel was restricted because of the frequent need to find a toilet. Concern about getting to a toilet could keep sufferers housebound.
    Most respondents said that stress made their IBS worse and had modified their lifestyle as a result.
    Having IBS affected all aspects of sufferers lives; work, leisure, travel and relationships. Sufferers wanted more information about IBS, its possible causes and treatment, and a greater appreciation of their condition.
    Reference:
    Dancey CP, Backhouse S. Towards a better understanding of patients with irritable bowel syndrome. J Adv Nurs 1993; 18: 1443-50.
  • IBS Presentation

    1. 1. 1 IRRITABLE BOWEL SYNDROMEIRRITABLE BOWEL SYNDROME (IBS)(IBS) Dr. Muhammad Imran Associate` Professor Medicine Services Institute of Medical Sciences Visiting Physician & Gastroenterologist Services Hospital, Lahore.
    2. 2. 2 Functional bowel disorderFunctional bowel disorder ……. is a functional gastrointestinal disorder. is a functional gastrointestinal disorder with symptoms attributable to the mid orwith symptoms attributable to the mid or lower gastrointestinal tract. Thelower gastrointestinal tract. The symptoms include abdominal pain,symptoms include abdominal pain, bloating or distension and variousbloating or distension and various symptoms of disordered defecation.symptoms of disordered defecation. ThompsonThompson et alet al, 1992, 1992
    3. 3. 3 IBS: HistoryIBS: History  ‘…‘….occasional pain in the intestines and derangement.occasional pain in the intestines and derangement of their powers of digestion,of their powers of digestion, with flatulence and a sense of suffocation’with flatulence and a sense of suffocation’  Practical remarks on the discrimination and successfulPractical remarks on the discrimination and successful treatment of spasmodic stricturetreatment of spasmodic stricture of the colonof the colon  ‘…‘…. the bowels are at one time constipated, at. the bowels are at one time constipated, at another lax, in the same person.…’another lax, in the same person.…’ Cumming, 1849Cumming, 1849 Howship, 1830Howship, 1830 Powell, 1820Powell, 1820
    4. 4. 4 IBS: HistoryIBS: History  ‘…‘…. a tenacious mucus, which may be. a tenacious mucus, which may be slimy and gelatinous, like frog-spawn….’slimy and gelatinous, like frog-spawn….’  Mucous colitisMucous colitis  Neurogenic mucous colitisNeurogenic mucous colitis BockusBockus et alet al, 1928, 1928 Hurst, 1921Hurst, 1921 Osler, 1892Osler, 1892
    5. 5. 5 IBS: 1992IBS: 1992 ……. a functional bowel disorder in which. a functional bowel disorder in which abdominal pain is associated withabdominal pain is associated with defecation or a change in bowel habitdefecation or a change in bowel habit, and, and with disordered defecation and withwith disordered defecation and with distensiondistension.. ThompsonThompson et alet al, 1992, 1992
    6. 6. 6 IBS: 1999IBS: 1999 ……. comprises a group of functional bowel. comprises a group of functional bowel disorders in which abdominal discomfort ordisorders in which abdominal discomfort or pain is associated with defecation or apain is associated with defecation or a change in bowel habit, and with features ofchange in bowel habit, and with features of disordered defecation.disordered defecation. ThompsonThompson et alet al, 1999, 1999
    7. 7. 7
    8. 8. 8 The Epidemiology ofThe Epidemiology of Irritable Bowel SyndromeIrritable Bowel Syndrome (IBS)(IBS)
    9. 9. 9 World Prevalence of IBSWorld Prevalence of IBS Adapted from Camilleri M, et al. Aliment Pharmacol Ther. 1997;11:3. Muller-Lisners et al. Digestion. 2001;64:200. Canada 13.5% US 10-20% Peru 18% Nigeria 30% France 9.4% UK 22% Australia 12% New Zealand 17% China 23% Japan 25% Germany 12%
    10. 10. 10 14%14% 14%14% 20%20% 9%9% 7-8%7-8% 13%13% 13%13% 25%25% 10%10% 13%13% 22%22% 9%9% 12%12% 15%15% 12%12% 17%17% IBS: PrevalenceIBS: Prevalence
    11. 11. 11 Disease prevalenceDisease prevalence  25% of patients examined by a G.P. suffer from a25% of patients examined by a G.P. suffer from a gastrointestinal disorder, IBS being the most frequentgastrointestinal disorder, IBS being the most frequent Source: American Gastroenterological Association Patients Care Committee, 1997
    12. 12. 12 Prevalence of IBS
    13. 13. 13 The Diagnosis ofThe Diagnosis of Irritable Bowel SyndromeIrritable Bowel Syndrome (IBS)(IBS)
    14. 14. 14 The Positive Diagnosis of IBS:The Positive Diagnosis of IBS: A Symptom-Based ApproachA Symptom-Based Approach Adapted from Paterson et al.Adapted from Paterson et al. Can Med Assoc J.Can Med Assoc J. 1999;161:154.1999;161:154. American Gastroenterological Association.American Gastroenterological Association. Gastroenterology.Gastroenterology. 1997;112:2120.1997;112:2120. Identify Current Primary SymptomsIdentify Current Primary SymptomsIdentify Current Primary SymptomsIdentify Current Primary Symptoms Look for ‘Red Flags’ Based on:Look for ‘Red Flags’ Based on:  HistoryHistory  Physical examPhysical exam  Laboratory testsLaboratory tests Perform Selected Physical and DiagnosticPerform Selected Physical and Diagnostic Tests to Rule Out Organic DiseaseTests to Rule Out Organic Disease Make a Positive DiagnosisMake a Positive Diagnosis  Abdominal pain / discomfort  Bloating  Constipation/Diarrhea
    15. 15. 15 Identify Red FlagsIdentify Red Flags HistoryHistory  Unintentional weight lossUnintentional weight loss  Onset in older patient (>50 years)Onset in older patient (>50 years)  Family history of cancer or IBDFamily history of cancer or IBD Initial labsInitial labs  ↓↓ HGBHGB  ↑↑ WBCWBC  ↑↑ ESRESR  Abnormal chemistryAbnormal chemistry  ↑↑ TSHTSH PhysicalPhysical  Abnormal examsAbnormal exams  Rectal bleeding / obstructionRectal bleeding / obstruction  Positive flexible sigmoidoscopyPositive flexible sigmoidoscopy or colonoscopy (>50 years)or colonoscopy (>50 years) Adapted from a technical review.Adapted from a technical review. Gastroenterology.Gastroenterology. 1997;112:2120.1997;112:2120. Paterson et al.Paterson et al. Can Med Assoc J.Can Med Assoc J. 1999;161:154.1999;161:154. Camilleri et al.Camilleri et al. Aliment Pharmacol Ther.Aliment Pharmacol Ther. 1997;11:3.1997;11:3. Red FlagsRed Flags
    16. 16. 16 The balance of IBS diagnosis
    17. 17. 17 IBS: Rome criteria (1992)IBS: Rome criteria (1992) At least 3 months continuous or recurrent symptoms of: 1. abdominal pain or discomfort which is: a. relieved with defecation, b. and/or associated with a change in frequency of stool, c. and/or associated with a change in consistency of stool; and 2. two or more of the following, at least a quarter of occasions or days: a. altered stool frequency, b. altered stool form (lumpy/hard or loose/watery), c. altered stool passage (straining or urgency, feeling of incomplete evacuation), d. passage of mucus, e. bloating or feeling of abdominal distension. ThompsonThompson et alet al, 1992, 1992
    18. 18. 18 IBS: Rome II criteria (1999)IBS: Rome II criteria (1999) At least 12 weeks, which need not be consecutive, in the preceding 12 months of abdominal discomfort or pain that has two of three features:  relieved with defecation; and/or  onset associated with a change in frequency of stool; and/or  onset associated with a change in form (appearance) of stool. ThompsonThompson et alet al, 1999, 1999
    19. 19. 19 IBS: Rome II criteria (1999)IBS: Rome II criteria (1999) The following symptoms cumulatively support the diagnosis of IBS:  abnormal stool frequency;  abnormal stool form (lumpy/hard or loose/watery stool);  abnormal stool passage (straining, urgency, or feeling of incomplete evacuation);  passage of mucus;  bloating or feeling of abdominal distension. Thompson et al, 1999
    20. 20. 20 Rome III – Irritable BowelRome III – Irritable Bowel SyndromeSyndrome Diagnostic Criteria* for Irritable Bowel SyndromeDiagnostic Criteria* for Irritable Bowel Syndrome  Recurrent abdominal pain or discomfort** at least 3 days per monthRecurrent abdominal pain or discomfort** at least 3 days per month in the last 3 months associated with 2 or more of the following:in the last 3 months associated with 2 or more of the following:  Improvement with defecationImprovement with defecation  Onset associated with a change in frequency of stoolOnset associated with a change in frequency of stool  Onset associated with a change in form (appearance) of stoolOnset associated with a change in form (appearance) of stool *Criteria fulfilled for the last 3 months with symptom onset at least 6 months*Criteria fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis.prior to diagnosis. **Discomfort means an uncomfortable sensation not described as pain.**Discomfort means an uncomfortable sensation not described as pain. Gastroenterology 2006;130:1480-1491Gastroenterology 2006;130:1480-1491
    21. 21. 21 Rome III – Irritable Bowel SyndromeRome III – Irritable Bowel Syndrome http://www.medscape.com/viewarticle/533460http://www.medscape.com/viewarticle/533460 Subtyping Irritable Bowel Syndrome (IBS)Subtyping Irritable Bowel Syndrome (IBS)  The Rome II committee subclassified IBS on the basis of expert opinionThe Rome II committee subclassified IBS on the basis of expert opinion and attempted to incorporate stool frequency, stool form, and defecationand attempted to incorporate stool frequency, stool form, and defecation symptoms.symptoms.  In the Rome III the subclassification was revised to be based solely onIn the Rome III the subclassification was revised to be based solely on stool consistencystool consistency , which has been supported by recent studies., which has been supported by recent studies.  Subclassification of IBS is important because it would likely beSubclassification of IBS is important because it would likely be associated with different treatment choices and pathophysiologicassociated with different treatment choices and pathophysiologic mechanisms.mechanisms.
    22. 22. 22 Rome III – Irritable Bowel SyndromeRome III – Irritable Bowel Syndrome Sub typing IBS by Predominant Stool PatternSub typing IBS by Predominant Stool Pattern Gastroenterology 2006;130:1480-1491Gastroenterology 2006;130:1480-1491 Patients with IBS-M have both hard and loose stools over periods of hours or days, whereas IBS patients with alternating bowel habits change subtype over periods of weeks and months.
    23. 23. 23 IBS: Further evaluationIBS: Further evaluation  SigmoidoscopySigmoidoscopy  Examination of stoolExamination of stool  Blood studiesBlood studies  Imaging studiesImaging studies Drossman, 1997; 1999
    24. 24. 24 The Pathophysiology ofThe Pathophysiology of Irritable Bowel SyndromeIrritable Bowel Syndrome (IBS)(IBS)
    25. 25. 25 IBS: Evolving understandingIBS: Evolving understanding 1950 1960 1970 1980 1990 2000 Abnormal motor function Visceral hyperalgesia Brain-gut interaction 5-HT mediated visceral sensitivity and gut motility Drossman et al, 1999
    26. 26. 26 IBS Pathophysiology Adapted from Camilleri and Choi.Adapted from Camilleri and Choi. Aliment Pharmacol Ther.Aliment Pharmacol Ther. 1997;11:3.1997;11:3. EnhancedEnhanced PerceptionPerception SympatheticSympathetic VagalVagal NucleiNuclei 5-HT5-HT AlteredAltered MotilityMotility VisceralVisceral HypersensitivityHypersensitivity
    27. 27. 27 IBS: Quality of lifeIBS: Quality of life Comparison with other diseasesComparison with other diseases 30 40 50 60 70 80 90 Physicalfunctioning Physicalfunctioning R ole physical R ole physical B ody pain B ody pain G eneralhealth G eneralhealth Vitality VitalitySocialfunctioning SocialfunctioningR ole em otional R ole em otional M entalhealth M entalhealth MeanMean SF-36SF-36 scorescore National normativeNational normative valuevalue Diabetes type IIDiabetes type II IBSIBS Clinical depressionClinical depression WellsWells et alet al, 1997, 1997
    28. 28. 28 IBS: Negative impact onIBS: Negative impact on quality of lifequality of life Theoretical normative valueTheoretical normative value HahnHahn et alet al, 1997, 1997 MeanMean IBSQOLIBSQOL scorescore 30 40 50 60 70 80 90 100 Em otional Em otionalM entalhealth M entalhealth Sleep Sleep Energy Energy Physicalfunctioning Physicalfunctioning D iet D iet Socialrole Socialrole Physicalrole PhysicalroleSexualrelations Sexualrelations IBSIBS
    29. 29. 29 The Management ofThe Management of Irritable Bowel SyndromeIrritable Bowel Syndrome (IBS)(IBS)
    30. 30. 30 DOCTORDOCTOR IBS: Patient's concernsIBS: Patient's concerns What is IBS?What is IBS? Do I haveDo I have cancer?cancer? I can't leadI can't lead a normal lifea normal life I can’t talkI can’t talk to anyoneto anyone about itabout it Where isWhere is the toilet?the toilet? Can it beCan it be treated?treated?
    31. 31. 31 TREATMENTTREATMENT  PATIENT EDUCATIONPATIENT EDUCATION  DIETARY INTERVENTIONDIETARY INTERVENTION  PHARMACOTHERAPYPHARMACOTHERAPY  PSYCHOTHERAPY/COGNITIVE ANDPSYCHOTHERAPY/COGNITIVE AND BAHAVIOR THERAPYBAHAVIOR THERAPY  HYPNOTHERAPYHYPNOTHERAPY
    32. 32. 32 Drug Treatment of IBSDrug Treatment of IBS Abdominal pain/discomfortAbdominal pain/discomfort • Antispasmodics • Antidepressants — TCAs/SSRIs Bloating and distentionBloating and distention • Antiflatulents • Antispasmodics • Dietary modification ConstipationConstipation • Fiber • Laxatives • PEG solutions DiarrheaDiarrhea • Opioids —Loperamide • Cholestyramine AbdominalAbdominal pain/pain/ discomfortdiscomfort Bloating/Bloating/ distentiondistention Altered bowelAltered bowel functionfunction None of these medications effectively treat the multiple symptoms of IBS; they may exacerbate individual symptoms (eg, fiber and bloating, antispasmodic, constipation).

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