Introduction • Exiting and confusing period because of the Definition revolution in the concept of FGID • It relates to the progress of the knowledgeAbdominal Bloating pain – the diversity of etiologic factors – pathophysiological mechanisms so Altered • No single, unifying mechanism has emerged to bowel explain symptoms. motility so • No universally effective therapy for IBS.
IBS history• “. . . occasional pain in the intestines and derangement of their powers of digestion, with flatulence . . .” Powell, 1818• “. . . spasmodic stricture of the colon – an occasional cause for confinement of the bowels . . .” Howship, 1830• “. . . the bowels are at one time constipated, at another time lax, in the same person . . . how the disease has two such different symptoms I do not profess to explain . . .” Cumming, 1849
Rome Diagnostic Criteria for IBSRome III criteria (2006) Rome II criteria ( 1999)• At least 3 months, with onset at least 12 weeks or more in the last 12 months 6 months previously of recurrent of abdominal discomfort or pain with abdominal pain or discomfort** 2 /3 of the following associated with 2 or more of the • Relieved by defecation following: • Associated with a change in• • Improvement with defecation; frequency of stool and/or • Associated with a change in• • Onset associated with a change in consistency of stool frequency of stool;• and/or The second group of criteria included in• • Onset associated with a change in Rome I are now considered supportive form (appearance) of stool rather than mandatory in the diagnosis.**Discomfort means an uncomfortable sensation not described as pain.
Rome III Criteria* – Irritable Bowel Syndrome Recurrent abdominal pain or discomfort at least 3 days/m In the last 3 months associated with 2 or more : Onset Onset Improvement associated with associated with with and and a change in a change in defecation frequency of form stool (appearance) of stool* Criteria fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis. Longstreth G., Gastroenterology 2006
Rome III – Subtypes of IBS 100 75 % Hard or lumpy 50 stools IBS-C IBS-M 25 IBS-U IBS-D 0 0 25 50 75 100 % Loose or watery stools
Does the patient with IBS really need treatment? prevalence Sweden 13% Canada Belgium 8% Denmark 7% 12% UK 22% Netherlands 9% China 23% US France 20% Germany 12%10–20% Spain 13% Japan 25% Nigeria 30%IBS data not included Australia 12% New Zealand 17% Camilleri et al. Aliment Pharmacol Ther 1997;11:3–15 Müller-Lissner et al. Digestion 2001;64:200–4 Drossman. Dig Dis Sci 1993;38:1569–80 Talley. Balliêre’s Clin Gastroenterol 1999;13:371–84 Talley et al. Gastroenterology 1991;101:927–34 Thompson et al. Dig Dis Sci 2002;47:225–35
Worldwide prevalence of IBS 70 60 50Prevalence (%) 40 30 20 10 0 UK1 USA2 New France4 China5 Nigeria6 Denmark7 Zealand3 1 Heaton et al., 1992; 2Longstreth and Wolde-Tsadnik, 1993 3 Welch and Pomare, 1990; 4Bommalaer et al., 1986 5 Bi-zhen and Qi-Ying, 1988; 6Olubuyide et al., 1995; 7Kay et al., 1994
Frequency of IBS vs other important diseases • US prevalence of IBS up to 20% 1 • US prevalence rates for other common diseases 2 – diabetes 3% – asthma 4% – heart disease 8% – hypertension 11% 1 Camilleri and Choi, 1997 2 Adams and Benson, 1991
IBS results in productivity burden Absenteeism from work or school during the last 12 months 14 12 10Days per year 8 6 p=0.0001 4 2 0 IBS Non-IBS Drossman et al., 1993
Physician visits per year 6 5 GI complaintsNumber of visits per year 4 Non-GI complaints 3 2 1 0 IBS Non-IBS Drossman et al., 1993 AGA Teaching Unit in IBS, 1997
Does the patient with IBS really need treatment? Costs of IBS • IBS results in an estimated $20• $8.4 billion estimated direct billion in lost productivity costs charges in 1992. Talley 1995 annually in the US. Martin, 2001 • IBS sufferers use significantly more• 2/3 of expenditures are for indirect healthcare resources than non-IBS costs. Fullerton 1998 sufferers Longstreth 2000 . Drossman WA, 1993
Overlap in the symptomatology of functional GI disorders Functional Functional abdominal abdominal pain bloatingFunctional Functional diarrhea constipation IBS
FIDG : part of a spectrum of disorders characterized by chronic pain and discomfort Primary Degree of overlap with secondary condition(%) diagnosis FMS CFS IBS TMD FMS NA 70 32-80 75 CFS 35-70 NA 58-92 20 IBS 32-65 58-92 NA 32-65 TMD 13-18 20 64 NA MCS 33-55 30 ND ND Dadabhoy D & Claw DJ , 2006
Impact of IBS on QoL compared with other medical conditions IBS-C General population IBS-D Migraine Asthma GERD 90 70SF–36 score 50 30 0 Physical Physical Bodily General Vitality Social Emotional Mental functioning role pain health functioning role health Frank et al. Clin Ther 2002;24:675–89
IBS - Conceptual Model Early Life • Genetics • Environment Psychosocial Factors • LIfe stress • Psychologic state • Coping • Social support CNS ENS Physiology • Motility • Sensation •Inflammaton Outcome IBS • Medications • Symptom • MD visits experience • Daily function • Behavior • Quality of life
Psychosocial Stress and Other Cognitive Factorsmodel of the putative importance of chronic life stress and enteric infection/inflammationand their interactions with both early life factors and concurrent modifying factors,in the genesis of the CNS-ENS dysregulation present in IBS.GI, gastrointestinal; EI, extraintestinal.