Download Irritable Bowel Syndrome

6/18/2016
Irritable Bowel Syndrome
 Chronic abdominal pain and altered bowel function in
the absence of known organic cause for at least three
months
 Prototype of Functional Bowel Disorders
Irritable Bowel Syndrome
Jeffrey Jump, MD
CHI Memorial Integrative Medicine Associates
[email protected]
Prevalence
Diagnosis
 Affects 10-15% of the population
 Rome III Criteria
 2:1 – 3:1 female to male ratio
 15% seek medical attention, but account for 25-30% of
all GI referrals
 Second highest cause of work absentism
 Recurrent abdominal pain/discomfort for at least three
months with at least two of the following
Improvement with defecation
Onset associated with change in frequency of stools
Onset associated with change in form of stools
Supportive Symptoms
IBS Subtypes
 Abnormal Stool Frequency: ≤ 3/week or ≥ 3/day
 IBS-C: hard/lumpy ≥ 25%, loose/watery ≤ 25% of BM’s
 Abnormal stool form: hard/lumpy, loose/watery
 IBS-D: loose/watery ≥ 25%, hard/lumpy ≤ 5% of BM’s
 Defecation straining, urgency, or a feeling of incomplete
bowel movement, passing mucous and bloating
 IBS-M: hard/lumpy ≥ 25%, loose/watery ≥ 25% of BM’s
 Unspecified: insufficient consistency of stool consistency
to meet above criteria
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Diagnostic Approach
Role of Alarm Symptoms
 Individual symptoms have limited accuracy for diagnosing IBS
and, therefore, the disorder should be considered as a
symptom complex.
 2009 ACG recommendations for diagnosis of IBS:
”in patients who fulfill symptom-based criteria of IBS,
the absence of selected alarm features, including
anemia, weight loss, and a family history of colorectal
cancer, inflammatory bowel disease, or celiac sprue,
should reassure the clinician that the diagnosis of IBS is
correct.”
 Alarm Symptoms
 Rectal Bleeding
 Nocturnal or progressive pain
 Weight Loss
 Lab abnormalities: anemia, increased inflammatory markers
and/or electrolyte abnormalities
 Family history of IBD, CRC, Celiac disease
R.S. 26 y/o female
Past Medical History
 CC: Chronic diarrhea, bloating and cramping.
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 HPI: Onset in high school of intermittent loose bowels, up
to 5-6 times a day, assoc. with bloating, abdominal
discomfort and cramping relieved by BM’s.
 Increased at times of stress
 BM’s frequently soon after eating
PCOS with irregular and heavy periods controlled with BCP’s
MCTD
IFG and elevated triglycerides – meets criteria of metabolic syndrome
GERD
IDA in high school
Medications:
 Plaquenil
 Mobic prn
 No other assoc. provoking factors or timing
 BCP’s
 No alarm features
 Pepcid prn
Family History
Social History
 Father: DM-2, Hypertension
 RN
 Mother: MG, Asthma, Morbid Obesity
 Recently divorced
 No history of CRC or other GI disease
 Moderate alcohol use, with some episodes of binge
drinking
 No Tabaco use
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Physical Exam
Routine Lab
 56” tall, 200 lbs. BMI: 32.3
 CBC and CMP normal except mildly elevated blood
sugar at 103 fasting
 Normal vital signs and normal exam
 TSH 1.34
 ESR 12
Celiac Testing
Celiac Disease
 Positive for serum IgA antibody to tissue
transglutaminase
 Routine serologic screening for celiac sprue should be pursued in patients
with IBS-D and IBS-M – 2009 ACG recommendations for diagnosis of IBS
 Father and one sister also tested positive for Celiac
 Meta-analysis of 14 studies focusing on unselected adults who met
diagnostic criteria for IBS, celiac disease was four times as likely as in
controls without IBS – 4%
 A prospective multicenter US study compared the prevalence of abnormal
celiac antibodies and biopsy proven celiac disease in patients with nonconstipated (NC) IBS to that of healthy controls. Although more than 7
percent of NC-IBS patients had celiac disease associated antibodies
suggesting gluten sensitivity, the prevalence of biopsy proven celiac
disease was similar in NC-IBS and controls
Disposition
KW – 36 y/o male
 RS had started a strict gluten free diet with resolution of
her symptoms. She did not desire endoscopy
confirmation of the diagnosis.
 Presenting complaint of diarrhea associated with
significant bloating, especially after meals for the past 3+
years. Symptoms are daily with 3-4 loose watery
BM’s/day. No weight loss or rectal bleeding. No
nocturnal symptoms. Mild cramping relieved by
defecation.
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Past Medical History
Family History
 GERD with grade 1 esophagitis on endoscopy at age 28,
small bowel biopsy negative for Celiac
 Father: CAD with an MI at age 52
 Medication
 No history of CRC or other GI disease
 Omeprazole 20mg daily
Social History
Physical Exam
 Married with 3 children
 74 inches tall, 200 lbs. BMI 25.7
 Lawyer with high stress levels
 Normal vital signs and exam
 Social alcohol use, no Tabaco use
 Frequent camping, hunting, fishing and hiking
Routine Lab
Other Testing
 CBC and BMP and Magnesium normal
 Stool O&P negative
 B12: 350 pg/ml
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Diagnosis
SIBO
 IBS - D
 Condition in which non-native bacteria and/or native
bacteria are present in increased numbers in the
proximal small bowel resulting in excessive fermentation,
inflammation, or malabsorption.
 Possible Small Intestinal Bacterial Overgrowth – SIBO
 Why?
 Suspicion of SIBO in chronic PPI use
 Theory of SIBO as underlying pathophysiologic mechanism
for IBS - JAMA. 2004;292(7):852-858.
 Present with nonspecific symptoms of bloating,
flatulence, or abdominal discomfort and diarrhea
 Most patients with SIBO have no laboratory
abnormalities
SIBO - Diagnosis
Breath Tests
 Jejunal aspirate cultures, considered the reference
standard for the diagnosis of SIBO, have limitations in
diagnosis and sensitivity and specificity.
 Studies to evaluate the performance of breath tests to diagnose
SIBO have several limitations including heterogeneity in patient
populations, small sample sizes, and the use of cutoffs to define a
positive test that have not been validated.
 Invasive
 Culture is difficult and only approximately 40 percent of the total gut
flora can be identified using conventional culture methods
 Oropharyngeal contamination is common
 Not to mention that the gold standard to which to compare breath
testing has difficulties that we just discussed
 Lactulose breath test has a sensitivity of 17 to 68 percent and
specificity of 44 to 86 percent
 Bacterial overgrowth can be patchy
 Poor reproducibility
Breath Test
 Negative Predictive Value:
Treatment Plan
_________SP_x_(1-Prev)
(1 – Sen)x Prev + SP x (1-Prev)
 sensitivity of 17 to 68 percent and specificity of 44 to 86 percent
 Prevalence of SIBO
 FODMAP diet
 FODMAPs are short chain carbohydrates, may not be digested or absorbed
well and are fermented upon by bacteria in the intestinal tract
 The FODMAPs: “Fermentable Oligo-, Di-, Mononsaccharides and Polyols”
 Meta-analysis chronic PPI use found OR, 7.587; CI, 1.8-31.9 of SIBO on aspirate
 Fructose (fruits, honey, high fructose corn syrup (HFCS), etc)
 500 PPI users and 200 IBS patients: prevalence of 50% and 24.5% respectively
 Lactose (dairy)
Negative Predictive Value between 34.6% - 72.8%
 Fructans (wheat, garlic, onion, inulin etc)
 Galactans (legumes such as beans, lentils, soybeans, etc)
 Polyols (sweeteners containing isomalt, mannitol, sorbitol, xylitol, stone fruits such
as avocado, apricots, cherries, nectarines, peaches, plums, etc)
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FODMAP Diet
Treatment Plan
 Most IBS patients have visceral hypersensitivity and
symptoms may be triggered by luminal distension. A
high FODMAP diet has been shown to lead to luminal
distension through colonic fermentation and increased
delivery of fluid to the colon.
 Wean off omeprazole by taking qod for 1 month and
then stopping, using OTC famotidine prn
 DGL – 2 tabs before each meal
 Rifaximin 550mg TID for 10 days
 In patients with SIBO reducing these carbohydrates may
also lessen the development of D-lactic acidosis, the
production of small bowel gas, bloating, and
discomfort.
Disposition
SD – 41 y/o female
 Resolution of IBS symptoms within the first week of
rifaximin treatment and going on the FODMAP diet
 Presenting Complaint: IBS
 Bloating and distention that is progressive over the day,
starts with eating, discomfort that is described as
“clenching, tight and achy”, periumbilical/generalized
 Recurrence after about 2 months with reintroduction of
carbohydrates to the diet. Repeated the treatment with
rifaximin and continued the FODMAP for 2-3 months,
after which he has had resolution of IBS symptoms
 Constipation: able to have BM most days with taking
Magnesium nightly, but never feels like BM is adequate.
 No diarrhea
 Ongoing most of adult life
 Increased symptoms noted with stress
Past Work-up
Past Treatments
 EGD 2005 unremarkable
 Omeprazole – no benefit
 Celiac testing by serology and biopsy negative in 2005
 Dicyclomine – no benefit
 H. Pylori serology negative in 2005
 Gluten and dairy free diet past several years – minimal
affect on GI symptoms, but states she has noted
decreased aching in joints, so has maintained diet
 Unremarkable abdominal U/S in 2005
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Past Medical History
Family History
 ADD
 B12 and Vitamin D deficiency
 Adopted and unknown
 No medication
 OTC’s:
 Multivitamin
 Fish Oil
 Magnesium Citrate
 Vitamin D
Social History
Physical Exam
 Married with 3 children ages 3, 6, and 8
 66 inches tall, 142 lbs., BMI 22.9
 Less than one alcoholic drink a week
 Vital signs and exam normal
 Quit smoking in 1998 – 5 pack/year history
Routine Lab
Diagnosis
 CBC: normal
 IBS - C
 TSH: 1.21
 Vitamin B12: 469
 Folate: 26.3
 Homocysteine: 6.5
 Vitamin D 25-OH: 40
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Treatment Plan
FODMAP DIET
 FOMAP’s diet
 The Low FODMAP Diet Improves Gastrointestinal Symptoms in Patients With
Irritable Bowel Syndrome R. H. de Roest; Int J Clin Pract. 2013;67(9):895-903.
 Referral for biofeedback
 The observation that constipation also improved on a low FODMAP diet
may seem counterintuitive given the proposed mechanism of action for
most FODMAPs. However, this may reflect other aspects of dietary advice,
which ensure sufficient fibre and other dietary constituents as part of a
balanced diet. A key aspect to the dietary advice is ensuring not only that
trigger foods are removed but also that the resultant diet is balanced. It is
conceivable that this may have led to more fibre in the diet of those who
previously had low fibre diets and were constipated.
Stress and IBS
Disposition
 One unifying hypothesis concerning the role of stress in IBS is based
upon corticotropin releasing factor (CRF)
 At the time of this writing she had gone through 6 weekly
sessions of biofeedback training and been following a
FODMAP diet with significant reduction in her symptoms.
She reports that her BM’s are now normal, bloating and
discomfort are significantly reduced, but not completely
eliminated.
 Data suggest that over activity in the brain CRF and CRF-receptor
signaling system contributes to anxiety disorders and depression.
Intravenous administration of CRF increases abdominal pain and
colonic motility in IBS patients to a higher degree than normal
controls. Furthermore, this response can be blunted by the
administration of a CRF receptor antagonist with no effect on the
hypothalamus-pituitary-adrenal axis. – uptodate.
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