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Sindrome dell'intestino irritabile: diagnosi e terapia - Gastrolearning®
This document summarizes research on the diagnosis and treatment of irritable bowel syndrome (IBS). It begins by defining IBS and reviewing its prevalence in Italy. It then discusses the diagnostic criteria for IBS, emphasizing the importance of a symptom-based positive diagnosis. Various IBS subtypes and comorbidities are also outlined. Regarding treatment, the document examines dietary approaches including low FODMAP diets, the use of probiotics and antibiotics, and the importance of the patient-physician relationship. It stresses the multifactorial nature of IBS and need for multidimensional diagnosis and treatment.
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Sindrome dell'intestino irritabile: diagnosi e terapia - Gastrolearning®
- 1. Sindrome dell'intestino irritabile:diagnosi e terapia Relatore: Prof. E. Corazziari (Roma)
- 2. FGID: DEFINITION “Variable combination of chronic or recurrent gastrointestinal symptoms not explained by structural or biochemical abnormalities” Drossman et al Gastroenterol Int 1990;3:159
- 3. FUNCTIONAL BOWEL DISORDERS ROME EVOLUTION From the Irritable Colon Syndrome to Functional Bowel Disorders Irritable Bowel Syndrome (Pain + Bowel Disorders) Functional Constipation (+/- Pain) Functional Diarrhea (no Pain) Functional Abdominal Bloating Unspecified bowel disorders
- 4. IBS PREVALENCE INITALY FACE-FACE INTERVIEW Physical Ex. & US Random/Electoral Rolls n=46,139 Resp. R 63,2% IBS ROME I CRITERIA F= 10.7% M= 5.4% E Corazziari et al. Digest and Liver Disease 2008;40:944-950 4
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- 6. IBS- DIAGNOSTIC CRITERIA HOW TO MAKE A DIAGNOSIS OF A CHRONIC FUNCTIONAL DISORDER WHEN NO BIOLOGICAL MARKER EXISTS ? By exclusion Positive-Symptom based
- 7. IBS- DIAGNOSTIC CRITERIA Exclusion of the Diseases with Detectable Diagnostic Markers useful to detect relevant disorders in few patients but it requires to submit many patients to many investigations with elevated costs and risks of iatrogenic damage and it does not offer any certainty about the origin of symptoms
- 8. IBS-DIAGNOSTIC CRITERIA Positivesymptom-based diagnosis OFFER CONFIDENT DIAGNOSIS? Reduce unneeded investigations Plan treatment Strengthen patient compliance to treatment and coping ability with chronic suffering and daily limitations
- 9. IBS SUBGROUPS ACCORDINGTO ROME QUESTIONNAIRE AND DIARY CARD IBS-D 47% IBS-C 22% 23% 12% 12% 53% 40% 60% N=68 K= 0.6 6% 75% 13% 6% 85% 6% 9% IBS-D IBS-C IBS-M IBS-U Piacentino D et al DDW 2010
- 10. ABDOMINAL PAIN ANDBLOATING DIFFER IN RELATION TO EATING AND DEFECATION IN IBS PATIENTS Carboni S, Cantarini R, Badiali D, Pallotta N, Corazziari E. DDW 2007
- 11. TWO YEAR (IN)STABILITYOF ROME II IBS Williams et al APT 2006; 23: 197-205 30% IDENTICAL IBS subtypes ROME II IBS N= 697 18% ABD PAIN 37% BOWEL 45% NO SYMPTOMS 52% NOT IBS 18% CHANGED SUBTYPES D C 4% M 7%
- 12. IBS-C-CIC AND IBS-D-FDOVERLAP Ford A.C. et al. Aliment Pharmacol Ther 2014;39:312-321
- 13. ONE YEAR (IN)STABILITY(%) OF ROME III IBS-C & FC Wong et al. Am J Gastroenterol 2010;105:2228 35.5 FC WELL IBS-M WELL IBS- C 14 25.5 39
- 14. BOWEL CHARACTERISTICS IN IBS-C vs CIC 90 80 70 60 50 40 30 20 10 0 <3 ev/WK Hard Stools Straining Inc. Empty. Stool block Digital IBS-C CIC % * p<0.001 * * * * Ford AC et al. APT 2014;39:312-321 * *
- 15. THE CONSTIPATION UNIVERSE Rey E et al. Am J Gastroenterol advance online publication, 4 March 2014;doi:10.1038/ajg.2014.18
- 16. THE VANISHING FUNCTIONAL ORGANIC BOUNDARIES Lactase deficiency Celiac disease Gluten sensitivity Bacterial overgrowth Bile salt malabsorption Non specific minimal change inflammation Subclinical intestinal inflammation
- 17. EXTRA-GI CONDITIONS INDBF (>30%) URINARY Interstitial cystitis Incontinence Detrusor instability MUSCOLOSKELETAL Fibromyalgia Backache Headache SEXUAL Dyspareunia Decreased libido Inhibited orgasm PSYCHOLOGICAL Affective disorders Stress sensitivity Illness behavior Health seeking behavior Whorwell et al 1986; Nyhlin et al 1993; Triadofilopoulos et al 1991
- 18. COMORBIDITIES ASSOCIATED WITHIBS COMORBIDITY REPORTED PREVALENCE IN IBS GI disorders Gastritis, duodenitis 31.2% Inflammatory bowel disease 27.9% Gastroesophageal reflux disease 19.0% Dyspepsia 17.4% Oesophagitis 15.5% Anal disease 15.4% Psychiatric disorders Depression 30.5% Stress reaction 17.2% Anxiety state 15.5% Symptom-based somatic diagnoses* Chronic fatigue, malaise 20.1% Fibromyositis (myalgia) 14.5% Pelvic pain, *vulvodynia p<0.05 8.6% Temporomandibular joint disorder 3.3% Dysmenorrhoea 2.3% Cystitis 1.8% Whitehead WE et al. Am J Gastroenterol 2007;102:2762
- 19. STRESSFUL EVENTS PREDICT Onset of FGIDs Symptom exacerbation and health seeking IBS symptom intensity Bennett EJ et al. Gut 1998: 43:256 Creed FH et al. Gut 1988; 29:235
- 20. PSYCHOPATHOLOGY IN IBSDYSPEPSIA COMORBIDITY Piacentino D et al. 2014 Submitted for publication
- 21. IBS SEVERITY DETERMINEDBY PATIENT’S SYMPTOM REPORT AND BEHAVIOR COMPOSITE OF GI & EXTRA GI SYMPTOMS DEGREE OF DISABILITY ILLNESS-RELATED PERCEPTIONS ILLNESS-RELATED BEHAVIOR PSYCHOSOCIAL DISTRESS GENDER / AGE Drossman DA et al. Am J Gastroenterol 2011;106:1759;doi:10.1038/ajg.2011.201;published online 12 July 2011
- 22. PSYCHOLOGICAL STATUS IN IBS-C vs CIC & IBS-D vs FD 40 35 30 25 20 15 10 5 0 IBS-C IBS-D CIC FD ANXIETY SOMATIZATION % * p<0.00 * * * * Ford AC et al. APT 2014;39:312-321
- 23. THE MULTIDIMENSIONAL DIAGNOSISOF IBS Symptom-based diagnosis of IBS Diagnose IBS-Subtype Assess IBS severity Assess Stress and Psychological Status Assess Gastrointestinal comorbidities Assess extragastrointestinal comorbidities And Related polytherapy
- 24. CONSIDERAZIONI SULLA DIAGNOSIDI IBS I CRITERI DI ROMA Categorizzano a fini classificativi le grandi sindromi funzionali Non identificano tutti i sottotipi di pazienti IBS-C E STIPSI FUNZIONALE, IBS-D E DIARREA FUNZIONALE FANNO PARTE DI UNO STESSO SPETTRO NELLA PRATICA IDENTIFICARE LE SOTTOSINDROMI E AGGIUNGERE ALTRE VALENZE CLINICHE DIAGNOSI MULTI DIMENSIONALE LA SEVERITÀ DI IBS NON E’ MISURABILE SUI SINTOMO INTESTINALI, MA DA UN COMPLESSO DI FATTORI. I FATTORI PSICOSOCIALI SONO FORTEMENTE ASSOCIATI ALLA SEVERITÀ DEL DOLORE NELLA PRATICA NECESSITÀ DI SISTEMATIZZARE UN METODO SEMPLICE PER VALUTARE IL GRADO E LE COMPONENTI DELLA SEVERITÀ
- 25.
- 26. PSYCHOLOGICAL IBS •GENETIC •DISEASES •STRESSORS PATIENT BEHAVIOR CNS STATUS GI ENS PHYSIOLOGY PHYSICIAN THERAPY
- 27. Doctor-Patient Relationship -FGIDs What the Patient Hears 23 Just to be sure . . . You have IBS . . . Nothing to worry about . . . Blah Cancer Blah Blah
- 28. They think it’s all in my head IBS - Patient’s Agenda My symptoms are worse Do I have cancer? I’m under more stress Why am I not getting better? Will you believe me? Am I crazy? 25
- 29. IBS - Doctor’sAgenda Serious disease Recent life stress Psychologic comorbidity Hidden agenda narcotics disability laxatives Referral elsewhere? Social and cultural factors What do I do? 26
- 30. IBS - RELAZIONEMEDICO-PAZIENTE Acquisire la fiducia di un paziente stigmatizzato e che non capisce l’origine dei disturbi • Capire la sofferenza • Spiegare i disturbi • Educare il paziente • Indicare obiettivi possibili
- 32. STRENGTH OF DOCTOR-PATIENT RELATIONSHIP Owens et al Am Int Med 1995 Placebo Effect: 20-40% Kathryn T et al. Plos One 2012;7; e48135 Number of FU Visits for FBD Genetics & Pl response Cathecol-O-Methyltransferase Val 108 Met Polym. PFC
- 33. PLACEBO RESPONSE INIBD Response % UC 17-28 CD 18-36 CD Fistula closure* 16-18 Sands B Dig Dis 2009;27:68-75 * Ford AC et al Clin Gastroenterol Hepatol 2014 S1542- 3565(14)01315-9.doi 10,1016/j.cgh.2014
- 34. TREATMENTS FOR FBD Bloating Diet Abdominal pain/discomfort Diet Diarrhea Diet Constipation Diet Bloating / distention Abdominal pain / discomfort Altered bowel function
- 35. DIET IN IBS(EIGHT STUDIES) Brandt LJ et al. American J Gastroenterol 2009;104 Suppl 1
- 36. FODMAP effects inthe IBS patients
- 37. LOW-FODMAP STUDIES Threestudies report symptom improvement with low-FODMAP diets in IBS patients 1. a significant number of IBS patients report gastrointestinal (GI) Staudacher et al, 2011: retrospective mmmmmmmmmmmmmmmmmmmmmsymptom foods containing 2. it has been hypothesized that gluten could act as a trigger for GI De Roest et al, 2013: observational symptoms IBS and other clinical conditions s 3. GS is characterized by GI and extra-GI symptoms in the absence of Halmos et al, 2014: the typical immunological and mucosal alterations caused by the ingestion of gluten - accurate control of nutrients - 77% fructose malabsorption - crossover with unblinding effect (only 17% of IBS patients did not symptoms in GS patients are similar to those of IBS patients, even recognize the type of diet) gluten hypersensitivity has been included among the possible etiopathogenetic or exacerbating factors for IBS symptoms
- 38. EFFECTS OF LOWFODMAP DIET IN IBS A DOUBLE BLIND PARALLEL CONTROLLED CLINICAL TRIAL BLOATING PAIN Piacentino et al. DDW 2014
- 39. TREATMENTS FOR FBD Constipation Fibers (Ispaghula/psyllium) Bloating / distention Abdominal pain / discomfort Altered bowel function
- 40. BULK LAXATIVES Evidence Level Recommendation Grade Bran 3 C Methylcellulose 3 C Psyllium 2 B Psyllium+Senna* 3 C Rankumar, Rao, AJGE 2005; American College GE, AJGE 2005; *Marlett et al AJGE, 1987 Aggravate Bloating, Dyspepsia, Bran Ineffective in Slow Rectal Transit, *Aggravate Bloating & Cramps
- 41. TREATMENTS FOR FBD Bloating Probiotics Abodminal pain/discomfort Probiotics Diarrhea Probiotics Constipation Probiotics Bloating / distention Abdominal pain / discomfort Altered bowel function
- 42. FLOW DIAGRAM OFIDENTIFIED STUDIES FOR META-ANALYSIS OF PROBIOTICS IN IBS NNT=7 AC Ford et al. Am J Gastroenterol 29 July 2014;doi:10,1038/ajg.2014,202
- 43. LIMITS OF PROBIOTICSTUDIES LITTLE NUMBER OF PROPERLY-PERFORMED STUDIES META-ANALYSIS POOL STUDIES WITH Different Probiotics Different Probiotic Species Combination Different Dosages Different Conditions Different Patients Few Patients Direct-to-consumer marketing and lack of regulation are obstacles to proper clinical studies 43 VERNA E.C. ET AL. THER ADV GASTROENTEROL 2010;5:307-319
- 44. FBD TREATMENT WITHPROBIOTICS DIARRHEA PAIN BLOATING GONFIORE DIARREA CONSTIPATION BLOATING GONFIORE Lactobacillus GG VSL #3 Lactobacillus Plantarum Lactobacillus Reuterii Bifidobacterium Infantis Lactobacillus Casei Saccharomyces Boulardii B.Longum/Rhamnosus Acidophilus L. Casei/Paracasei /Thermophilus B. Lactis Animalis L. Casei Shirota
- 45. TREATMENTS FOR IBS Bloating Antibiotics Diarrhea Antibiotics Bloating / distention Abdominal pain / discomfort Altered bowel function
- 46. EFFECT OF RIFAXIMINON NON-CONSTIPATED IBS 46 Pimentel M et al. N Engl J Med 2011;364:22-32
- 47. TREATMENTS FOR FBD Abdominal pain/discomfort Antispasmodics Antidepressants Abdominal pain / discomfort Bloating / - TCAs/SSRIs/SNRIs distention Altered bowel function
- 48. ANTISPASMODICS IN IBS Poynard T. et al . Aliment Pharmacol Ther 2001;15:355-361
- 49. ANTIDEPRESSIVI NELLA SII ANTIDEPRESSIVI Jackson JL et al A J Med 2000 Disordine dell’asse Cervello- Studi controllati Visceri Alterata motilità GI Ipersensibilità viscerale Alterazione dei meccanismi centrali di regolazione Neuroendocrino Autonomico Cognitivo della percezione del dolore
- 50. EFFICACY OF ANTIDEPRESSANTSAND PSYCHOLOGICAL THERAPIES IN IBS NNT 95%CI TCA 4 3-6 SSRI 4 2.5-20 CBT 3 2-6 Hypnot 4 3-8 Ford AC et al. AJG 2014;109:1350-65
- 51. ANTIDEPRESSANTS FOR IBS CLINICAL CONSIDERATION TCAs in IBS-D, SSRIs in IBS-C SSRI/SNRI for anxiety Poor response3 Satisfactory response3 Switch to different class antidepressant Combine treatments as augmentation Obtain psychiatry consultation Continue at minimum effective dose for 6 to 12 months Long-term therapy may be warranted for some patients 1. ACG Task Force on IBS. Am J Gastroenterol 2009;104(suppl 1):S1-S35 2. Ford AC et al. Gut 2009;58:367-378 3. Grover M. Drossman A. Curr Opin Pharmacol 2008;8:715-723
- 52. TREATMENTS FOR FBD Constipation Secretagogs Linaclotide Bloating / distention Abdominal pain / discomfort Altered bowel function
- 53. T53 Chloride Channelsin Intestinal Transport Cl- Cl- CFTR channel Na+ K+ K+ 2Cl K+ - Tight junction H2O Na+ H2O Na+ Ion Transport Na+ Enterocytes Cl C2 channel
- 54. AZIONE DELLA LINACLOTIDE SULL’EPITELIO INTESTINALE Corsetti M, Tack J. UEG Journal 2013;1:7-20
- 55. EFFETTO DELLA LINACLOTIDENELLA IBS-C Chey WD et al. AJG 2012;107:1702-12
- 56. EFFECT OF LINACLOTIDE VS PLACEBO IBS-C 290g NNT CC 145g NNT CSBM(3/WK) 8 7 Abd. Pain/Disc. 8 9 CSBM+Abd Pain 12 5 Adequate Relief (>75%) 5 4
- 57. TREATMENTS FOR FBD Bloating Diet Probiotics Antibiotics Abdominal pain/discomfort Probiotics Antispasmodics Antidepressants - TCAs/SSRIs/SNRIs Diarrhea Diet Probiotics Antibiotics Colestyramine Loperamide Constipation Diet Fibers (Ispaghula/psyllium) Probiotics Linaclotide Water-binding macrogol/Osmotic laxatives Prucalopride Bloating / distention Abdominal pain / discomfort Altered bowel function Psychotherapy CBT Hypnotherapy
- 58. EFFECTIVENESS VS INVASIVENESSOF IBS TREATMENT Less Effective More Effective 58 More Invasive and/or Less Safe Less Invasive and/or Safer Modified from Simrén M. et al Gut 2013;62:159-176 Linaclotide Loperamide Antibiotics Probiotics Loperamide Prebiotics TCA Antispasm Systematic Exclusion Diets Low FODMAP DIET Placebo
- 59. FMT IN REFRACTORYIBS (N=13) % Pinn et al. Presented at AM College Gastroenterology 2013
- 60. EFFECTIVENESS VS INVASIVENESSOF IBS TREATMENT Less Effective More Effective 60 More Invasive and/or Less Safe Less Invasive and/or Safer Modified from Simrén M. et al Gut 2013;62:159-176 Linaclotide Loperamide Antibiotics Probiotics Loperamide Prebiotics TCA Antispasm Systematic Exclusion Diets Low FODMAP DIET Placebo
- 61. APPROCCIO MULTIDIMENSIONALE ALPAZIENTE CON MALATTIA CRONICA Stabilire una relazione terapeutica • Valutare la storia medica, la personalità e la famiglia Valutare la qualità di vita e il livello di attività quotidiana Valutare la storia psicosociale Prescrivere test diagnostici Fare una diagnosi • Spiegare e rassicurare • Istituire terapia appropriata
- 62. GENETIC IBS DIETARYFACTORS INFLAMMATION HYPERSENSITIVITY IMMUNE RESPONSE STRESS CNS/ENS ALTERATIONS PSYCHOSOCIAL FACTORS GI SECRETION ALTERED MOTILITY DYSBIOSIS BEHAVIOR
- 63. IBS SEVERITY DETERMINEDBY PATIENT’S SYMPTOM REPORT AND BEHAVIOR COMPOSITE OF GI & EXTRA GI SYMPTOMS DEGREE OF DISABILITY ILLNESS-RELATED PERCEPTIONS ILLNESS-RELATED BEHAVIOR PSYCHOSOCIAL DISTRESS GENDERE / AGE Drossman DA et al. Am J Gastroenterol 2011;106:1759;doi:10.1038/ajg.2011.201;published online 12 July 2011
- 64. CO MORBIDITY SYMPTOM SEVERITY EPISODE FREQUENCY IBS QOL
- 65. MULTIDIMENSIONAL DIAGNOSTIC ASSESSMENTOF IBS PATIENT COMORBIDITY BILE AC. MALABSORPTION DIETARY FACTORS HYPERSENSITIVITY ENVIRONMENTAL FACTORS RAPID TRANSIT POLY THERAPY LOPERAMIDE, TCA FIBER, LINACLOTIDE LAXATIVES, PRUCALOPRIDE SPASMOLYTICS COGNITIVE BEHAVIORAL TH STRESS PSYCHOLOGICAL ALTERATIONS SLOW TRANSIT SPASM DYSBIOSIS S ILLNESS BEHAVIOR IBS Pain Severity Episode Frequency Episode Duration QoL COLESTYRAMINE PROPER DIET TCA 5HT3 ANTAGONIST RELAXATION TRAINING HYPNOSIS SSRI SNRI PSYCHOTHERAPY PROBIOTICS ANTIBIOTICS
- 66. LONG DURATION HIGH SYMPTOM SEVERITY LOW CONTINUOUS INTERMITTENT SHORT DURATION HIGH FREQUENCY LOW IBS EPISODE REASSURANCE ON DEMAND
- 67. CONSIDERAZIONI SULLA TERAPIADI IBS LE TERAPIA FARMACOLOGICHE SONO STATE TESTATE SU IBS, IBS-C E IBS-D. MANCANO STUDI SULLE SOTTOSINDROMI FONDAMENTALE IL RAPPORTO MEDICO-PAZIENTE E L’EFFETTO PLACEBO NELLA PRATICA ESALTARE LE CAPACITÀ DEL MEDICO LA DIETA LOW-FODMAP OFFRE NOTEVOLE BENEFICIO LA LINACLOTIDE, PRIMO FARMACO CHE AGISCE TOPICAMENTE SULL’EPITELIO SIA SU STIPSI CHE DOLORE NELLA PRATICA IDENTIFICARE CHI RISPONDE ALLA DIETA LOW-FODMAP E ALLA LINACLOTIDE