Irritable Bowel Disease

2,513 views

Published on

Published in: Education
0 Comments
6 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
2,513
On SlideShare
0
From Embeds
0
Number of Embeds
3
Actions
Shares
0
Downloads
236
Comments
0
Likes
6
Embeds 0
No embeds

No notes for slide

Irritable Bowel Disease

  1. 1. Irritable Bowel Syndrome (IBS) Rakesh Kumar.Adi M.D.(D.M)
  2. 2. <ul><li>In GE OP , > 30% of patients have functional gastrointestinal disorders. </li></ul><ul><li>IBS is the most common functional bowel disorder . </li></ul><ul><li>In 1966, DeLor coined the term to the irritable bowel syndrome (IBS) , defining it as a functional enteropathy. </li></ul>
  3. 3. <ul><li>IBS is defined as “a functional bowel </li></ul><ul><li>disorder in which abdominal pain is </li></ul><ul><li>associated with defecation or a change in </li></ul><ul><li>bowel habits” </li></ul>Thompson et al. Gut. 1999;1143-1147.
  4. 4. EPIDEMIOLOGY <ul><li>IBS is a common disorder all over the world. </li></ul><ul><li>Prevalence 3% to 20% in the U.S . </li></ul><ul><li>Younger people have a higher prevalence of IBS </li></ul><ul><li>Female predo-minance, M : F - 2 : 1 </li></ul>
  5. 5. IBS Vs Other Imp Diseases <ul><li>US prevalence of IBS up to 20% </li></ul><ul><li>US prevalence rates for other common diseases </li></ul><ul><li>– Diabetes 3% </li></ul><ul><li>– Asthma 4% </li></ul><ul><li>– Heart disease 8% </li></ul><ul><li>– Hypertension 11% </li></ul>
  6. 6. Risk factors <ul><li>Young age, </li></ul><ul><li>Female gender, </li></ul><ul><li>Affluent childhood </li></ul><ul><li>environment </li></ul><ul><li>Recent antibiotic use </li></ul><ul><li>Food intolerance, </li></ul><ul><li>Bacterial gastroenteritis (commonly Campylobacter ) </li></ul><ul><li>Depression </li></ul><ul><li>Adverse life events and </li></ul><ul><li>Hypochondriasis </li></ul><ul><li>Extraintestinal somatic symptoms. </li></ul>
  7. 7. IBS Subtypes <ul><li>􀁺 Constipation predominant </li></ul><ul><li>􀁺 Diarrhea predominant </li></ul><ul><li>􀁺 Alternator (alternating bouts of </li></ul><ul><li>diarrhea and constipation) </li></ul><ul><li>This classification was suboptimal because it was not evidence based . </li></ul>
  8. 8. Revised subclassification <ul><li>ROME III proposed new subtyping based on stool consistency alone is </li></ul><ul><li>1. IBS with constipation (IBS-C) </li></ul><ul><li>2. IBS with diarrhea (IBS-D) </li></ul><ul><li>3. IBS mixed type (IBS-M) </li></ul><ul><li>4. IBS unsubtyped (IBS-U). </li></ul>
  9. 9. Pathophysiology of IBS
  10. 11. 1. Abnormal Motility <ul><li>Colonic and SI transit has been shown to be delayed in IBS with constipation and accelerated in IBS with diarrhea, but not all studies concur. </li></ul><ul><li>There is no consensus on the exact patterns of motor derangement that actually induce constipation or diarrhea. </li></ul><ul><li>Not sufficient to explain symptoms of </li></ul><ul><li>abdominal pain </li></ul>
  11. 12. 2. Visceral Hypersenstivity <ul><li>Balloon distention in the rectum was shown to induce pain at lower vol in pts with IBS </li></ul><ul><li>In IBS there is abnormal sensitization within the dorsal horn of the spinal cord or CNS . </li></ul><ul><li>But Visceral Hypersenstivity is found only in 60% of patients . </li></ul>
  12. 13. 3. Brain Gut Axis <ul><li>The brain-gut axis is a system of integrated circuits that allows gut activity to influence the brain, and brain activity to influence the gut. </li></ul><ul><li>The symptoms in IBS are hypothesized to arise from dysregulation within the brain-gut axis. </li></ul><ul><li>Numerous brain-gut neurotransmitters (ie, enkephalins, NO ,tachykinins, CGRP, CCK , 5-HT) </li></ul>
  13. 14. <ul><li>It is now realized that the </li></ul><ul><li>1. Altered colonic motility </li></ul><ul><li>2. Visceral hypersensitivity in IBS are determined by reciprocal interactions between gut and brain. </li></ul>
  14. 15. 4. Dysregulation of Chemical Signaling <ul><li>Serotonin (5-HT) is a chemical signal that plays an important role in IBS </li></ul><ul><li>It has been shown that 5-HT is involved at most levels in the bidirectional communication occurring along the brain-gut axis. </li></ul>
  15. 17. <ul><li>The 5-HT released from EC cells causes </li></ul><ul><li>1) stimulate extrinsic afferent pathways involved </li></ul><ul><li>in pain perception by the CNS and </li></ul><ul><li>2) stimulate intrinsic afferent neurons involved </li></ul><ul><li>in triggering intestinal motor responses. </li></ul><ul><li>5-HT, present in both the (CNS) and (ENS), is </li></ul><ul><li>a key mediator of visceral hypersensitivity </li></ul><ul><li>and heightened bowel motility in patients with IBS. </li></ul>
  16. 18. Others….. <ul><li>Local inflammation </li></ul><ul><li>Abnormal colonic flora & Bacterial overgrowth </li></ul><ul><li>Abnormal gas propulsion </li></ul><ul><li>Food intolerance </li></ul><ul><li>Psychological factors </li></ul><ul><li>Genetics </li></ul>
  17. 19. summary
  18. 20. Symptoms <ul><li>Chronic or recurrent GI symptoms </li></ul><ul><li>– Lower abdominal pain/discomfort </li></ul><ul><li>– Altered bowel function (urgency, altered </li></ul><ul><li>stool consistency, altered stool frequency, </li></ul><ul><li>incomplete evacuation) </li></ul><ul><li>– Bloating </li></ul><ul><li>Not explained by identifiable structural </li></ul><ul><li>or biochemical abnormalities </li></ul>
  19. 21. Diagnostic Approaches <ul><li>􀁺 1950s: Increased gut motility </li></ul><ul><li>􀁺 1980 to 1999: Symptom-based criteria </li></ul><ul><li>– Manning criteria </li></ul><ul><li>– Rome criteria </li></ul><ul><li>􀁺 1999 : Rome II criteria </li></ul><ul><li>2006 : Rome III criteria </li></ul>
  20. 22. Manning Criteria <ul><li> Abdominal pain that is relieved after a bowel movement . </li></ul><ul><li> Looser stool at pain onset , </li></ul><ul><li> More frequent stools at pain onset   </li></ul><ul><li>Abdominal distention (visible) </li></ul><ul><li>Sensation of incomplete rectal evacuation *     </li></ul><ul><li>Passage of mucus * </li></ul>
  21. 23. Contd… <ul><li>Demerits : Symptoms were specific, but not sensitive, for identifying IBS </li></ul><ul><li>They were of greater diagnostic value in women. </li></ul><ul><li>Merit :The Manning criteria identify additional patients with IBS-like symptoms who arguably also should be classified as true IBS. </li></ul>
  22. 24. Rome I Criteria <ul><li> ≥3 mo of continuous or recurrent abdominal pain or discomfort relieved with defecation </li></ul><ul><li>   and    </li></ul><ul><li>Disturbed defecation ( ≥ 2 of the following):    </li></ul><ul><li>1. Altered stool frequency    </li></ul><ul><li>2. Altered stool form (hard or loose/watery)   </li></ul><ul><li> 3. Altered stool passage (straining or urgency, </li></ul><ul><li>feeling of incomplete evacuation)   </li></ul><ul><li> 4. Passage of mucus   </li></ul>
  23. 25. Rome II Criteria <ul><li>Abdominal pain   ≥12wk, which need not be consecutive, in the preceding 12 mon asso. with least 2 of the 3 following features:   </li></ul><ul><li>1. Relieved with defecation    </li></ul><ul><li>2. Onset asso. with a change in stool frequency </li></ul><ul><li>3. Onset asso. with a change in stool form </li></ul>
  24. 26. <ul><li>Comparisons of the criteria have shown that both identify similar patient populations, </li></ul><ul><li>Although the Rome II criteria was more restrictive in some studies. </li></ul>
  25. 27. Rome III Criteria <ul><li>Recurrent abdominal pain atleast 3 days in a </li></ul><ul><li>month in last 3 mon asso. with ≥ 2 of the </li></ul><ul><li>following 1. Improvement with defecation 2. Onset asso. with a change in stool frequency 3. Onset asso. with a change in stool form </li></ul><ul><li>With onset of symptoms at least 6 months </li></ul><ul><li>previously . </li></ul>Drossman DA, Rome III: Digestive Disease Week; May 20-25, 2006
  26. 28. <ul><li>Changes instituted from Rome II to Rome III criteria are: </li></ul><ul><li>(1) frequency threshold of symptoms needed to meet criteria (ie, 3 or more days per mon in the last 3 mons; </li></ul><ul><li>(2) duration of symptoms (< 6 months) before one can make a firm diagnosis; </li></ul><ul><li>(3) refining the subtyping of IBS. </li></ul>
  27. 29. Diagnosis <ul><li>AGA Practice Guidelines </li></ul><ul><li>– Symptom-based diagnostic criteria (Rome II) </li></ul><ul><li>with careful history and physical exam </li></ul><ul><li>– Search for organic disease </li></ul>
  28. 30. RED FLAGS <ul><li>Anemia </li></ul><ul><li>Fever </li></ul><ul><li>Persistent diarrhea </li></ul><ul><li>Rectal bleeding </li></ul><ul><li>Severe constipation </li></ul><ul><li>Nocturnal symptoms </li></ul><ul><li>Family history of GI cancer, </li></ul><ul><li>IBD or SPRUE </li></ul><ul><li>New onset of sym in </li></ul><ul><li>pts 50+ yrs of age </li></ul><ul><li>Weight loss </li></ul>
  29. 31. Treatment <ul><li>Treatment program is based on dominant </li></ul><ul><li>symptoms and their severity </li></ul><ul><li>􀁺 Education and support </li></ul><ul><li>Diet </li></ul><ul><li>􀁺 Medical management </li></ul><ul><li>􀁺 Psychological or behavioral options </li></ul><ul><li>– Psychotherapy </li></ul><ul><li>– Stress management </li></ul>
  30. 32. <ul><li>Education and reassurance :Reassure patient that there is no serious organic disease or alarming symptoms . </li></ul><ul><li>Diet : The standard of care for IBS typically has been a high-fiber diet . </li></ul><ul><li>Improves constipation with sufficient </li></ul><ul><li>supplementation (20-30 g per day) </li></ul><ul><li>May worsen some IBS symptoms (ie, bloating </li></ul><ul><li>and abdominal pain) </li></ul>
  31. 33. Medical management <ul><li>1 .Antispasmodics/Anticholinergics : </li></ul><ul><li>Dicyclomine HCl </li></ul><ul><li>Belladonna and phenobarbital </li></ul><ul><li>Clidinium bromide with chlordiazepoxide </li></ul><ul><li>They seem most useful for those with postprandial pain when taken 30 minutes prior to eating. </li></ul>
  32. 34. <ul><li>Non anticholinergic antispasmodics, include </li></ul><ul><li>1. Mebeverine (a smooth muscle relaxant), </li></ul><ul><li>2. Selective calcium channel blockers (e.g., </li></ul><ul><li>pinaverium ), and </li></ul><ul><li>3. Opiate agonists (e.g., trimebutine ) </li></ul>
  33. 35. <ul><li>2. Laxatives </li></ul><ul><li>Symptomatic treatment of C-IBS </li></ul><ul><li>Osmotic laxatives (MgSO4, lactulose) </li></ul><ul><li>Stimulant laxatives </li></ul><ul><li>Some laxatives agents can exacerbate abdominal pain and bloating </li></ul>
  34. 36. <ul><li>3. Antidiarrheals : </li></ul><ul><li>Loperamide is efficacious in IBS with diarrhea; </li></ul><ul><li>Decreases frequency of bowel movements </li></ul><ul><li>Improves stool consistency </li></ul><ul><li>Does not affect abdominal pain or distention </li></ul>
  35. 37. <ul><li>4. Tricyclic Antidepressants & SSRIs </li></ul><ul><li>Reserved for patients with sev or refractory pain </li></ul><ul><li>Improve global well-being more than symptoms </li></ul><ul><li>TCA tend to be constipating and, therefore, may be of most benefit in IBS - D, </li></ul><ul><li>SSRIs may be more beneficial in IBS-C because they accelerate small bowel transit. </li></ul>
  36. 38. <ul><li>5. Serotonergic Agent </li></ul><ul><li>Treatment of C-IBS Tegaserod maleate </li></ul><ul><li>􀁺 5-HT4 receptor partial agonist </li></ul><ul><li>􀁺 Indicated for the short-term treatment of </li></ul><ul><li>women with IBS whose primary bowel </li></ul><ul><li>symptom is constipation </li></ul>
  37. 39. <ul><li>Treatment of D-IBS Alosetron </li></ul><ul><li>5-HT3 receptor antagonist </li></ul><ul><li>Indicated only for women with sev IBS- D who have: </li></ul><ul><li>– Chronic IBS symptoms (generally lasting 6 months or longer) </li></ul><ul><li>– Not responded adequately to conventional therapy </li></ul>
  38. 40. IBS & Ischemic Colitis <ul><li>Patients with IBS are eight times more likely than are other patients to develop ischemic colitis, </li></ul><ul><li>Ischemic colitis occurs in 0.1% of pts on Alosetron but usually transient and without irreversible consequence. </li></ul>Annual Digestive Disease Week. Volume 36 , Issue 16 , (15 Aug 2006)
  39. 41. <ul><li>Psychological treatment : </li></ul><ul><li>Psychotherapy, </li></ul><ul><li>Hypnotherapy, and </li></ul><ul><li>Cognitive behavioral therapy (CBT) </li></ul><ul><li>IBS patients with abdominal pain, diarrhea, and psychological distress appear most likely to have a beneficial response to such intervention </li></ul>
  40. 42. PROGNOSIS <ul><li>Once made, diagnosis is maintained in 97% of IBS patients , </li></ul><ul><li>Survival in IBS was not different from expected, </li></ul><ul><li>Some IBS patients have spontaneous improvement over time, but usually IBS is a relapsing disorder . </li></ul><ul><li>The presence of excessive psychological distress or anxiety, as well as a long duration of complaints, tends to indicate a poorer prognosis. </li></ul>
  41. 43. thankq

×