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THE ILLUSIVE IRRITABLE
ILLNESS OF THE
INTESTINE
DR.RISHIKESAN K.V
SPECIALIST A PHYSICIAN
VENNIYIL MEDICAL CENTRE
SHARJAH
DEFINITION
• IRRITABLE BOWEL SYNDROME IS PREDOMINANTLY A DISORDER
OF CHRONIC PAIN AND ALTERED BOWEL HABITS
• ABSENCE OF ABDOMINAL PAIN PRECLUDES THE DIAGNOSIS OF
IBS
• USUALLY LOWER ABDOMINAL PAIN
• PAIN IS RELATED TO (RELIEVED OR WORSENED BY) BOWEL
MOVEMENTS
• MANY BELIEVE IT AS A NEUROPSYCHIATRIC , GI DISORDER
• SYMPTOMS RARELY OCCURS AT NIGHT WHILE THE PATIENT IS
SLEEPING
IBS ILLUSTRATED
• AMONG THE MOST COMMONLY DIAGNOSED GI CONDITION
• AFFECT QoL AND PRODUCTIVITY
• MOST SYMPTOMATIC AMONG 25-54 Y.AGE
• COMMON AMONG PROFESSIONALS
• WOMEN ARE DIAGNOSED MORE THAN MEN 2-3:1
• HISTORY OF SEXUAL ASSAULT IS LOOSELY CORRELATED
WITH IBS IN AROUND 33% OF FEMALE PTS.WITH IBS
• THERE ARE NO LAB MARKERS THAT INDICATE IBS
CLASSIFICATION OF FUNCTIONAL BOWEL
DISORDERS
ROME IV CRITERIA
ROME IV CRITERIA
• The Rome IV committee defines IBS as reccurent
abdominal pain on an average at least 1 per week that is
associated with at least 2 of the following 3 characteristics:
1. A change in stool form, and /or
2. A change in stool frequency, and/or
3. and/or related with defecation.
• The Criteria must be fulfilled for the last 3 months , with
symptoms onset at least 6 months before diagnosis
Lacy BE et al. Gastroenterology.2016;150 : 1393-1407.
UPDATED ROME IV DIAGNOSTIC
CRITERIA
ROME III CRITERIA
ROME III Vs ROME IV :
WHAT HAS CHANGED
WORLD PREVALENCE OF IBS IS HIGH
oPOOLED GLOBAL
PREVALENCE = 11.2%
(RANGE 1.1 – 45)
oUS PREVALENCE 12%
oAPPROX. 1 IN 10
AMERICANS
oSIGNIFICANT IMPACT ON
QoL
oSIGNIFICANT IMPACT ON
ECONOMY
INCIDENCE
 MOVE OUT
 LEAVE HOME
 CHANGE DIET
 START A NEW JOB
 START AND…..
 END RELATIONSHIP
WHY YOUNG ADULTS ?
QoL OF IBS VS. OTHER CHRONIC AND
EPISODIC ILLNESS
BRISTOL STOOL FORM
• STOOL FORM A MARKER OF WHOLE GUT (COLON) TRANSIT
TIME
• LIQUID STOOLS CORRELATE WITH SHORTER COLON
TRANSIT
• HARDER STOOL CORRELATES WITH LONGER COLON
TRANSIT
• ACTUALLY IT IS A PHYSIOLOGICAL TEST
• AND IT IS A PHYSICAL SIGN !
IRRITABLE BOWEL SYNDROME
SUBTYPES
FACTORS CONTRIBUTING
TO IBS
PATHOPHYSIOLOGY OF
IRRITABLE BOWEL SYNDROME
HYPERALGESIA AND ALLODYNIA
HYPERALGESIA, A LOWERED PAIN THRESHOLD IN
RESPONSE TO STIMULI, IS A CHARACTERISTIC
FEATURE OF IBS.
RESEARCH HAS SHOWN THAT PATIENTS WITH IBS
HAVE A LOWER PAIN THRESHOLD WITH BALLOON
DISTENTION OF THE BOWEL COMPARED WITH NORMAL
PATIENTS (VISCERAL HYPERALGESIA).
THEY MAY ALSO HAVE INCREASED PAIN SENSITIVITY
TO NORMAL INTESTINAL FUNCTION (EG, ALLODYNIA)
PATHOPHYSIOLOGY OF IBS
IBS IN TWINS: BOTH GENES AND
ENVIRONMENT ARE RELEVANT
2% OF IBS LINKED TO A MUTATION:SODIUM
CHANNELOPATHY SCN5A
DYSBIOSIS AND IBS
COLONIC DYSBIOSIS
• IT IS AN ALTERATION IN THE GUT FLORA
• WE HAVE ABOUT 4 POUNDS OF BACTERIA IN THE COLON
• THEY BELONG TO MORE THAN 1000-2000 SPECIES
• THERE ARE MORE LIVING CELLS IN THE COLON THAN IN THE
ENTIRE BODY
• INCREDIBLY DELICATELY BALANCED.
• WHEN THIS BALANCE IS DISTURBED IT CAN ELICIT
INFLAMMATION AND IMMUNE RESPONSE
INCREASED MAST CELLS IN COLON AND
SMALL INTESTINE:A BIOMARKER OF IBS
IBS AS AN IBD
CYTOKINE STORM
PRACTICAL APPROACH TO THE WORK UP
TAKE A
CAREFUL
HISTORY
1
ASSESS FOR
ALARM
FEATURES
2
APPLY
SYMPTOM -
BASED
CRITERIA
(ROME IV)
3
CLASSIFY
APPROPRIATE
SUB-TYPE
BASED ON
SYMPTOMS
4
PERFORM A
THOROUGH
PHYSICAL
EXAM
5
ROME IV DIAGNOSTIC TESTING
• CBC, CRP, STOOL CALPROTECTIN TO EXCLUDE IBD
• ROUTINE THYROID TEST IF CLINICALLY WARRANTED
• CELIAC TEST IN PATIENTS WHO FAIL EMPIRIC THERAPY
• ??? BREATH TEST TO EXCLUDE CARBOHYDRATE
MALABSORPTION IN PATIENTS WITH IBS-D AND PERSISTENT
SYMPTOMS
• COLONOSCOPY (>50 years , Red flags, F h/o CRC, Abnormal PE)
• BILE ACID MALABSORPTION TESTING IN PATIENTS WHO FAIL
EMPIRIC THERAPY
• C.DIFFICILE TESTING AND COLONOSCOPY WITH RANDOM
BIOPSY TO LOOK FOR MICROSCOPIC COLITIS ESP.IN OLDER
WOMEN
SIBO :SMALL INTESTINAL BACTERIAL
OVERGROWTH
BREATH TESTING IS NOT NECESSARY IN THE EVALUATION OF
IBS
IT IS NOT AT ALL A VERY SENSITIVE TEST AND YOU MAY GET
A LOTS OF FALSE POSITIVE RESULTS
YIELD OF LACTULOSE BREATH TEST IS SIMILAR IN HEALTHY
CONTROLS AND IBS PATIENTS
THERE IS NO ESTABLISHED RELATIONSHIP BETWEEN IBS AND
SMALL INTESTINAL BACTERIAL OVERGROWTH (SIBO)
ALARM
FEATURES
OF
ORGANIC
DISORDERS
UNINTENDED WEIGHT LOSS > 10% IN 3
MONTHS
BLOOD IN STOOL NOT DUE TO
HAEMORRHOIDS OR FISSURES
NOCTURNAL SYMPTOMS THAT AWAKEN THE
PATIENT
FEVER , SEVERE PROGRESSIVELY WORSENING SX.
F H/O CRC (POLYPOSIS), CELIAC DISEASE, IBD
IF ALARM FEATURES ARE PRESENT
INVESTIGATE AND TREAT APPROPRIATELY
VALUE OF A COMPLETE
DIGITAL RECTAL EXAM
EMERGING BLOOD BIOMARKERS FOR IBS -D
TEST CAN DETECT IBS-D VS.
OTHER CONDITIONS THAT
PRESENT WITH DIARRHEA
TESTS FOR TWO ANTIBODIES:
1. ANTI-CYTOLETHAL
DISTENDING TOXIN B
(CdtB) LEADS TO THE
PRODUCTION OF :
2. ANTI-VINCULIN ANTIBODY
WHICH CAUSES ALTERED
BOWEL MOTILITY AND
DYSBIOSIS
TEST HAS BETTER
SPECIFICITY THAN
SENSITIVITY
DIAGNOSTIC TEST FOR
CONSTIPATION:ABCD
A
B
C
D
MANAGEMENT OF PATIENTS WITH IBS
oNO CURE EXISTS
oGOAL IS SYMPTOM
MANAGEMENT
oTREATMENT STRATEGY
BASED ON NATURE AND
SEVERITY OF SYMPTOMS
oTAILOR TREATMENT TO
PATIENT
oCORNERSTONE IS A
STRONG PATIENT-
PROVIDER RELATIONSHIP
AND COMMUNICATION
DOES EXERCISE HELP?
TREATMENT- DIETARY MANIPULATION
• ACCORDING TO CURRENT GUIDELINES, THE INITIAL THERAPY
OF IBS SHOULD INCLUDE LIFESTYLE MODIFICATION.
• SEVERAL DIETS HAVE SHOWN EFFICACY IN PATIENTS WITH
IBS.
• THESE DIETS INCLUDE CARBOHYDRATE- AND GLUTEN-
RESTRICTED DIETS (EVEN IN PATIENTS WHO DO NOT HAVE
CELIAC DISEASE)
• A LOW-FODMAP DIET (LIMITED IN FERMENTABLE
OLIGOSACCHARIDES, DISACCHARIDES, AND
MONOSACCHARIDES AND POLYHYDRIC ALCOHOLS) HAS SHOWN
BENEFIT IN CLINICAL TRIALS
• STUDIES HAVE SHOWN THAT THESE DIETS ARE OPTIMUM
WHEN THEY ARE INITIATED AND MONITORED BY A TRAINED
DIETITIAN
IBS AND DIET ; THEN WHAT IS LEFT TO
EAT?
ELIMINATION DIET
IgG ELIMINATION DIET
LOW CARBOHYDRATE
LOW FRUCTOSE/FRUCTAN
LOW GLUTEN
LOW FODMAP:
oLEAN PROTEINS
oGLUTEN FREE BREADS, ROLLS
AND PASTA
oRICE ,CORN,OAT PRODUCTS
oQUINOVA
oSAFE FRUITS AND VEGETABLES:
MANDARIN ORANGES,SNOW
PEAKS
POTENTIAL ROLE OF FODMAPs
• IN SMALL INTESTINE : NON ABSORBED CARBOHYDRATE
INCREASE OSMOTIC LOAD LEADING TO INCREASED BIOMASS
AND ACCELERATED TRANSIT TIME
• IN THE COLON: BACTERIAL FERMENTATION PRODUCE GAS &
SCFA AND MODULATES
1. MOTILITY
2. MICROBIOME
3. VISCERAL SENSITIVITY
4. IMMUNE ACTIVATION AND PERMEABILITY
RESULTS IN GI SYMPTOMS OF PAIN, BLOATING AND ALTERED
BOWEL MOVEMENTS
LOW FODMAP DIET CONCEPT
IBS AND LOW GLUTEN DIET
STUDIES HAVE SHOWN THAT GLUTEN DIET WAS ASSOCIATED
WITH INCREASED SMALL BOWEL PERMEABILITY IN
GEN.PREDISPOSED INDIVIDUALS ESP.AFTER AN INFECTIOUS
DIARRHOEA.
NON CELIAC GLUTEN INTOLERANCE
GLUTEN OPENS UP THE TIGHT JUNCTIONS IN THE GUT
MUCOSA.
THINGS CAN TRICKLE THROUGH FROM THE LUMEN INTO THE
DEEPER LAYERS,
INFLAMMATION AND IMMUNE RESPONSE FOLLOWS
MAST CELLS ARE ACTIVATED,CHEMICALS AND CYTOKINES ARE
RELEASED
PATIENTS WHO DO NOT
HAVE CELIAC DISEASE
MAY FIND RELIEF ON A
GLUTEN-FREE DIET,
ELIMINATING
• FRUCTANS
• FERMENTABLE
OLIGOSACCHARIDES,
• DISACCHARIDES,
• MONOSACCHARIDES,
• POLYHYDRIC
ALCOHOLS
ROLE OF FIBERS IN IBS
ALL PATIENTS SHOULD BE ON HIGH
FIBER DIET 5 GRAMS PER DAY
AEs OF FIBER INCLUDE BLOATING AND
GAS
DO NOT INCREASE BY MORE THAN 5
G/DAY ANY SOONER THAN EVERY 1 TO
2 WEEKS.
WESTERNISED DIET LACKS FIBER
DIETARY FIBER HELPS TO RELIEVE
CONSTIPATION BY STIMULATION OF
MORE MUCUS PRODUCTION
THEY HELP TO ABSORB EXCESS WATER
FROM THE LUMEN OF INTESTINE AND
REGULARISE BOWEL MOVEMENTS
PROBLEMS WITH DIETARY MODIFICATIONS
o POOR COMPLIANCE
o THE DIETS CERTAINLY ARE NOT UNIVERSALLY EFFECTIVE,.
o INSURANCE COMPANIES OFTEN DO NOT COVER THE SERVICES
OF A DIETICIAN,
o AND MANY PATIENTS CANNOT OR WILL NOT PAY OUT OF
POCKET.
STUDIES HAVE DEMONSTRATED THAT UP TO 70% OF PATIENTS
WHO USE OTC THERAPIES ARE DISSATISFIED WITH THEIR
TREATMENT .
PROBIOTICS PUTATIVE MECHANISM
• ANTI INFLAMMATORY EFFECTS
• IMMUNE MODULATION
• COMPETITIVE INHIBITION
• ALTERATION OF INTRALUMINAL pH AND PHYSIOLOGY
• PROVIDES NUTRITION TO COLONOCYTES
• PROMOTES THE PRODUCTION OF VARIOUS SUBSTANCES LIKE
ENZYMES , SCFA,AND BACTERIOCIDAL AGENTS
IBS PHARMACOLOGIC THERAPY BY SYMPTOMS
IBS-C AND CIC
• 1.LUBIPROSTONE : PGE
DERIVATIVE,
• Cl-CHANNEL ACTIVATOR.
• 24mcg PO BID IN CIC
• 8 micrograms PO BID IBS-C
2.LINACLOTIDE: GCC
ACTIVATOR
• 290 micrograms PO DAILY
3.PLECANATIDE (UNDER FDA
REVIEW)
• 3mg.PO DAILY
EFFECTS OF GCC RECEPTOR ACTIVATION
IN IBS-C
TENAPANOR
TENAPANOR , THE NHE3 INHIBITOR IN THE GI
TRACT REDUCE THE ABSORPTION OF DIETARY
SODIUM, LEADING TO INCREASED SODIUM WITHIN
THE GUT.
THIS SODIUM INCREASES FLUID IN THE GUT,
LOOSENING STOOL, THEREBY ALLEVIATING
CONSTIPATION.
TENAPANOR 50MG.BID HAS SHOWN A DESIRED
BENEFIT IN THE ABDOMINAL PAIN ENDPOINT FOR
IBS-C TRIALS
PRESCRIPTION AGENTS FOR IBS-D (FDA APPROVED)
AGENTS MECHANISM INDICATIONS NOTES
ALOSETRON
5-HT3 antagonist; slows
GI motility and potentially
reduces pain
Women with severe IBS-
D who have not responded
adequately to conventional
therapy
Risk of severe
constipation and
ischemic colitis
RIFAXIMIN
Nonabsorbable antibiotic;
likely functions by altering
the gut microbiome
Treatment of IBS-D in
adults
Often requires
retreatment; high
recurrence rate in
responders
ELUXADOLINE
Mixed μ and κ receptor
agonist/δ-opioid receptor
antagonist; decreases GI
motility and improves
abdominal discomfort
Adults with IBS-D Contraindicated in
patients without a GB
or with history of
pancreatitis or
alcohol abuse
ELUXADOLINE
RIFAXIMIN
1
SEMISYNTHETIC
DERIVATIVE OF
RIFAMYCIN
2
NON ABSORBABLE
<1%
3
FDA APPROVAL IN
2015 FOR IBS-D
4
PREVIOUSLY APPROVED
AS TREATMENT FOR
TRAVELER’S DIARRHOEA
DUE TO E.COLI AND IN
ADULTS WITH
RECURRENT HEPATIC
ENCEPHALOPATHY
RIFAXIMIN IMPROVES GLOBAL IBS-D
SYMPTOMS AND BLOATING
OFF LABEL MEDICATIONS
TRICYCLIC
ANTIDEPRESSANTS
REDUCES VISCERAL
AFFERENT
NEURONAL
FIRING,VISCERAL
HYPERSENSITIVITY,
AND PAIN
ADJUNCTIVE TO
PRIMARY THERAPY
LIMITED BY
ADV.EVENTS WITH
HIGHER DOSES
BILE ACID
SEQUESTRANTS
REMOVES THE BILE
ACIDS FROM
CIRCULATION
ADJUNCTIVE TO
PRIMARY THERAPY
THE 7 ALPHA C4
SERUM TEST MAY
HELP IDENTIFY
NEED.EXERCISE
CARE IN TIMING OF
ADMINISTRATION
OF OTHER
MEDICATIONS
ANTIDEPRESSANTS IN IBS
• SUPERIOR TO PLACEBO
• NNT = AROUND 4
• TCAs : LOW DOSE PROBABBLY WORKS AS WELL AS HIGH DOSES
(ANTEDEPRESSANT DOSE)
• START LOW, GO SLOW
• SLOW INTESTINAL TRANSIT-
• CONSIDER TCAs IN IBS –D (BUT CAN IMPROVE ALL SUBTYPES)
AND
• SSRI IN IBS-C
• SSRI/SNRI FOR ANXIETY
BILE ACID SEQUESTRANT
o BILE ACID MALABSORPTION MAY PLAY A ROLE IN CHRONIC
IDIOPATHIC DIARRHEA, INCLUDING BOTH FUNCTIONAL
DIARRHEA AND IBS-D
o BILE ACID SEQUESTRANTS(COLESEVELAM AND
CHOLESTYRAMINE) ARE CHOLESTEROL-LOWERING AGENTS
TAKEN ORALLY.
o THEIR MOST COMMON ADVERSE EVENT IS CONSTIPATION.
o THE 7ΑC4 SERUM TEST, MAY ALLOW US TO IDENTIFY
PATIENTS WHO MIGHT BENEFIT FROM EARLY INITIATION OF
BILE ACID SEQUESTRANTS.
o BEST TEST 75SeHCAT
TAKE HOME MESSAGE
• IBS IS VERY PREVALENT
• IT IS A SYMPTOM BASED POSITIVE DIAGNOSIS
• IMPACTS QoL AND PRODUCTIVITY
• HETEROGENEOUS PATHOGENESIS
• NOT JUST ONE DISEASES,BUT SEVERAL DISEASES
• A LOW FODMAP DIET IMPROVES Q0L AND REDUCES ACTIVITY
IMPAIRMENT IN IBS PATIENTS
• MANY FAIL STANDARD THERAPY
• NEW TREATMENTS WITH NOVEL MECHANISM OF
ACTION,PROVIDE A GREAT OPPORTUNITY TO IMPROVE
PATIENTS IBS SYMPTOMS
REFERENCES
• Lacy BE et al. Gastroenterology.2016;150 : 1393-1407.
• Longstreth GF et al. Gastroenterology.2016;130:1480-91
• Bengtson et al.Gut.2006 ;55:1754-9
• Beyder , Tally et al.Gastroenterology.2014;146:1659-68
• Simren M. Gastroenterology 2014;146:10-12
• Wade PR et al. Br J Pharmacol.2012;167:1111-1125
• http://Medscape.org
• Spiller RC, et al.Gut.2000;47:804-811
• Barbara G , et al.Gastroenterology.2007;132:26-37
• Pimentel M , et al. NEJM.2011;364:22-32

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The Elusive Irritable Illness of the Intestine: Understanding IBS

  • 1. THE ILLUSIVE IRRITABLE ILLNESS OF THE INTESTINE DR.RISHIKESAN K.V SPECIALIST A PHYSICIAN VENNIYIL MEDICAL CENTRE SHARJAH
  • 2. DEFINITION • IRRITABLE BOWEL SYNDROME IS PREDOMINANTLY A DISORDER OF CHRONIC PAIN AND ALTERED BOWEL HABITS • ABSENCE OF ABDOMINAL PAIN PRECLUDES THE DIAGNOSIS OF IBS • USUALLY LOWER ABDOMINAL PAIN • PAIN IS RELATED TO (RELIEVED OR WORSENED BY) BOWEL MOVEMENTS • MANY BELIEVE IT AS A NEUROPSYCHIATRIC , GI DISORDER • SYMPTOMS RARELY OCCURS AT NIGHT WHILE THE PATIENT IS SLEEPING
  • 3. IBS ILLUSTRATED • AMONG THE MOST COMMONLY DIAGNOSED GI CONDITION • AFFECT QoL AND PRODUCTIVITY • MOST SYMPTOMATIC AMONG 25-54 Y.AGE • COMMON AMONG PROFESSIONALS • WOMEN ARE DIAGNOSED MORE THAN MEN 2-3:1 • HISTORY OF SEXUAL ASSAULT IS LOOSELY CORRELATED WITH IBS IN AROUND 33% OF FEMALE PTS.WITH IBS • THERE ARE NO LAB MARKERS THAT INDICATE IBS
  • 6. ROME IV CRITERIA • The Rome IV committee defines IBS as reccurent abdominal pain on an average at least 1 per week that is associated with at least 2 of the following 3 characteristics: 1. A change in stool form, and /or 2. A change in stool frequency, and/or 3. and/or related with defecation. • The Criteria must be fulfilled for the last 3 months , with symptoms onset at least 6 months before diagnosis Lacy BE et al. Gastroenterology.2016;150 : 1393-1407.
  • 7. UPDATED ROME IV DIAGNOSTIC CRITERIA
  • 9. ROME III Vs ROME IV : WHAT HAS CHANGED
  • 10. WORLD PREVALENCE OF IBS IS HIGH oPOOLED GLOBAL PREVALENCE = 11.2% (RANGE 1.1 – 45) oUS PREVALENCE 12% oAPPROX. 1 IN 10 AMERICANS oSIGNIFICANT IMPACT ON QoL oSIGNIFICANT IMPACT ON ECONOMY
  • 12.  MOVE OUT  LEAVE HOME  CHANGE DIET  START A NEW JOB  START AND…..  END RELATIONSHIP WHY YOUNG ADULTS ?
  • 13. QoL OF IBS VS. OTHER CHRONIC AND EPISODIC ILLNESS
  • 14. BRISTOL STOOL FORM • STOOL FORM A MARKER OF WHOLE GUT (COLON) TRANSIT TIME • LIQUID STOOLS CORRELATE WITH SHORTER COLON TRANSIT • HARDER STOOL CORRELATES WITH LONGER COLON TRANSIT • ACTUALLY IT IS A PHYSIOLOGICAL TEST • AND IT IS A PHYSICAL SIGN !
  • 16.
  • 19. HYPERALGESIA AND ALLODYNIA HYPERALGESIA, A LOWERED PAIN THRESHOLD IN RESPONSE TO STIMULI, IS A CHARACTERISTIC FEATURE OF IBS. RESEARCH HAS SHOWN THAT PATIENTS WITH IBS HAVE A LOWER PAIN THRESHOLD WITH BALLOON DISTENTION OF THE BOWEL COMPARED WITH NORMAL PATIENTS (VISCERAL HYPERALGESIA). THEY MAY ALSO HAVE INCREASED PAIN SENSITIVITY TO NORMAL INTESTINAL FUNCTION (EG, ALLODYNIA)
  • 21. IBS IN TWINS: BOTH GENES AND ENVIRONMENT ARE RELEVANT
  • 22. 2% OF IBS LINKED TO A MUTATION:SODIUM CHANNELOPATHY SCN5A
  • 24. COLONIC DYSBIOSIS • IT IS AN ALTERATION IN THE GUT FLORA • WE HAVE ABOUT 4 POUNDS OF BACTERIA IN THE COLON • THEY BELONG TO MORE THAN 1000-2000 SPECIES • THERE ARE MORE LIVING CELLS IN THE COLON THAN IN THE ENTIRE BODY • INCREDIBLY DELICATELY BALANCED. • WHEN THIS BALANCE IS DISTURBED IT CAN ELICIT INFLAMMATION AND IMMUNE RESPONSE
  • 25. INCREASED MAST CELLS IN COLON AND SMALL INTESTINE:A BIOMARKER OF IBS
  • 26. IBS AS AN IBD
  • 28. PRACTICAL APPROACH TO THE WORK UP TAKE A CAREFUL HISTORY 1 ASSESS FOR ALARM FEATURES 2 APPLY SYMPTOM - BASED CRITERIA (ROME IV) 3 CLASSIFY APPROPRIATE SUB-TYPE BASED ON SYMPTOMS 4 PERFORM A THOROUGH PHYSICAL EXAM 5
  • 29. ROME IV DIAGNOSTIC TESTING • CBC, CRP, STOOL CALPROTECTIN TO EXCLUDE IBD • ROUTINE THYROID TEST IF CLINICALLY WARRANTED • CELIAC TEST IN PATIENTS WHO FAIL EMPIRIC THERAPY • ??? BREATH TEST TO EXCLUDE CARBOHYDRATE MALABSORPTION IN PATIENTS WITH IBS-D AND PERSISTENT SYMPTOMS • COLONOSCOPY (>50 years , Red flags, F h/o CRC, Abnormal PE) • BILE ACID MALABSORPTION TESTING IN PATIENTS WHO FAIL EMPIRIC THERAPY • C.DIFFICILE TESTING AND COLONOSCOPY WITH RANDOM BIOPSY TO LOOK FOR MICROSCOPIC COLITIS ESP.IN OLDER WOMEN
  • 30. SIBO :SMALL INTESTINAL BACTERIAL OVERGROWTH BREATH TESTING IS NOT NECESSARY IN THE EVALUATION OF IBS IT IS NOT AT ALL A VERY SENSITIVE TEST AND YOU MAY GET A LOTS OF FALSE POSITIVE RESULTS YIELD OF LACTULOSE BREATH TEST IS SIMILAR IN HEALTHY CONTROLS AND IBS PATIENTS THERE IS NO ESTABLISHED RELATIONSHIP BETWEEN IBS AND SMALL INTESTINAL BACTERIAL OVERGROWTH (SIBO)
  • 31.
  • 32. ALARM FEATURES OF ORGANIC DISORDERS UNINTENDED WEIGHT LOSS > 10% IN 3 MONTHS BLOOD IN STOOL NOT DUE TO HAEMORRHOIDS OR FISSURES NOCTURNAL SYMPTOMS THAT AWAKEN THE PATIENT FEVER , SEVERE PROGRESSIVELY WORSENING SX. F H/O CRC (POLYPOSIS), CELIAC DISEASE, IBD IF ALARM FEATURES ARE PRESENT INVESTIGATE AND TREAT APPROPRIATELY
  • 33. VALUE OF A COMPLETE DIGITAL RECTAL EXAM
  • 34. EMERGING BLOOD BIOMARKERS FOR IBS -D TEST CAN DETECT IBS-D VS. OTHER CONDITIONS THAT PRESENT WITH DIARRHEA TESTS FOR TWO ANTIBODIES: 1. ANTI-CYTOLETHAL DISTENDING TOXIN B (CdtB) LEADS TO THE PRODUCTION OF : 2. ANTI-VINCULIN ANTIBODY WHICH CAUSES ALTERED BOWEL MOTILITY AND DYSBIOSIS TEST HAS BETTER SPECIFICITY THAN SENSITIVITY
  • 36. MANAGEMENT OF PATIENTS WITH IBS oNO CURE EXISTS oGOAL IS SYMPTOM MANAGEMENT oTREATMENT STRATEGY BASED ON NATURE AND SEVERITY OF SYMPTOMS oTAILOR TREATMENT TO PATIENT oCORNERSTONE IS A STRONG PATIENT- PROVIDER RELATIONSHIP AND COMMUNICATION
  • 38. TREATMENT- DIETARY MANIPULATION • ACCORDING TO CURRENT GUIDELINES, THE INITIAL THERAPY OF IBS SHOULD INCLUDE LIFESTYLE MODIFICATION. • SEVERAL DIETS HAVE SHOWN EFFICACY IN PATIENTS WITH IBS. • THESE DIETS INCLUDE CARBOHYDRATE- AND GLUTEN- RESTRICTED DIETS (EVEN IN PATIENTS WHO DO NOT HAVE CELIAC DISEASE) • A LOW-FODMAP DIET (LIMITED IN FERMENTABLE OLIGOSACCHARIDES, DISACCHARIDES, AND MONOSACCHARIDES AND POLYHYDRIC ALCOHOLS) HAS SHOWN BENEFIT IN CLINICAL TRIALS • STUDIES HAVE SHOWN THAT THESE DIETS ARE OPTIMUM WHEN THEY ARE INITIATED AND MONITORED BY A TRAINED DIETITIAN
  • 39.
  • 40.
  • 41. IBS AND DIET ; THEN WHAT IS LEFT TO EAT? ELIMINATION DIET IgG ELIMINATION DIET LOW CARBOHYDRATE LOW FRUCTOSE/FRUCTAN LOW GLUTEN LOW FODMAP: oLEAN PROTEINS oGLUTEN FREE BREADS, ROLLS AND PASTA oRICE ,CORN,OAT PRODUCTS oQUINOVA oSAFE FRUITS AND VEGETABLES: MANDARIN ORANGES,SNOW PEAKS
  • 42. POTENTIAL ROLE OF FODMAPs • IN SMALL INTESTINE : NON ABSORBED CARBOHYDRATE INCREASE OSMOTIC LOAD LEADING TO INCREASED BIOMASS AND ACCELERATED TRANSIT TIME • IN THE COLON: BACTERIAL FERMENTATION PRODUCE GAS & SCFA AND MODULATES 1. MOTILITY 2. MICROBIOME 3. VISCERAL SENSITIVITY 4. IMMUNE ACTIVATION AND PERMEABILITY RESULTS IN GI SYMPTOMS OF PAIN, BLOATING AND ALTERED BOWEL MOVEMENTS
  • 43. LOW FODMAP DIET CONCEPT
  • 44. IBS AND LOW GLUTEN DIET STUDIES HAVE SHOWN THAT GLUTEN DIET WAS ASSOCIATED WITH INCREASED SMALL BOWEL PERMEABILITY IN GEN.PREDISPOSED INDIVIDUALS ESP.AFTER AN INFECTIOUS DIARRHOEA. NON CELIAC GLUTEN INTOLERANCE GLUTEN OPENS UP THE TIGHT JUNCTIONS IN THE GUT MUCOSA. THINGS CAN TRICKLE THROUGH FROM THE LUMEN INTO THE DEEPER LAYERS, INFLAMMATION AND IMMUNE RESPONSE FOLLOWS MAST CELLS ARE ACTIVATED,CHEMICALS AND CYTOKINES ARE RELEASED
  • 45. PATIENTS WHO DO NOT HAVE CELIAC DISEASE MAY FIND RELIEF ON A GLUTEN-FREE DIET, ELIMINATING • FRUCTANS • FERMENTABLE OLIGOSACCHARIDES, • DISACCHARIDES, • MONOSACCHARIDES, • POLYHYDRIC ALCOHOLS
  • 46. ROLE OF FIBERS IN IBS ALL PATIENTS SHOULD BE ON HIGH FIBER DIET 5 GRAMS PER DAY AEs OF FIBER INCLUDE BLOATING AND GAS DO NOT INCREASE BY MORE THAN 5 G/DAY ANY SOONER THAN EVERY 1 TO 2 WEEKS. WESTERNISED DIET LACKS FIBER DIETARY FIBER HELPS TO RELIEVE CONSTIPATION BY STIMULATION OF MORE MUCUS PRODUCTION THEY HELP TO ABSORB EXCESS WATER FROM THE LUMEN OF INTESTINE AND REGULARISE BOWEL MOVEMENTS
  • 47. PROBLEMS WITH DIETARY MODIFICATIONS o POOR COMPLIANCE o THE DIETS CERTAINLY ARE NOT UNIVERSALLY EFFECTIVE,. o INSURANCE COMPANIES OFTEN DO NOT COVER THE SERVICES OF A DIETICIAN, o AND MANY PATIENTS CANNOT OR WILL NOT PAY OUT OF POCKET. STUDIES HAVE DEMONSTRATED THAT UP TO 70% OF PATIENTS WHO USE OTC THERAPIES ARE DISSATISFIED WITH THEIR TREATMENT .
  • 48. PROBIOTICS PUTATIVE MECHANISM • ANTI INFLAMMATORY EFFECTS • IMMUNE MODULATION • COMPETITIVE INHIBITION • ALTERATION OF INTRALUMINAL pH AND PHYSIOLOGY • PROVIDES NUTRITION TO COLONOCYTES • PROMOTES THE PRODUCTION OF VARIOUS SUBSTANCES LIKE ENZYMES , SCFA,AND BACTERIOCIDAL AGENTS
  • 50. IBS-C AND CIC • 1.LUBIPROSTONE : PGE DERIVATIVE, • Cl-CHANNEL ACTIVATOR. • 24mcg PO BID IN CIC • 8 micrograms PO BID IBS-C 2.LINACLOTIDE: GCC ACTIVATOR • 290 micrograms PO DAILY 3.PLECANATIDE (UNDER FDA REVIEW) • 3mg.PO DAILY
  • 51. EFFECTS OF GCC RECEPTOR ACTIVATION IN IBS-C
  • 52. TENAPANOR TENAPANOR , THE NHE3 INHIBITOR IN THE GI TRACT REDUCE THE ABSORPTION OF DIETARY SODIUM, LEADING TO INCREASED SODIUM WITHIN THE GUT. THIS SODIUM INCREASES FLUID IN THE GUT, LOOSENING STOOL, THEREBY ALLEVIATING CONSTIPATION. TENAPANOR 50MG.BID HAS SHOWN A DESIRED BENEFIT IN THE ABDOMINAL PAIN ENDPOINT FOR IBS-C TRIALS
  • 53. PRESCRIPTION AGENTS FOR IBS-D (FDA APPROVED) AGENTS MECHANISM INDICATIONS NOTES ALOSETRON 5-HT3 antagonist; slows GI motility and potentially reduces pain Women with severe IBS- D who have not responded adequately to conventional therapy Risk of severe constipation and ischemic colitis RIFAXIMIN Nonabsorbable antibiotic; likely functions by altering the gut microbiome Treatment of IBS-D in adults Often requires retreatment; high recurrence rate in responders ELUXADOLINE Mixed μ and κ receptor agonist/δ-opioid receptor antagonist; decreases GI motility and improves abdominal discomfort Adults with IBS-D Contraindicated in patients without a GB or with history of pancreatitis or alcohol abuse
  • 55. RIFAXIMIN 1 SEMISYNTHETIC DERIVATIVE OF RIFAMYCIN 2 NON ABSORBABLE <1% 3 FDA APPROVAL IN 2015 FOR IBS-D 4 PREVIOUSLY APPROVED AS TREATMENT FOR TRAVELER’S DIARRHOEA DUE TO E.COLI AND IN ADULTS WITH RECURRENT HEPATIC ENCEPHALOPATHY
  • 56. RIFAXIMIN IMPROVES GLOBAL IBS-D SYMPTOMS AND BLOATING
  • 57. OFF LABEL MEDICATIONS TRICYCLIC ANTIDEPRESSANTS REDUCES VISCERAL AFFERENT NEURONAL FIRING,VISCERAL HYPERSENSITIVITY, AND PAIN ADJUNCTIVE TO PRIMARY THERAPY LIMITED BY ADV.EVENTS WITH HIGHER DOSES BILE ACID SEQUESTRANTS REMOVES THE BILE ACIDS FROM CIRCULATION ADJUNCTIVE TO PRIMARY THERAPY THE 7 ALPHA C4 SERUM TEST MAY HELP IDENTIFY NEED.EXERCISE CARE IN TIMING OF ADMINISTRATION OF OTHER MEDICATIONS
  • 58. ANTIDEPRESSANTS IN IBS • SUPERIOR TO PLACEBO • NNT = AROUND 4 • TCAs : LOW DOSE PROBABBLY WORKS AS WELL AS HIGH DOSES (ANTEDEPRESSANT DOSE) • START LOW, GO SLOW • SLOW INTESTINAL TRANSIT- • CONSIDER TCAs IN IBS –D (BUT CAN IMPROVE ALL SUBTYPES) AND • SSRI IN IBS-C • SSRI/SNRI FOR ANXIETY
  • 59. BILE ACID SEQUESTRANT o BILE ACID MALABSORPTION MAY PLAY A ROLE IN CHRONIC IDIOPATHIC DIARRHEA, INCLUDING BOTH FUNCTIONAL DIARRHEA AND IBS-D o BILE ACID SEQUESTRANTS(COLESEVELAM AND CHOLESTYRAMINE) ARE CHOLESTEROL-LOWERING AGENTS TAKEN ORALLY. o THEIR MOST COMMON ADVERSE EVENT IS CONSTIPATION. o THE 7ΑC4 SERUM TEST, MAY ALLOW US TO IDENTIFY PATIENTS WHO MIGHT BENEFIT FROM EARLY INITIATION OF BILE ACID SEQUESTRANTS. o BEST TEST 75SeHCAT
  • 60. TAKE HOME MESSAGE • IBS IS VERY PREVALENT • IT IS A SYMPTOM BASED POSITIVE DIAGNOSIS • IMPACTS QoL AND PRODUCTIVITY • HETEROGENEOUS PATHOGENESIS • NOT JUST ONE DISEASES,BUT SEVERAL DISEASES • A LOW FODMAP DIET IMPROVES Q0L AND REDUCES ACTIVITY IMPAIRMENT IN IBS PATIENTS • MANY FAIL STANDARD THERAPY • NEW TREATMENTS WITH NOVEL MECHANISM OF ACTION,PROVIDE A GREAT OPPORTUNITY TO IMPROVE PATIENTS IBS SYMPTOMS
  • 61. REFERENCES • Lacy BE et al. Gastroenterology.2016;150 : 1393-1407. • Longstreth GF et al. Gastroenterology.2016;130:1480-91 • Bengtson et al.Gut.2006 ;55:1754-9 • Beyder , Tally et al.Gastroenterology.2014;146:1659-68 • Simren M. Gastroenterology 2014;146:10-12 • Wade PR et al. Br J Pharmacol.2012;167:1111-1125 • http://Medscape.org • Spiller RC, et al.Gut.2000;47:804-811 • Barbara G , et al.Gastroenterology.2007;132:26-37 • Pimentel M , et al. NEJM.2011;364:22-32