2. Irritable bowel syndrome is a functional GI disorder with
symptoms including abdominal pain associated with a
change in stool form or frequency
Substantial impact on quality of life and social functioning
Affects between 5% and 10% of the general population
Treatment aims to improve abdominal pain and bowel habit
Sub grouped -Predominant stool pattern
IBS with diarrhoea
IBS with constipation
IBS with mixed stool pattern
IBS unclassified
3. Precise estimates of prevalence
is difficult to obtain
No universally accepted
biomarker available
Diagnosis relies on self-
reported symptom clusters
Population-based
epidemiological studies
provide a prevalence between
5% to 10%
with Rome III criteria 1·1% in
Iran to 45% in Pakistan in 2016
4. Gender --women >men
Age < 50 years (most common in women aged 20–40 y)
Functional somatic syndromes
Fibromyalgia
Chronic fatigue
Anxiety and Depression
Sleep Disorders
Psychosocial, biological, and environmental factors
Enteric infection ,most well recognized risk factor for IBS, (10%
patients of IBS), risk >by 4 times in exposed individuals 12 months
after infection, better prognosis, can be seen upto 8 years post
infection
Post - infection IBS:
Bacterial
Viral
Protozoal infection
Non-specific gastrointestinal infections
5. Biopsychosocial model to explain symptoms of
abdominal pain and disordered bowel habit in
IBS conceptualized a genetic predisposition, in
which adverse events in early life,
psychological factors, or gastrointestinal
infections trigger alterations in the enteric
nervous system, which controls
gastrointestinal motor, sensory, mucosal
barrier, and secretory responses
8. IBS is a chronic relapsing disorder
Usually seen in younger age (average age is 45)
Multifactorial and heterogeneous disorder
Coexistent mood problems, and extra intestinal symptoms back pain,
gynaecological and bladder symptoms, headache, and fatigue
Overlap with other functional gastrointestinal disorders
Abdominal pain : (abdominal pain is essential to the definition of IBS)
Chronic
Recurrent/Intermittent
Usually in the lower abdomen
Associated with defecation
Stool frequency or consistency Alterations
Excessive straining, sense of incomplete rectal evacuation, or digitation of
the anus to facilitate defaecation support IBS –C diagnosis
Bloating supports the diagnosis, particularly if it is diurnal. often
accompanied by visible abdominal distension.
Sub grouped according to predominant stool pattern
9.
10. IBS Recurrent abdominal pain, on average for at least 1 day per week in
the past 3 months, associated with two or more of the following:
related to defaecation, a change in frequency of stool, a change in stool
form; criteria must be fulfilled for the past 3 months, with symptom
onset at least 6 months before diagnosis
IBS with
constipation
≥25% of bowel movements of Bristol Stool Form types 1 or 2, and
<25%Bristol Stool Form types 6 or 7
IBS with
diarrhoea
≥25% of bowel movements of Bristol Stool Form types 6 or 7, and
<25%of Bristol Stool Form types 1 or 2
IBS mixed ≥25% of bowel movements of Bristol Stool Form types 1 or 2, and
≥25% of bowel movements of Bristol Stool Form types 6 or 7
IBS
unclassified
Patients who meet criteria for IBS, but do not fall into one of the other
three subgroup
11. Diagnosis is clinical
Positive diagnosis by use of symptom-based diagnostic criteria Rome
IV(2016)
No universally accepted biomarker
Investigation to exclude an organic cause are expensive & non reassuring
Performance of the Rome criteria can be enhanced
Absence of nocturnal stools
Presence of anxiety Depression
Extra intestinal symptoms
Normal full blood count C-reactive protein
Alarm symptoms
Age >50
IDA
Bleeding PR
Nocturnal Diarrhoea
Symptom of bowel obstruction
F/H of CRC
F/H of IBD
F/H of coeliac disease
12.
13. Faecal calprotectin, which is a cytosol protein released by neutrophils, can differentiate
between IBS and IBD
14. Coeliac disease:
TTG, Duodenal biopsies
IBD:
ESR,CRP,FCP
Microscopic colitis:
age >50, women ,short history
Autoimmune disease:
Nocturnal diarrhoea
Carbohydrate intolerance:
Lactose/fructose/sucrose intolerance, Elimination of dairy from diet, Enzyme
immunoassay, breath tests
NSAIDS & ,PPI use:
Usually report nocturnal diarrhoea
Bile acid diarrhoea:
Ileal dysfunction , Chronic pancreatitis, Celiac disease,ideopathic (SeHCAT scanning,
48 h faecal bile acid excretion, bile acid sequestrant trial ),fasting serum C4.
15. SIBO:
H/O gastric or intestinal surgery or known structural abnormalities
diverticulosis -breath tests, aspirates & empirical ABX
Food allergy:
Angioedema—symptoms of swelling and SOB
Carcinoid Diarrhoea:
Hyper secretion of serotonin from neuroendocrine cells 5--hydroxyindoleacetic
acid (found in the urine) and chromogranin A- found in the serum
Chronic Pancreatitis:
CT,MRCP ,HBA1C,Stool Elastase
Ovarian Cancers :
Constipation - CT scan ,MRI
Pelvic floor outlet obstruction disorders :
IBS-C (Dyssynergia, Symptoms of incomplete evacuation, straining, prolonged
toileting, DRE,Manometery,defecography,balloon explusion test
Endometreosis:
Chronic pelvic Pain ,MRI , laparoscopy
16. Fluctuating symptoms, in terms of bowel habit
New onset IBS was approximately 1·5–2·5% per year
Prevalence remains stable (new symptoms appear/ symptoms
disappear or fluctuate)
IBS causes morbidity, but not mortality
Affects quality of life, work productivity, social integration, and
psychosocial factors, such as general and gut-related anxiety,
depression, and somatization
Diarrhoea limits travel or leaving the house because of concerns
about toilet access
Constipation- avoid sexual intercourse and reported difficulty
concentrating
Reduced quality of life, increased rates of psychological
symptoms, and reduced coping
17. No medical therapy is proven to alter natural history
Empathetic approach is key
Discuss the limitations of available therapies to manage
expectations
Explain the disorder, its pathophysiology, and natural
history
Symptoms improvement is in only 25–30%
Treatment is directed towards the predominant symptom
The final decision of the choice of treatment should be the
patient’s
18. Exercise :
Instructed by a physiotherapist--symptoms improved significantly
Dietary fiber
Increase intake help, soluble (e.g., barley, beans, oat bran, psyllium (Ispaghula Husk)
rather than insoluble (e.g., wheat bran, whole grains, some vegetables) fiber improves
global symptoms of IBS
FODMAP:
Restriction -improvement in IBS symptoms, long term use may -deleterious alterations in
the microbiome
Gluten-free diet :
Little evidence to support benefit , wheat contains fructan a FODMAP, a gluten-free diet
incorporates elements of a low FODMAP diet
Probiotics:
which combination, species, or strain is effective data is limited
Eat small regular meals, avoid known trigger foods, and reduce alcohol
and caffeine
19.
20. Laxatives (osmotic and stimulant laxatives)
Antidiarrhoeals (loperamide)
Antispasmodics (otilonium, cimetropium,
pinaverium, & hyoscine)
Peppermint oil also appeared superior to placebo
Glutamine powder 5 g three times daily for 8 weeks
Daily bowel movement
Frequency and stool form and
Normalization of intestinal permeability versus placebo
21. Antidepressant
Tricyclic Antidepressants- neuromodulatory properties and slow gastrointestinal
transit, best for patients with predominant pain, diarrhoea, or both
Selective serotonin reuptake inhibitors
Neuromodulators
Adverse events are common
Pregabalin
improvements in global symptoms, pain, diarrhoea, and bloating
5-HT4 agonists
accelerate gastrointestinal transit
Prucalopride, was superior to placebo in chronic constipation
Intestinal secretagogues
lubiprostone, linaclotide, plecanatide, and tenapanor act on ion channels in
enterocytes, leading to water efflux, thereby accelerating gastrointestinal transit
Linaclotide ranked first for improvements in global symptoms, abdominal
pain, and stool frequency
22. Alosetron and Ramosetron:
5-HT3 antagonists selective serotonin (5-HT3) receptor antagonist-
Dose -0.5 to 1.0 mg twice daily for at least 6 months
5-HT3 antagonists also alter rectal compliance
5-HT3 antagonists ranked first for improvement in global symptoms,
abdominal pain, and stool consistency
Eluxadoline :
Peripherally acting mixed μ-opioid and κ-opioid receptor agonist and δ-
opioid receptor antagonist
Dose is 75–100 mg bid for up to 6 months
Rifaximin :
Minimally absorbed antibiotic ,Rifaximin has been tested on the basis that
alterations in the gastrointestinal microbiota and small intestinal bacterial
overgrowth might, in part, be responsible for symptoms.
Dose : 550-mg tablet three times daily for 2 weeks, may receive up to two
additional rifaximin courses for symptom recurrence
25. Involves the transfer of donor fecal matter by
enema, endoscopy, or an oral pill
Did not significantly decrease global symptoms
of IBS compared with placebo
ACG guideline for IBS management
recommends against the use of FMT for
treatment of IBS