an over view of IBS in the general population, talks about aetiology pathology clinical features and diagnosis with special reference to the ROME criteria and the differences between ROME II and III.
Irritable Bowel Syndrome: An Update in Pathophysiology and Management Monkez M Yousif
Irritable bowel syndrome is the commonest health problem in hospital outpatient clinics and in private health care facilities and represents a big challenge for patients and physicians. This presentation discusses a different aspect of the disease from pathophysiology, clinical presentation and management
gutCARE IBS Talk on 20/5/2020.
In this talk, we update Singapore local epidemiology about increasing trend of IBS locally since 1998. There is also challenges in diagnosing IBS confidently in primary care due to patient presentation and symptoms.
We also update audience about latest diagnostic criteria for IBS.
New treatment for IBS, relationship between Small intestine bacterial overgrowth and IBS and the role of hydrogen breath testing in managing IBS.
We hope you enjoy the slides.
Irritable bowel syndrome - diagnosis, pathophysiology and pharmacologySIVASWAROOP YARASI
irritable bowel syndrome (IBS) is a common disorder that affects the large intestine. Signs and symptoms include cramping, abdominal pain, bloating, gas, and diarrhoea or constipation, or both. IBS is a chronic condition that you'll need to manage long term.
Irritable Bowel Syndrome: An Update in Pathophysiology and Management Monkez M Yousif
Irritable bowel syndrome is the commonest health problem in hospital outpatient clinics and in private health care facilities and represents a big challenge for patients and physicians. This presentation discusses a different aspect of the disease from pathophysiology, clinical presentation and management
gutCARE IBS Talk on 20/5/2020.
In this talk, we update Singapore local epidemiology about increasing trend of IBS locally since 1998. There is also challenges in diagnosing IBS confidently in primary care due to patient presentation and symptoms.
We also update audience about latest diagnostic criteria for IBS.
New treatment for IBS, relationship between Small intestine bacterial overgrowth and IBS and the role of hydrogen breath testing in managing IBS.
We hope you enjoy the slides.
Irritable bowel syndrome - diagnosis, pathophysiology and pharmacologySIVASWAROOP YARASI
irritable bowel syndrome (IBS) is a common disorder that affects the large intestine. Signs and symptoms include cramping, abdominal pain, bloating, gas, and diarrhoea or constipation, or both. IBS is a chronic condition that you'll need to manage long term.
Irritable Bowel Syndrome Part 1 - Dr Vivek BaligaDr Vivek Baliga
In this presentation, Dr Vivek Baliga discusses the important aspects of irritable bowel syndrome - a common medical problem in clinical practice. For more articles, visit http://baligadiagnostics.com/author/drbvb/
IRRITABLE BOWEL SYNDROME
The term irritable bowel syndrome is used to describe a functional gastrointestinal disorder characterized by a variable combination of chronic and recurrent intestinal symptoms not explained by structural or biochemical abnormalities.
Irritable bowel syndrome is a common condition affecting the digestive system.
Symptoms of irritable bowel syndrome include stomach cramps, bloating, diarrhoea and constipation. These may come and go over time.
Making changes to your diet and lifestyle, like avoiding things that trigger your symptoms, can help ease irritable bowel syndrome.
UC is an idiopathic IBD that affects the colonic mucosa.
Hallmark of UC is bloody diarrhea often with prominent symptoms of rectal urgency and tenesmus.
The clinical course is marked by exacerbations and remissions.
The diagnosis of UC is suspected on clinical grounds and supported by the appropriate findings on
Proctosigmoidoscopy or colonoscopy
Biopsy
By negative stool examination for infectious causes
NAFLD is a vast topic and recently gaining a lot of importance. Fatty liver, NASH, are other topics discussed here. sleissenger, sheila sherlock and Harrisons are used for reference
Irritable bowel syndrome (IBS) is a group of symptoms, including pain discomfort in your abdomen combined with changes in your bowel movement patterns.
For More detail visit this link:
http://goo.gl/RaZhvc
Constipation refers to bowel movements that are infrequent or hard to pass. Constipation is a common cause of painful defecation. Severe constipation includes obstipation (failure to pass stools or gas) and fecal impaction, which can progress to bowel obstruction and become life-threatening.
Constipation is a symptom with many causes. These causes are of two types: obstructed defecation and colonic slow transit (or hypo mobility). About 50 percent of people evaluated for constipation at tertiary referral hospitals have obstructed defecation. This type of constipation has mechanical and functional causes. Causes of colonic slow transit constipation include diet, hormonal disorders such as hypothyroidism, side effects of medications, and rarely heavy metal toxicity. Because constipation is a symptom, not a disease, effective treatment of constipation may require first determining the cause. Treatments include changes in dietary habits, laxatives, enemas, biofeedback, and in particular situations surgery may be required.
Constipation is common; in the general population rates of constipation varies from 2–30 percent. In elderly people living in care homes the rate of constipation is 50–75 percent.[4] In the United States expenditures on medications for constipation are greater than US$250 million per year.
The definition of constipation includes the following:
infrequent bowel movements (typically three times or fewer per week)
difficulty during defecation (straining during more than 25% of bowel movements or a subjective sensation of hard stools; straining in this context is a strong effort to push out stool often by holding one's breath and by pushing the respective muscles in the abdominal area hard), or
the sensation of incomplete bowel evacuation.
The Rome III criteria are widely used to diagnose chronic constipation, and are helpful in separating cases of chronic functional constipation from less-serious instances.
Another definition states that less than three bowel movements per week and straining on more than 75% of occasions represents constipation in clinical surveys.
Irritable Bowel Syndrome Part 1 - Dr Vivek BaligaDr Vivek Baliga
In this presentation, Dr Vivek Baliga discusses the important aspects of irritable bowel syndrome - a common medical problem in clinical practice. For more articles, visit http://baligadiagnostics.com/author/drbvb/
IRRITABLE BOWEL SYNDROME
The term irritable bowel syndrome is used to describe a functional gastrointestinal disorder characterized by a variable combination of chronic and recurrent intestinal symptoms not explained by structural or biochemical abnormalities.
Irritable bowel syndrome is a common condition affecting the digestive system.
Symptoms of irritable bowel syndrome include stomach cramps, bloating, diarrhoea and constipation. These may come and go over time.
Making changes to your diet and lifestyle, like avoiding things that trigger your symptoms, can help ease irritable bowel syndrome.
UC is an idiopathic IBD that affects the colonic mucosa.
Hallmark of UC is bloody diarrhea often with prominent symptoms of rectal urgency and tenesmus.
The clinical course is marked by exacerbations and remissions.
The diagnosis of UC is suspected on clinical grounds and supported by the appropriate findings on
Proctosigmoidoscopy or colonoscopy
Biopsy
By negative stool examination for infectious causes
NAFLD is a vast topic and recently gaining a lot of importance. Fatty liver, NASH, are other topics discussed here. sleissenger, sheila sherlock and Harrisons are used for reference
Irritable bowel syndrome (IBS) is a group of symptoms, including pain discomfort in your abdomen combined with changes in your bowel movement patterns.
For More detail visit this link:
http://goo.gl/RaZhvc
Constipation refers to bowel movements that are infrequent or hard to pass. Constipation is a common cause of painful defecation. Severe constipation includes obstipation (failure to pass stools or gas) and fecal impaction, which can progress to bowel obstruction and become life-threatening.
Constipation is a symptom with many causes. These causes are of two types: obstructed defecation and colonic slow transit (or hypo mobility). About 50 percent of people evaluated for constipation at tertiary referral hospitals have obstructed defecation. This type of constipation has mechanical and functional causes. Causes of colonic slow transit constipation include diet, hormonal disorders such as hypothyroidism, side effects of medications, and rarely heavy metal toxicity. Because constipation is a symptom, not a disease, effective treatment of constipation may require first determining the cause. Treatments include changes in dietary habits, laxatives, enemas, biofeedback, and in particular situations surgery may be required.
Constipation is common; in the general population rates of constipation varies from 2–30 percent. In elderly people living in care homes the rate of constipation is 50–75 percent.[4] In the United States expenditures on medications for constipation are greater than US$250 million per year.
The definition of constipation includes the following:
infrequent bowel movements (typically three times or fewer per week)
difficulty during defecation (straining during more than 25% of bowel movements or a subjective sensation of hard stools; straining in this context is a strong effort to push out stool often by holding one's breath and by pushing the respective muscles in the abdominal area hard), or
the sensation of incomplete bowel evacuation.
The Rome III criteria are widely used to diagnose chronic constipation, and are helpful in separating cases of chronic functional constipation from less-serious instances.
Another definition states that less than three bowel movements per week and straining on more than 75% of occasions represents constipation in clinical surveys.
IBS(Irritable Bowel Syndrome) Management Update-2021Pritom Das
Some slides are taken from different textbooks of medicine like Davidson, Kumar and Clark and Oxford, and some from other presentations made by respected tutors. I'm barely responsible for compilation of various resources per my interest. These resources are free for use, and I do not claim any copyright. Hoping knowledge remains free for all, forever.
This is a presentation regarding the epidemiology, pathophysiology,clinical features,symtoms,diagnosis,treatment and management options for the disease -irritable bowel disease.
This is the latest update on irritable bowel syndrome and gastroesophageal reflux by Associate Professor Reuben Wong from gutCARE. This is presented during the latest GP symposium
Review of gastrointestinal symptoms for Fabry disease.
Review of impact from Fabry disease.
Review of differential diagnosis for Fabry disease.
Explanation of GI study for Fabry disease.
Es un síndrome, por lo tanto, tiene signos y síntomas. Se caracteriza sólo por tener una alteración de la motilidad intestinal, excluyendo cualquier otra patología (infecciosa, cáncer, hemorragias, entre otros)
Why Does My Stomach Ache? - Dennis Han, MD, Gastroenterologist - Morristown &...Summit Health
Do you have stomach issues which are bothering you and you can't figure out why? Learn about conditions that could be causing abdominal pain or discomfort at this virtual program. Our expert will discuss different conditions such as: Irritable Bowel Syndrome; Inflammatory Bowel Disease; Celiac Disease and other conditions that require a gluten-free diet; and GERD (Reflux). He will explain the differences between these various conditions, how they are diagnosed, and treatment options available. Hosted by Morristown & Morris Township Public Library.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
2. Conflict of Interest Statement
• Sponsored by Abbott for this lecture
• No other conflicts of interest
2
3. Short Version
• Irritable Bowel Syndrome
– Definition?
– Aetiology?
– Pathology?
– Clinical Features
– Diagnosis?
– Treatment?
– Prognosis +/-
3
4. Introduction
• First described in 1771.
• 50% of patients present <35 years old.
• 70% of sufferers are symptom free after 5 years.
• GPs will diagnose one new case per week.
• GPs will see 4-5 patients a week with IBS.
• Point prevalence of 40-50 patients per 2000
patients.
4
5. What Is IBS?
• A syndrome.
• One man’s
constipation is
another man’s
normality.
• Cause unknown.
• 20% seem to start
after an episode of
gastroenteritis.
5
6. Psychosocial factors
•IBS aetiology is multi-factorial
•Emotions significantly affect colonic response in IBS
– Stressful stimuli disrupt upper GI motility in several ways,
including mean
• oesophageal peristaltic amplitude,
• rate of gastric emptying,
• small bowel transit, and
• increased upper oesophageal sphincter pressure
Aetiology
7. Psychosocial factors
•The response to stress is mediated by corticotrophin
releasing factor (CRF) secreted by the enteric neurons,
enteroendocrine cells and immune cells
– CRF binds to CRF receptors present on smooth muscle cells
and increase the number of discrete cluster contractions
– Psychosocial factors exacerbate the symptoms of IBS but a
definite link has not been established
Aetiology
9. • Exact pathophysiology remains
uncertain
• Dysregulation within the brain gut axis,
• interactions between genetics,
• psychosocial factors,
• post-inflammatory changes and
• motor and sensory dysfunction
are all likely to influence the development of IBS
Pathophysiology
Spiller R, Aziz Q, Creed F, et al. Guidelines on the irritable bowel syndrome: mechanisms and practical
management. Gut 2007;56:1770-1798.
Mawe GM, Coates MD, Moses PL. Intestinal serotonin signalling in irritable bowel syndrome. Aliment
Pharmacol Ther 2006;23:1067-1076.
10. • Exact pathophysiology remains
uncertain
• Visceral hypersensitivity – enhanced pain sensitivity of
the gut – may play an important role in the development
of chronic pain and discomfort in IBS1
• Heightened sensitivity of the peripheral nervous system
is caused by immune and inflammatory mediators acting
at the site of tissue injury and inflammation
Pathophysiology
Spiller R, Aziz Q, Creed F, et al. Guidelines on the irritable bowel syndrome: mechanisms and practical management.
Gut 2007;56:1770-1798.
Mawe GM, Coates MD, Moses PL. Intestinal serotonin signalling in irritable bowel syndrome. Aliment Pharmacol Ther
2006;23:1067-1076.
11. • Exact pathophysiology remains
uncertain
• Serotonin (5-HT) – present extensively in the GI tract – is
the most important neurotransmitter in the pathogenesis
of IBS,
• peripheral sensitisation causes an area of
hypersensitivity to develop in the surrounding uninjured
tissue – this phenomenon is called central sensitisation
Pathophysiology
Spiller R, Aziz Q, Creed F, et al. Guidelines on the irritable bowel syndrome: mechanisms and practical
management. Gut 2007;56:1770-1798.
Mawe GM, Coates MD, Moses PL. Intestinal serotonin signalling in irritable bowel syndrome. Aliment
Pharmacol Ther 2006;23:1067-1076.
12. Disturbances in GI motility
•A proportion of IBS patients, specifically those reporting
constipation or dyspeptic symptoms, exhibit delayed gastric
emptying, especially of solids, this correlates with absence
of post-prandial increase in electrogastrography (EGG)
amplitude
Pathophysiology
Hammerle CW, Surawicz CM. Updates on treatment of irritable bowel syndrome. World J Gastroenterol
2008;14(17):2639-2649.
13. Disturbances in GI motility
•Disturbances in small bowel motor activity occur, including
• frequency and duration of discrete cluster contractions,
• increased frequency of migrating motor complex (MMC),
• more retrograde duodenal and jejunal contractions
• exaggerated motor response to meal ingestion
Pathophysiology
Hammerle CW, Surawicz CM. Updates on treatment of irritable bowel syndrome. World J Gastroenterol
2008;14(17):2639-2649.
14. Disturbances in GI motility
•Corticotrophin releasing hormone, e.g. secreted in
response to stress, increases the number of discrete
cluster contractions.
•More commonly observed in IBS patients with diarrhoea
than in those with constipation
Pathophysiology
Hammerle CW, Surawicz CM. Updates on treatment of irritable bowel syndrome. World J Gastroenterol
2008;14(17):2639-2649.
15. Visceral hypersensitivity
•Visceral pain and discomfort cause considerable morbidity in IBS1
•Visceral hypersensitivity seen in two-thirds of patients with IBS and
plays an important role in abdominal pain and discomfort1
•Animal and human studies suggest that visceral hypersensitivity is
caused by a combination of factors involving heightened sensitivity of
peripheral and central nervous system1
Pathophysiology
Spiller R, Aziz Q, Creed F, et al. Guidelines on the irritable bowel syndrome: mechanisms and
practical management. Gut 2007;56:1770-1798
20. Manning Kruis Rome
Rome I Rome II Rome III
1978 1984 1989 1990 1999 2006
IBS diagnostic criteria
21. Manning’s Criteria.
• Three or more features should have been
present for at least 6 months:
– Pain relieved by defecation.
– Pain onset associated with more frequent stools.
– Looser stools with pain onset.
– Abdominal distension.
– Mucus in the stool.
– A feeling of incomplete evacuation after defecation.
21
22. Rome Publications
Gastroenterolo
gy
International
Journal
1989 1990 1994
1999 2000
2006
1st
IBS
criteria
1992-1995
5 Rome I
publications
2003
Rome
Foundation
Gastroenterolo
gy Supplement
+
Rome III Book
Degnon Assoc.
1683
1st
FGID
classificatio
n
Rome I Book
Little Brown
Rome II
Gut
Supplement
Rome II
Book
Degnon Assoc.
23. Rome II
Diagnostic criteria for IBS
At least 12 weeks, which need not be consecutive,
in the preceding 12 months of abdominal
discomfort or pain that has two of three features:
• Relieved with defecation; and/or
• Onset associated with a change in frequency of stool;
and/or
• Onset associated with a change in form (appearance)
of stool.
Thompson et al Gut 1999;45 Suppl 2:II43-II47
24. Rome II Diagnostic Criteria.
• Supportive symptoms.
– Constipation predominant: one or more of:
• Bowel movement less than 3 times a week.
• Hard or lumpy stools.
• Straining during a bowel movement.
– Diarrhoea predominant: one or more of:
• More than 3 bowel movements per day.
• Loose [mushy] or watery stools.
• Urgency.
24
25. Rome II Diagnostic Criteria.
–General:
• Feeling of incomplete evacuation.
• Passing mucus per rectum.
• Abdominal fullness, bloating or swelling.
25
26. Rome III Committees – Issues and Limitations
• Criteria Not Fully Evidence Based
Limited data for most functional GI disorders
Original criteria by consensus
Changes based on new evidence
New changes need validation
•The Field is Expanding and Growing
Information not “set in stone”
Knowledge can quickly become outdated
Classifications will change – e.g., “Organification”
•Need for Quality Control
Disclosure of relationships with Pharmaceuticals
Confidentiality statements
International Resource Committee
Embargo on information until final editing stages
1778
27. Rome III
Diagnostic Criteria for IBS*
• Recurrent abdominal pain or discomfort
≥ 3 days per month in the last three months
associated with two or more of the following
• Improvement with defecation; and/or
• Onset associated with a change in frequency of stool;
and/or
• Onset associated with a change in form (appearance)
of stool
* Criteria fulfilled for the last 3 months with symptom onset ≥ 6
months prior to diagnosis
28. Rome III Criteria* –
Irritable Bowel Syndrome
Improveme
nt with
defecation
Recurrent abdominal pain or discomfort at least 3
days/month
In the last 3 months associated with 2 or more :
Onset
associated
with a change
in frequency
of stool
Onset
associated
with a change
in form
(appearance)
of stool
and and
Longstreth GF, Gastroenterology 2006 1782
29. • Introduction of a frequency threshold of ≥3 days/
month over 3 months for symptoms
• Reduction of the duration of symptoms before one can
make firm diagnosis from 12 to 6 months
• Refining of subtypes
Main Changes in IBS Criteria
30. Subclassifying IBS Why bother?
• Important for choosing therapies which alter bowel
habit
• Subtypes likely to have different pathophysiology
• Transit
• Stool consistency
• Rectal sensitivity?
31. Previous Features Used to subclassify IBS
Patients
• Diarrhea-predominant 1 or more of 2, 4, or 6 and none of
1, 3, or 5 (or 2 of 2, 4 or 6 and 1 of 1 or 5 but not 3)
• Constipation-predominant 1 or more of 1, 3, or 5 and none of
2, 4, or 6 (or 2 of 1, 3 or 5 and 1 of 2, 4 or 6)
1. Fewer than three bowel movements a week
2. More than three bowel movements a day
3. Hard or lumpy stools
4. Loose (mushy) or watery stools
5. Straining during a bowel movement
6. Urgency (having to rush to have a bowel movement)
32. Problems With Old System
• Complex to apply and caused confusion in both
patients and clinicians!
• Multidimensional but different dimensions don’t
correlate well
• Failed to deal adequately with patients with both
hard and loose stools
33. IBS Patients with Features of Both
Constipation and Diarrhea are
Common
Reference N IBS-D IBS-C IBS-M
Mearin 2003 209 10 24 37
Tillisch
2005
1102 32 17 32
Drossman
2005
317 36 34 31
34. Rome III subtyping is based on
Stool Consistency alone
• Assessed from stool form
36. Why Stool Consistency as Main
Determinant of Subtype?
• Correlates best with colonic transit
37. Why Stool Consistency as Main
Determinant of Subtype?
• Correlates best with colonic transit
• Correlates best with what patients and
community samples think of as “diarrhoea”
• Principle determinant of incontinence
• Other features occur in IBS with both loose &
hard stools
• Stool frequency <3/weeks or >3/day
• Urgency, Sense of incomplete evacuation
38. Association of bowel symptoms with
stool consistency
Tillisch et al Am J Gastroenterol. 2005; 100:896-904
39. Proposed New Subtyping Based on
Stool Consistency Alone
• IBS with constipation - IBS-C
• IBS with diarrhoea - IBS-D
• IBS mixed type - IBS-M
• IBS unsubtyped - IBS-U
• IBS-mixed : patients with both hard & loose stools
over periods of hours or days
42. Quantifying Stool Form
Date Pain Pain
Severity
Urgency
Y/N
Bloating
Y/N
1 2 3 4 5 6 7 8
Pain: grade 0-10 0= absent 5=moderate 10 very severe
Stool form
1= separate hard lumps, like nuts 6 = fluffy pieces with ragged edges
2= sausage shaped but lumpy 7 = watery, no solid pieces
3= like a sausage or snake, but with cracks
on its surface
4= like a sausage or snake, smooth and soft
5= soft blobs with clear cut edges
43. Changes to IBS classification
Rome III Summary
• No change to basic criteria
• Length of time needed to define chronicity reduced
to 6 months
• Threshold ≥3 days / month introduced for
frequency of pain / discomfort
• Subtyping simplified (stool consistency)
• Stability of subtypes and link to other features like
visceral sensitivity and response to treatment
remain to be determined
44. Manning Kruis Rome
Rome I Rome II Rome III
1978 1984 1989 1990 1999 2006
IBS diagnostic criteria
Rome IV
2016
INTERNAL USE ONLY. DO NOT COPY. DO NOT DISTRIBUTE EXTERNALLY.
45. Associated Symptoms
• In people with IBS in hospital OPD.
– 25% have depression.
– 25% have anxiety.
• Patients with IBS symptoms who do not
consult doctors [population surveys] have
identical psychological health to general
population.
• In one study 70% of women IBS sufferers
have dyspareunia.
45
46. Associated Symptoms
• Stressful life events are associated.
• Compared with controls people with IBS are
less well educated and have poorer general
health.
• Women:Men = 3:1.
46
47. Reasons to Refer
• Age > 45 years at
onset.
• Family history of
bowel cancer.
• Failure of primary care
management.
• Uncertainty of
diagnosis.
• Abnormality on
examination or
investigation.
47
49. Differential Diagnosis
• Inflammatory bowel disease.
• Cancer.
• Diverticulosis.
• Endometriosis.
• A positive diagnosis, based on
Manning’s criteria may provoke less
anxiety than extensive tests.
49
50. Examination
• Results should be
normal or non-specific.
• Abdomen and rectal
examination.
• FBC, CRP.
• No consensus as to
whether FOBs or
sigmoidoscopy is
needed.
50
52. Patients’ Concerns.
• Usually very concerned about a serious cause
for their symptoms
– Cancer phobias
• Take time to explore the patients agenda.
• Remember that investigations may heighten
anxiety.
52
53. Explanation.
53
• Must offer a plausible reason for
symptoms.
• Even if cause is unknown, patients
require some explanation.
• Drawing a parallel with baby colic may
help.
• Stress is currently a socially acceptable
explanation for many symptoms in life.
54. Treatment Approaches.
54
• Placebo effect of up to 70% in all IBS
treatments.
• Treatment should depend on
symptom sub-type.
• Often considerable overlap between
sub-groups.
55. Psychotherapy
• Antidepressants
– Poor evidence for efficacy
– Better evidence for tricyclics
• May have some effect other than antidepressant
effect
– Very little evidence for SSRIs
• Relaxation therapies may be useful adjunct.
• CBT (Cognitive Behavioral Therapy)
55
57. Constipation Predominant.
• Increased fibre.
• Osmotic laxatives helpful, Ispaghula
husk is one.
• Stimulant laxatives make symptoms
worse.
• Lactulose may aggravate distension
and flatulence.
57
58. Pain Predominant.
• Antispasmodics will help 66%.
• Mebeverine is probably first choice.
• Hyoscine 10mg qid can be added.
• Bloating may be helped by peppermint
oil.
• Nausea may require metoclopramide.
58
62. Spiller and Thompson 2010
World Gastroenterology Organisation Global Guideline 2009
IBS-C, irritable bowel syndrome with constipation;
IBS-D, irritable bowel syndrome with diarrhoea;
SSRI, selective serotonin reuptake inhibitor
IRRITABLE BOWEL SYNDROME
Rome/WGO management cascade
Patient with chronic or
recurrentabdominal
pain/discomfort
associated with
disordered bowel habit
no
History and clinical
examination
Alarm features?
yes
Investigations as
indicated
Consider limited
screening tests
Any
abnormality
identified?
yes
IRRITABLE
BOWEL
SYNDROME (IBS)
Initial therapy: treat
primary symptom:
spasmolytic
yes
Symptom relief?
no
Assess symptom
pattern
Long-term
management
IRRITABLE
BOWEL
SYNDROME WITH
DIARRHOEA (IBS-
D)
IRRITABLE
BOWEL
SYNDROME WITH
CONSTIPATION
(IBS-C)
IRRITABLE
BOWEL
SYNDROME WITH
PAIN
Alosetron, rifaximin,
….?
Lubiprostone,
linaclottide, ….. Tricytlic, SSRI, …..
63. Referral
• About 15% of patients seen by GPs with IBS
are referred.
• Gastroenterology – Mainly upper GI
symptoms.
• General Surgical – Lower GI symptoms.
•
63
64. Psychological Thoughts
• Should a mental health assessment
always be done?
• Should all therapy be directed at
psychological causes?
• Is IBS a physical or a somatisation
disorder?
64
Singh RK, Pandey HP, Singh RH. Irritable bowel syndrome: Challenges ahead. Current Science 2003;84(12):1525-1533.
Coleman N, Spiller R. New pharmaceutical approaches to the treatment of IBS: Future development and research. Annals of Gastroenterology. 2002;15(3):278-289.
Spiller R, Aziz Q, Creed F, et al. Guidelines on the irritable bowel syndrome: mechanisms and practical management. Gut 2007;56:1770-1798.
Hulisz D. The burden of illness of irritable bowel syndrome: Current challenges and hope for the future. J Manag Care Pharm 2004;10(4):299-309.
Singh RK, Pandey HP, Singh RH. Irritable bowel syndrome: Challenges ahead. Current Science 2003;84(12):1525-1533.
Coleman N, Spiller R. New pharmaceutical approaches to the treatment of IBS: Future development and research. Annals of Gastroenterology. 2002;15(3):278-289.
Spiller R, Aziz Q, Creed F, et al. Guidelines on the irritable bowel syndrome: mechanisms and practical management. Gut 2007;56:1770-1798.
Hulisz D. The burden of illness of irritable bowel syndrome: Current challenges and hope for the future. J Manag Care Pharm 2004;10(4):299-309.
Spiller R, Aziz Q, Creed F, et al. Guidelines on the irritable bowel syndrome: mechanisms and practical management. Gut 2007;56:1770-1798.
Mawe GM, Coates MD, Moses PL. Intestinal serotonin signalling in irritable bowel syndrome. Aliment Pharmacol Ther 2006;23:1067-1076.
Spiller R, Aziz Q, Creed F, et al. Guidelines on the irritable bowel syndrome: mechanisms and practical management. Gut 2007;56:1770-1798.
Mawe GM, Coates MD, Moses PL. Intestinal serotonin signalling in irritable bowel syndrome. Aliment Pharmacol Ther 2006;23:1067-1076.
Spiller R, Aziz Q, Creed F, et al. Guidelines on the irritable bowel syndrome: mechanisms and practical management. Gut 2007;56:1770-1798.
Mawe GM, Coates MD, Moses PL. Intestinal serotonin signalling in irritable bowel syndrome. Aliment Pharmacol Ther 2006;23:1067-1076.
Hammerle CW, Surawicz CM. Updates on treatment of irritable bowel syndrome. World J Gastroenterol 2008;14(17):2639-2649.
Hammerle CW, Surawicz CM. Updates on treatment of irritable bowel syndrome. World J Gastroenterol 2008;14(17):2639-2649.
Hammerle CW, Surawicz CM. Updates on treatment of irritable bowel syndrome. World J Gastroenterol 2008;14(17):2639-2649.
Spiller R, Aziz Q, Creed F, et al. Guidelines on the irritable bowel syndrome: mechanisms and practical management. Gut 2007;56:1770-1798.
Time of 12 months designed to avoid giving a chronic disease label to transient symptoms eg due to infection etc Reduced time needed to establish chronicity to 6 months unlikely that new diagnosis will emerge or that symptoms will disappear if have lasted 6 months Better and faster investigations mean that other diagnoses are rapidly eliminated
Threshold of &gt;3 days per month based on ? Designed to exclude trivial complaints 3/ month
Problems that many patients have both features to some extent end up being excluded from either diagnosis
Further using multiple dimensions
Further recognised that straining can often be present even when stool is loose and frequency correlates poorly with other parameters determined by many factors including social and psychological factors
Evidence that mixed pattern is quite common
Also that stool consistency is most important concern since it relates to urgency
This is an important group as hsown in the next slide
Mearin used slightly different criteria requiring subjects ot have 1 of three rome II criteria to qualify for any one category
Tilisch figures are clasified by stool consistency
Not all figures add up to 100% since around 5% were not classified into given categories
As is shown on the next slide
Change sequence to emphasise they are part of IBS spectrum share many features particularly the central ones but differ with respect to bowel pattern
Prefer mixed to alternators