All you need to know about IBS

1. Irritable Bowel Syndrome
PPE III/IV
PHAR 660/665
Zeinab Noormonavar
4/14/2021
(IBS)

2. What you need to know?
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3. Outline
At the end of the presentation we’ll be able to:
 Recall the pathophysiology, diagnosis, clinical presentation, epidemiology of IBS
 learn Non-Pharmacological and pharmacological treatment modalities.
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4. Definition Of IBS
• Irritable Bowel Syndrome is not a disease. It’s a functional
disorder, which means that the bowel simply does not works as it
should.
• It is the most common disorder diagnosed by gastroenterologists
and one of the most common seen by primary care physicians.
• IBS is a common disorder that affects the large intestine (colon).
• IBS commonly causes cramping, abdominal pain, bloating,
gas, diarrhea and constipation or both.
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5. Definition (Cont’d)
• According to the Rome IV criteria, Irritable bowel syndrome is
defined as recurrent abdominal pain on average, at least one day
per week in the last three months with two or more of the
following:
1. Related to defecation
2. Associated with a change in frequency of stool
3. Associated with a change in form (appearance) of stool
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6. Epidemiology
• Prevalence: 3-22% worldwide,10-15% USA/Europe and 5% Asian
countries.
• Incidence: 1-2% per year
• Spent related to IBS: 8 billion dollars/year
• Onset before age 35: 40%
• Onset age 35-50: 50%
• Female > Male: 3:1
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7. Types Of IBS
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Constipation
IBS-C
• Hard/Lumpy: ≥ 25%
• Loose/Watery:<25%
Diarrhea
IBS-D
• Hard/Lumpy: <25%
• Loose/Watery:≥25%
Mixed (C+D)
IBS-M
• Hard/Lumpy: ≥25%
• Loose/Watery:≥25%
Unspecified
IBS-U
• Hard/Lumpy:<25%
• Loose/Watery:<25%

8. Pathophysiology
• IBS pathophysiology is not clear.
• Many theories have been put forward, but the exact cause of IBS is still
uncertain.
1) Alteration in GI motility: alteration in frequency and regularity of luminal contractions.
2) Visceral hypersensitivity: increased sensation in response to stimuli.
3) Brain gut axis: alteration in communications between enteric nervous systemic and CNS.
4) Post infectious: about 10% of IBS cases are triggered by an acute gastroenteritis infection.
5) Genetics
6) Inflammation: Cytokines,lymphocytes & mast cell are identified in IBS patients.
7) Serotonin receptors (95% found in GIT):
Type 3: increase motility → IBS-D
 Type 4: decrease motility → IBS-C
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10. Common
Constipation
Diarrhea
Alternation (C+D)
Abdominal pain
Abdominal bloating or
distention
Alarming
Wight loss
Fever
Frequent nocturnal symptoms
Rectal bleeding
Unexplained iron deficiency
Associated
Psychiatric illness
Chronic fatigue
Sexual disfunction
Heartburn
Nausea/Vomiting
Urinary frequency and urgency
Clinical Presentation 10

11. Diagnosis
Sigmoidoscopy
Or
colonoscopy
Screening
for celiac
disease
Stool
examination
Blood
test
Lactose
Intolerance
Test
Hydrogen
breath
test
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13. Non-Pharmacological Treatment
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Increase physical activity
• Increase fiber intake (IBS-C)
• Exclusion of gas producing food (IBS-D)
• Lactose & Gluten avoidance (IBS-D)
• Try Probiotic for one month
Dietary modification
Follow low FODMAP diet

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16. General Approach to Treatment
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17. Abdominal pain
Bloating
Constipation
or Diarrhea
Treatment
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19. 1-Abdominal pain
Antispasmodics
• Used when needed
• Decrease fecal urgency
• Short term relieve for abdominal pain
Caution incase of IBS-C : Antispasmodics will
worsen constipation due to anticholinergic effect.
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20. Antispasmodics Agents
Spasmine
•Mebeverine,200 mg capsule
•Taken 20 min before a meal max 3 doses/day
•Relax muscles of the gut
•SE: heart burn,indigestion,constipation insomnia
•CI:paralytic ileus, constipation
Debutine
•Trimebutine,200mg tablet
•Taken before meal, 1 tab 3x/day
•SE: Anticholinergics(dry mouth,N,Fatigue,C,dizziness)
Buscopan
•Hyoscine butylbromide,10mg tablet
•Taken 1 tab 3x/day or increase to 2 tab 4x/day
•Decreases contractions of the muscles of stomach,bowel,and bladder
•SE: anticholinergics
•CI: Myasthenia Gravis, paralytic ileus
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21. Used in low dose if
persistent pain (10-25
mg/day)
TCAs used for 3-5 days
Side effects:
anticholinergic,
sedation, QT
prolongation,
constipation, weight
gain
Antidepressants
Caution incase of IBS-C, and in patients with heart problems
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Antidepressants have analgesic properties
independent of their mood improving effects.
Tricyclic antidepressants (TCAs), via their
anticholinergic properties, also slow intestinal
transit time, which may provide benefit in
Diarrhea-predominant IBS

22. •Amitriptylline
Tryptizol
•Nortriptylline
Nortrilen
•Imipramine
Tofranil
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23. 2-Bloating
Dietary
modifications
Anti-
spasmodic
Anti-
flatulence
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24. Anti-flatulence Agents
Ovol
Simethicone,180 mg taken 3-4x/day after a meal and at
bedtime
Infloran
Bifidobacterium & lactobacillus, capsule
1 dose/day
Normix
Rifaximin, 200 mg 1 tab 3x/day for 2 week trial for IBS-D
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25. 3- Constipation & Diarrhea
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26. DIET
IBS-C IBS-D
• Sources of fiber include whole-grain bread
and cereals, fruits, vegetables, and beans.
(gradually)
• Dried plums, prune juice, ground flaxseed
and water as well.
• Stay away from coffee , carbonated
drinks, alcohol and processed foods
such as chips, cookies, and white bread and
rice.
• Avoid chocolate, fried foods,
alcohol, caffeine, carbonated
drinks, the artificial
sweetener sorbitol, and
fructose.
• Be careful with fiber.
• Drink plenty of water every day.
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27. OTC DRUG
IBS-C IBS-D
FIBERS:
1. Wheat bran
2. Corn fiber
3. Calcium polycarbophil (Fibercon)
4. Psyllium (Fiberall, Metamucil, Perdiem, and
others).
LAXATIVES:
1. Bulk forming: psyllium, Ca carbophil and
methylcellulose (Best)
2. Peg based laxatives: include lactulose and
polyethylene glycol.
3. Stimulants: Bisacodyl (Correctol, Dulcolax),
sennosides (Ex-Lax, Senokot), castor oil, and
the plant cascara .
1. Bismuth subsalicylate (Kaopectate, Pepto-
Bismol).
2. Loperamide (Imodium).
3. Simethicone (Gas-X, Mylicon)
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IBS-C
FIBERS
Wheat bran
Corn fiber
Calcium
polycarbophil
Psyllium
LAXATIVES
Bulk
forming
psyllium
Ca
carbophil
Methylcellulose
Peg based
laxatives
lactulose
PEG
Stimulants
Bisacodyl
sennosides
castor oil
plant
cascara
IBS-D
Bismuth
subsalicylate
Loperamide
Simethicone

29. PRESCRIPTION DRUG
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30. IBS-C
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31. Drug MOA Adm-counseling SE CI
LINACLOTIDE
(linzess)
oligo-peptide agonist
of guanylate cyclase
2C
145-290mcq qd taken
on an empty stomach
30 mins before 1st
meal for 12 weeks
DIARRHEA
flatulence
In patient prone to
water or electrolytes
disturbances
LUBIPROSTONE
(amitiza)
Chloride channel
activator.
Adults with CIC:
Take 24mcg bid po
with food
Adult women with
IBS:
Take 8 mcg BID po
with food.
Both for up to 52
weeks.
NAUSEA
DIARRHEA
DYSPNEA
BOWEL OBS
Fecal incontinence
Decreased appetite
rash
Mechanical GI
obstruction.
Severe Diarrhea
PRUCALOPRIDE
(reslor)
5-HT4 receptor
agonist
Taken as 2-4 mg/d NAUSEA
VOMIT
HA
IRRITABILITY
FATIGUE
Severe renal
impairment.
Dialysis patient.
Colonic obstruction.
Inflammatory bowel
disease.
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32. IBS-D
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33. Drug MOA Adm-counseling SE CI
Loperamide
(immodium)
ANTIDIARRHEAL Take 2 mg 45 mins
before a meal
N,V,Dry mouth
Abdominal pain
infectious diarrhea.
torsades de pointes.
paralysis of the
intestines.
liver problems.
bloody diarrhea.
Eluxadoline
(viberzi)
ANTIDIARRHEAL Take 100 mf PO BID
with food.
N,V,C,URTI
Nasopharyngitis
Pancreatitis
Without gallbladder
Biliary duct obs.
Alcohol Abuse.
Cholestyramine
Colestipol
Coleselvam
Bile acid sequestrants taken 2 to 16
grams/day given once
or in divided doses.
Bloating, flatulence.
Abd discomfort.
Constipation
hypertrigylceridemia
(>250 mg/dL)
Alosteron
(lotronex)
Serotonin 3
antogonist
0.5 mg bid for 4
weeks.
Best for females with
severe ibd symp
Constipation
Nausea
Ischemic colitis
Constipation
Intestinal obs
Ischemic colitis
Impaired intestinal
circulation
IBD
Hepatic impair
Fluvoxamine
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34. • Improvement in the IBS Symptom Severity Score and Rescue Medication Use.
• Increase in Bowel Movement Frequency in Participants with IBS-C.
• Decrease in the Bowel Movement Frequency in Participants with IBS-D.
• No Significant Changes in the Bowel Movement Frequency in Participants with IBS-M.
• Improvements in Mental Health Measures in Participants Given Probiotics.
• Improvement within 4-8 weeks.
https://pubmed.ncbi.nlm.nih.gov/32326347/
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35. References
1) https://www.uptodate.com/contents/treatment-of-irritable-bowel-syndrome-in-
adults?search=irritable%20bowel%20syndrome&source=search_result&selectedTitle=1~150&usage_
type=default&display_rank=1
2) https://www.uptodate.com/contents/pathophysiology-of-irritable-bowel-
syndrome?search=irritable%20bowel%20syndrome&topicRef=2631&source=see_link
3) https://www.mayoclinic.org/diseases-conditions/irritable-bowel-syndrome/diagnosis-
treatment/drc-
20360064#:~:text=These%20criteria%20include%20abdominal%20pain,or%20stool%20consistency%2
0is%20altered
4) https://www.ibsdiets.org/fodmap-diet/fodmap-food-list
5) https://www.webmd.com/ibs/guide/digestive-diseases-irritable-bowel-syndrome
6) https://journals.lww.com/ajg/Fulltext/2021/01000/ACG_Clinical_Guideline__Management_of_Irr
itable.11.aspx
7) https://www.uspharmacist.com/article/ibs-treatment-guidelines
8) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2265348
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