Irritable Bowel syndrome

1. Irritable
bowel
syndrome
(IBS)
Dr.S.Vadivel Kumaran.,MD.,DM
Consultant Medical
Gastroenterologist/Interventional
Endoscopist/Hepatologist

2. Functional gastrointestinal (GI) disorder
abdominal pain and altered bowel habit
Absence of a specific and unique organic
pathology
Incidence-1%-2% per year
Prevalence-10%-20%

4.  Normal bowel movement- 3/day to 3/week.
 Problems arises when bowel movements
frequency decreases or increases.
 Control loss of bowel sphincters.
Normal bowel movements

5. Bowel movement Disorders
• Diarrhea
Passage of loose or watery stools, typically at least three times in a
24-hour period
• Constipation
Stool frequency of less than three per week
• Irritable Bowel Syndrome

6. Causes of diarrhea
• Infection: Diarrhoea caused by a host of bacterial, viral and
parasitic organisms- spread by faeces-contaminated water
.
• Malabsorption
• Inflammatory bowel disease
• Irritable bowel syndrome

7. Constipation
Constipation is a symptom, not a disease.
Different patients have different perceptions:
-Straining
-Hard, pellet-like stools
-Inability to defecate when desired
-Infrequent defecation.

8. Causes of Constipation
Mechanical causes:
Colorectal tumors
Strictures
Neurological causes:
Autonomic neuropathy
Multiple sclerosis
Gastrointestinal:
IBS
Diet:
Low fiber intake
Fluid depletion
Metabolic causes:
Diabetes mellitus
Electrolytes imbalance
Medications:
Antidepressants, calcium-
channel blockers.. etc.

9. IBS- Components
Altered bowel habit
Abdominal pain
Abdominal bloating/distention

10. Altered bowel habit
Constipation
Diarrhea
Postprandial urgency

12. Inflammation
Genetics
Motility
Postinfecious
Microflora
Alterations
Sensitivity
Psychosocial

13. Abdominal pain
-Diffuse without radiation
-Lower abdomen- left lower quadrant
-Acute episodes of sharp pain- superimposed
-Meals may precipitate pain
-Defecation commonly improves pain
-Gas pockets- anterior chest pain or left upper
quadrant abdominal pain

15. Four bowel patterns
IBS-D (diarrhea predominant)
IBS-C (constipation predominant)
IBS-M (mixed diarrhea and constipation)
IBS-U (unclassified; the symptoms cannot
be categorized into one of the above three
subtypes)

16. Others
Clear or white mucorrhea of a noninflammatory
etiology
Dyspepsia, heartburn
Nausea, vomiting
Sexual dysfunction (including dyspareunia and poor
libido)
Urinary frequency and urgency have been noted
Worsening of symptoms in the perimenstrual period
Comorbid fibromyalgia
Stressor-related symptoms

17. Abdominal examination
Inspection
Bloatn
ess
Palpitation
Organ
megaly
masse
s
Rectal
Percussion
Auscultation
Bowel
movements

18.  Unintentional and unexplained weight loss.
 Rectal bleeding.
 A family history of bowel or ovarian cancer.
 In people aged over 60, a change in bowel
habit lasting more than 6 weeks with looser
and/or more frequent stool.
 Anemia.
 Abdominal masses.
 Rectal masses.
Alarming Symptoms !!!

19. Diagnosis
• It is Difficult.
• It Needs to balance between few and many
investigations.
• Red flag symptoms should be ruled out.
• The Diseases that causing similar symptoms
should ruled out.

20. Investigations
Inflammatory markers for inflammatory bowel disease.
In women ovarian cancer should have their serum CA125
measured.
When the above have been excluded, the following tests
should be done to exclude other diagnoses:
• Full blood count
• Erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP)
• Antibodies for coeliac disease (endomysial antibodies [EMA]
or tissue transglutaminase [TTG]).

21. Management
Patients need “Basic” and “Beyond Basic”
education regarding IBS
Help seeking behavior need to be modified to
decrease costs spent on acute attacks.
 Dealing with symptoms
 What are the worrying symptoms?
 When to seek help?
Education

22. Management
Life style:
Diet:
• Regular meals
• Decrease caffeine
• Increase fiber?
• Probiotics
• If persistent  specific
food avoidance
- Reduce stress, increase leisure and relaxation time
- Increase physical activity

23. Dietary measures
Fiber supplementation may improve the
symptoms of constipation and diarrhea
Judicious water intake
Caffeine avoidance- limit anxiety and symptom
exacerbation
Lactose, fructose, and/or FODMAPs
(fermentable oligosaccharides,
disaccharides, monosaccharides, and
polyols) should be limited or avoided
Probiotics

26. Food Items To Limit
Dairy products for lactose-intolerant.
High-fiber foods, such as raw fruits and vegetables, and whole
grains, bran.
Gas-producing foods such as cabbage, broccoli, and onions, and
foods with hulls, such as seeds, nuts, and corn.
High-fat foods, such as fried foods, butter and margarine,
mayonnaise, peanut butter, nuts, ice cream, and fatty cuts of
red meat.
Spicy foods.
Foods with caffeine, such as chocolate, tea and coffee.
Carbonated drinks.
Alcohol.

27. Do's And Dont's
Don'ts:
Avoid Caffeine or Alcohol
Avoid eating high fibre
legumes
Avoid Processed Foods
Avoid Dairy Products
Avoid whole Nuts
Do's:
Choose Lean Meats &
Protein
Eat Cooked Vegetables
Eat Bland Food
Eat Smaller Meals
Keep a Food Diary

28. Food Items You Can Easily
Consume
Cereal- oatmeal, rice, pasta
Fruits and vegetables- banana, stewed apple, avocado,
potato,okra,pureed vegetable soups, lettuce
Meat and eggs- fish (salmon), lean chicken, turkey, eggs
Pulses and legumes
Fats and oils- 3-4 tsp oil/ day
Sugars- 1-2 tsp table sugar/ day
Milk and milk products- yogurt, skim milk, almond milk

29. Management
Pharmacological:
Psychological: Mainly in refractory IBS
• Antispasmodics (otilonium, hyoscine)
• Constipation laxatives (osmotic,
linaclotide)
• Diarrhea  antimotility (loperamide)
• TCAs (amitriptyline) or SSRIs
• Cognitive behavioral therapy (CBT)
• Hypnotherapy
• Psychotherapy

30. Follow up
• Agreed between physician and patient.
• Depends on response of the person’s
symptoms to intervention.
• ‘Red flag’ symptoms should prompt further
investigation and/or referral to secondary
care.

31. When to Refer to a specialist?
Refer when there is:
• More than minimal rectal bleeding
• Weight loss
• Unexplained iron deficiency anemia
• Nocturnal symptoms
• Family history of Colorectal cancer IBD
Celiac disease

32. Psychological intervention
cognitive-behavioral therapy,
dynamic psychotherapy, and
Hypnotherapy
Relaxation therapy- usual care

33. Patient education remains the cornerstone of successful
treatment of irritable bowel syndrome. Teach the patient to
acknowledge stressors and to develop avoidance
techniques. Many patients successfully manage their
symptoms with attention to dietary triggers.

34. Thank You
For Your Attention