Irritabile bowl syndrome

1. Irritable Bowel Syndrome
A functional or an organic condition?
Ferrara, September 27th, 2014
Reinhold W. Stockbrugger
Em. Prof. Gastroenterology and Hepatology, University Maastricht/NL
Contract Prof. Internal Medicine, University Ferrara/I
Editor European Journal of Gastroenterology & Hepatology
rstockbrugger635@gmail.com

2. What is a functional condition?
? I do not function ?
? It functions me ?
? Am I healthy ?
? Sick leave for functional disorders ?
? Do I need a psychologist ?
? Or a pension ?
? Why has the doctor said that that (s)he cannot
help me? I think (s)he does not function !!!

3. RS: body + soul?
Fortunately much more!
My parents (or the lack of them)
The alcohol
The politics
The bugs
My boss
The weather
The fast and slow food
The sex
The money
The music
The diabetes
The sports
The future and the anxiety

4. IBS – Critical Review 2014
epidemiology
etiology, pathogenesis
clinical presentation and diagnosis
treatment
outcome
future needs

5. The IBS Manual, 1999
Copyright 1999 Harcourt Publishers Limited
Prevalence of IBS in community-based
populations
Fig 2.4

6. IBS – Epidemiology
In Northern Greece
Katsinelos et al. Eur J Gastroenterol Hepatol 2009; 21: 183-9
Setting: Primary Care, 2004 - 2007
N= 2397 (f: 70.6%; mean age 46.1 years)
IBS in 15.7% (D-IBS 36.5%; C-IBS 44.2%; M-IBS 19.3%)
IBS patients more likely to be:
female
from urban areas

8. IBS – Epidemiology
In Asia
Gwee et al. J Gastroenterol Hepatol 2009; 24: 1601-7
Early studies: prevalence <5%
Now: Singapore 8.6%
Tokyo 9.8%
India: 4.2%
Symptomatology different from Rome criteria

9. IBS
Etiology, pathogenesis
“The times, they are changing …”
1980 Motility
1990 Psychology
2000 Microbiology
2005 Neurophysiology
2009 Motility, Metabolism, Diet
2014 FODMAPs (Fermentable Oligosaccharides Disaccharides
Monosaccharaides And Polyols)

10. The Newcomer: FODMAPs
“A diet low in FODMAPs reduces symptoms of Irritable
Bowel Syndrome”
Halmos E.P. et al. Gastroenterology 2014; 146: 67 – 75
• High FODMAP food (things to avoid / reduce)
• Vegetables and Legumes
• Garlic – avoid entirely if possible
• Onions – avoid entirely if possible
• Artichoke
• Asparagus
• Baked beans
• Beetroot
• Black eyed peas For this you really could need a dietician!
• Broad beans
• Butter beans
• Cauliflower
• Celery – greater than 5cm of stalk
• Kidney beans
• Leeks
• Mange Tout
• Mushrooms
• Peas
• Fruit – fruits can contain high fructose + other 121 items!
• Apples
• Apricots
• Avocado

11. Diet and IBS
Fig 6.3

12. COLONIC FERMENTATION
Hypothesis: Is over-eating one further cause of increasing IBS in
the wealthy part of the Western world?
 Entrez PubMed: irritable bowel syndrome + diet:
150 hits
 www.google.com: irritable bowel syndrome + diet:
46.100 hits

13. A pleasant Limburgian gentleman!
Mr. Alphonse de X., date of birth 1934, a retired official of the
Limburgian provincial government is happily married and calls himself a
gourmet. He consults 1/1999: occasional nausea, abdominal cramping,
heartburn, intermittend diarrhoea of watery to porridgy consistency
with urgency
Previous history:
 Guillain-Barre’s disease, completely recovered.
 1987 possible cardiac infarction; stopped smoking at a weight of 82
kg at a length of 1.84 m (BMI 24.2).
 After that (and retirement!) weight increase to 102 kg.
 Family history: CRC in 2 first-degree relatives; several colonoscopies
without pathological findings
Examination:
 BMI 30.1; 102 kg; serum triglycerides 2.37 mmol/l.
What does Alphonse suffer from? What diagnostic
steps are You taking?

14. 72-hour faecal collection some days later:
faecal mass (g) 312 428 157
faecal fat (g) 65.3 per 72 hours
chymotrypsin U/g 19.8 40.2 20.1
osmotic gap (mosmol/kg) 150 240 64
Your diagnosis? Your treatment?

15. Alphonse, two years after: no symptoms,
94 kg = BMI 27.7
72-hour faecal collection 12/2000
faecal mass (g): 144 212 222
faecal fat (g): 25 g per 72 hours
chymotrypsin (U/g) 18.4 17.6 16.4
osmotic gap (mosmol/kg) 0 0 18
Au revoir, Alphonse?

16. Post-infectious IBS
• 7-30 % of patients with a proven bacterial gastroenteritis will develop IBS.
• Definition:
PI-IBS is an acute Rome II criteria positive IBS developing after an infectious
illness, characterised by two or more of the following:
-fever
-vomiting
-acute diarrhoea
-positive stool culture
• PI-IBS: clinically distinct subgroup characterized by more diarrheal symptoms,
less psychiatric illness, and increased serotonin-containing Enterochromaffin
cells (EC cells) compared to those with non–PI-IBS.
• unlike most other IBS there is a clearly defined start date

17. The pathogenesis of post-infectious Irritable Bowel
Syndrome:
• Inflammation  increased production of serotonin by EC cells
 impairment of expression of SERT  impaired clearance of
serotonin from the gut
• Consequences:
- enhanced motility
- increased intestinal permeability
- increased sensitivity
• Gut. 2002 Sep;51(3):410-3.
• Prognosis in post-infective irritable bowel syndrome: a six year follow up
study.
• Neal KR, Barker L, Spiller RC.

18. IBS and the diagnosis
positive diagnostic criteria
vs.
exclusion diagnosis?
WRONG QUESTION:
DIAGNOSIS IS ABOUT PROBABILITIES!

19. IBS: Doctor's concerns
IBS: Doctor's concerns
Psychological
Psychological
comorbidity
comorbidity
Serious
Serious
disease
disease
Hidden agenda
Hidden agenda
narcotics,laxatives,
narcotics,laxatives,
benefits
benefits
Shall I refer?
Shall I refer?
Recent
Recent
stressful event
stressful event
Impaired
Impaired
daily
daily
function
function
Drossman
Drossman et al
et al, 1995; 1997
, 1995; 1997

20. The IBS Manual, 1999
Copyright 1999 Harcourt Publishers Limited
‘Time heals everything’
Fig 1.12
MY WAY:

21. IBS
Clinical presentation and diagnosis
To consider (depending on history, physical and
mental examination, basic lab, and
environment):
- Postinfectious IBS (onset!)
- Lactose intolerance
- Other nutritional causes (fructose, BMI)
- Chronic parasitic infection
- Inflammatory Bowel Disease
- Early childhood trauma
- Psychosocial stress/events (chronic > acute)

22. IBS
Clinical diagnosis
Useless:
- Genetic testing
- Explorative allergy testing
- Extended microbiology of the faeces
- Sophisticated motility tests (barostat)
- Primary psychiatry consultation

23. IBS
Clinical presentation and diagnosis
Useful:
- Comorbidity (fibromyalgia; dyspepsia;
dysuria; etc)
- Assessment anxiety and depression
(HADS)
- Assessment Health-Related Quality of Life
(HRQoL)

24. 0
10
20
30
40
50
60
70
80
90
100
PF RP BP GH VT SF RE MH
A0D0
A1D0
A1D1
Relation between concurrent anxiety and/or
depression and SF-36
Mean
score
SF-36 subscales

25. IBS
Treatment
Is there a standard treatment for IBS?
NO (and YES)

26. Overlap FD and IBS
Therapy: the SCEPT concept
Sincerity
Compassion
Education
Patience
Time

27. IBS
Treatment, some progress (1)
Bijkerk et al. BMJ 2009; 339: b3154
“Soluble or insoluble fibre in irritable bowel syndrome in
primary care? Randomised placebo controlled trial”
Setting: General practice, Netherlands
N= 275
Treatment: psyllium 10 g or bran 10 g or placebo 10 g
Outcome: psyllium better than both alternatives, with the
best symptom reduction after 3 months

28. IBS
Treatment, some progress (2)
Simren et al. Aliment Pharmacol Ther 2010; 31: 217-27
“Clinical trial: the effects of a fermented milk containing three
probiotic bacteria in patients with irritable bowel syndrome, a
randomized, double-blind, controlled trial”
Setting: outpatient N= 74
Probiotic: 2 lactobacilli, 1 bifidobacter, in acidified milk
Duration: 8 weeks; weekly assessment
Response: probiotic 38%, placebo 27% (n.s.); probiotics better in the
initial 2 weeks

29. The last meta-analysis
• Am J Gastroenterol. 2014 Jul 29. doi: 10.1038/ajg.2014.202.
[Epub ahead of print]
• Efficacy of Prebiotics, Probiotics, and Synbiotics in
Irritable Bowel Syndrome and Chronic Idiopathic
Constipation: Systematic Review and Meta-analysis.
• Ford AC1, Quigley EM2, Lacy BE3, Lembo AJ4, Saito YA5,
Schiller LR6, Soffer EE7, Spiegel BM8, Moayyedi P9

30. Postinfectious IBS
Outcome (1)
Good hope:
Jung et al. J Clin Gastroenterol 2009; 43: 534-40
“The clinical course of postinfectious irritable bowel
syndrome: a five-year follow-up study”
Setting: Hospital personnel; 5 years after Shigella
infection outbreak
N= 119 (Shigella exposed 60; controls 59)
Follow-up at 1, 3, 5 years

31. Postinfectious IBS
Outcome (2)
IBS after infection (in %)
Time Shigella + Shigella –
1 year 13,8 1.1 s.
3 years 14.9 4.5 s.
5 years 20.8 12.2 n.s.

32. IBS
Future needs (1)
At short term:
- Knowledge about causes and natural history
- Capacity to apply a bio-psycho-social model to
diagnosis, therapy and follow-up (SPECT)
- Patient-orientated healthcare organisation
- More public information about “functional”
gastrointestinal disorders and their comorbidity

33. IBS
Future needs (2)
At longer term, individualised care:
- Markers for the pathogenetic contribution of
Central and Peripheral Nervous System, gut
flora and immune system, as well as for the
psycho-social risks factors
- Drugs and clinical techniques that can
interfere at central, intermediate and/or
peripheral levels

34. There is always hope!