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IRRITABLE BOWEL SYNDROMEIRRITABLE BOWEL SYNDROME
(IBS)(IBS)
Dr. Muhammad Imran
Associate` Professor Medicine
Services In...
2
Functional bowel disorderFunctional bowel disorder
……. is a functional gastrointestinal disorder. is a functional gastro...
3
IBS: HistoryIBS: History
 ‘…‘….occasional pain in the intestines and derangement.occasional pain in the intestines and ...
4
IBS: HistoryIBS: History
 ‘…‘…. a tenacious mucus, which may be. a tenacious mucus, which may be
slimy and gelatinous, ...
5
IBS: 1992IBS: 1992
……. a functional bowel disorder in which. a functional bowel disorder in which
abdominal pain is asso...
6
IBS: 1999IBS: 1999
……. comprises a group of functional bowel. comprises a group of functional bowel
disorders in which a...
7
8
The Epidemiology ofThe Epidemiology of
Irritable Bowel SyndromeIrritable Bowel Syndrome
(IBS)(IBS)
9
World Prevalence of IBSWorld Prevalence of IBS
Adapted from Camilleri M, et al. Aliment Pharmacol Ther. 1997;11:3.
Mulle...
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: Prev...
11
Disease prevalenceDisease prevalence
 25% of patients examined by a G.P. suffer from a25% of patients examined by a G....
12
Prevalence of IBS
13
The Diagnosis ofThe Diagnosis of
Irritable Bowel SyndromeIrritable Bowel Syndrome
(IBS)(IBS)
14
The Positive Diagnosis of IBS:The Positive Diagnosis of IBS:
A Symptom-Based ApproachA Symptom-Based Approach
Adapted f...
15
Identify Red FlagsIdentify Red Flags
HistoryHistory
 Unintentional weight lossUnintentional weight loss
 Onset in ol...
16
The balance of IBS diagnosis
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IBS: Rome criteria (1992)IBS: Rome criteria (1992)
At least 3 months continuous or recurrent symptoms of:
1. abdominal ...
18
IBS: Rome II criteria (1999)IBS: Rome II criteria (1999)
At least 12 weeks, which need not be consecutive,
in the prece...
19
IBS: Rome II criteria (1999)IBS: Rome II criteria (1999)
The following symptoms cumulatively support the
diagnosis of I...
20
Rome III – Irritable BowelRome III – Irritable Bowel
SyndromeSyndrome
Diagnostic Criteria* for Irritable Bowel Syndrome...
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Rome III – Irritable Bowel SyndromeRome III – Irritable Bowel Syndrome
http://www.medscape.com/viewarticle/533460http:/...
22
Rome III – Irritable Bowel SyndromeRome III – Irritable Bowel Syndrome
Sub typing IBS by Predominant Stool PatternSub t...
23
IBS: Further evaluationIBS: Further evaluation
 SigmoidoscopySigmoidoscopy
 Examination of stoolExamination of stool
...
24
The Pathophysiology ofThe Pathophysiology of
Irritable Bowel SyndromeIrritable Bowel Syndrome
(IBS)(IBS)
25
IBS: Evolving understandingIBS: Evolving understanding
1950 1960 1970 1980 1990 2000
Abnormal motor function
Visceral h...
26
IBS Pathophysiology
Adapted from Camilleri and Choi.Adapted from Camilleri and Choi. Aliment Pharmacol Ther.Aliment Pha...
27
IBS: Quality of lifeIBS: Quality of life
Comparison with other diseasesComparison with other diseases
30
40
50
60
70
80...
28
IBS: Negative impact onIBS: Negative impact on
quality of lifequality of life
Theoretical normative valueTheoretical no...
29
The Management ofThe Management of
Irritable Bowel SyndromeIrritable Bowel Syndrome
(IBS)(IBS)
30
DOCTORDOCTOR
IBS: Patient's concernsIBS: Patient's concerns
What is IBS?What is IBS?
Do I haveDo I have
cancer?cancer?
...
31
TREATMENTTREATMENT
 PATIENT EDUCATIONPATIENT EDUCATION
 DIETARY INTERVENTIONDIETARY INTERVENTION
 PHARMACOTHERAPYPHA...
32
Drug Treatment of IBSDrug Treatment of IBS
Abdominal pain/discomfortAbdominal pain/discomfort
• Antispasmodics
• Antide...
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IBS Presentation

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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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