Download A 67 years old woman with abdominal pain

Irritable Bowel Syndrome
Dr.Asgari
Assistant professor, Digestive Disease
Imamreza hospital,
Kermanshah University of Medical
Sciences,Kermanshah, Iran.
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Irritable bowel syndrome (IBS) is a functional bowel
disorder characterized by abdominal pain or
discomfort and altered bowel habits
in the absence of detectable structural
abnormalities.
No clear diagnostic markers exist for IBS, thus the
diagnosis of the disorder is based on clinical
presentation.
Throughout the world, about 10–20% of adults
and adolescents have symptoms consistent with
IBS
 most studies show a female predominance.
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often overlap with other functional disorders
such as fibromyalgia, headache, backache, and
genitourinary symptoms.
Severity of symptoms varies and can significantly
impair quality of life, resulting in high health
care costs.
PATHOPHYSIOLOGY
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IBS is a gastrointestinal disorder characterized by
chronic abdominal pain and altered bowel habits in the
absence of an identified cause.
The pathophysiology of IBS remains uncertain.
Although motor abnormalities of the gastrointestinal
tract (increased frequency and irregularity of luminal
contractions, abnormal transit time) are detectable in
some patients with IBS, no predominant pattern of
motor activity has emerged as a marker for IBS
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Selective hypersensitization of visceral afferent
nerves in the gut has been observed in patients
with IBS and is one explanation for IBS
symptoms.
Immunohistologic investigation has revealed
mucosal immune system activation characterized
by alterations in particular immune cells and
markers in some patients with IBS.
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The complex ecology of the fecal microflora has led to
speculation whether changes in its composition could
be associated with IBS.
An association between IBS and small intestinal
bacterial overgrowth has been conflicting.
The role of food in the pathophysiology of IBS is not
clear.
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familial patterns may also reflect underlying
social factors.
Associations between specific genes and IBS are
under investigation.
Psychosocial factors may influence the expression
of IBS symptoms
Diagnostic Criteria for Irritable Bowel Syndrome
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Recurrent abdominal pain or discomfort at least 3 days
per month in the last 3 months associated with two or
more of the following:
1: Improvement with defecation
2:Onset associated with a change in frequency of stool
3:Onset associated with a change in form (appearance) of
stool
CLINICAL FEATURES
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IBS is a disorder that affects all ages, although most
patients have their first symptoms before age 45.
Women are diagnosed with IBS two to three times as
often as men and make up 80% of the population
with severe IBS
 pain or abdominal discomfort is a key symptom for
the diagnosis of IBS.
 These symptoms should be improved with defecation
and/or have their onset associated with a change in
frequency or form of stool.
 Painless diarrhea or constipation does not fulfill the
diagnostic criteria to be classified as IBS.
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Supportive symptoms that are not part of the
diagnostic criteria include
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defecation straining
urgency or a feeling of incomplete bowel
movement
passing mucus, and bloating
ABDOMINAL PAIN
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Abdominal pain in IBS is highly variable in intensity
and location.
frequently episodic and crampy , but it may be
superimposed on a background of constant ache.
malnutrition due to inadequate caloric intake is
exceedingly rare with IBS.
Sleep deprivation is also unusual because abdominal
pain is almost uniformly present only during waking
hours
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Pain is often exacerbated by eating or emotional stress
and improved by passage of flatus or stools.
female patients with IBS commonly report worsening
symptoms during the premenstrual and menstrual
ALTERED BOWEL HABITS
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Alteration in bowel habits is the most consistent
clinical feature in IBS.
The most common pattern is constipation
alternating with diarrhea, usually with one of these
symptoms predominating.
At first, constipation may be episodic, but
eventually it becomes continuous and increasingly
intractable to treatment with laxatives.
Stools are usually hard with narrowed caliber
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Diarrhea resulting from IBS usually consists of small
volumes of loose stools
Most patients have stool volumes of <200 mL. Nocturnal
diarrhea does not occur in IBS.
 Diarrhea may be aggravated by emotional stress or
eating.
 Stool may be accompanied by passage of large amounts of
mucus.
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Bleeding is not a feature of IBS unless hemorrhoids are
present
malabsorption or weight loss does not occur
GAS AND FLATULENCE
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Patients with IBS frequently complain of abdominal
distention and increased belching or flatulence
most patients who complain of increased gas generate no
more than a normal amount of intestinal gas.
Most IBS patients have impaired transit and tolerance of
intestinal gas loads.
patients with IBS tend to reflux gas from the distal to
the more proximal intestine, which may explain the
belching.
UPPER GASTROINTESTINAL SYMPTOMS
Between 25 and 50% of patients with IBS complain of
 dyspepsia
 heartburn
 Nausea and vomiting.
IBS symptoms are prevalent in noncardiac chest pain
patients
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IBS may be induced by GI infection.
"post infective" IBS occurs more commonly in
females and affects younger rather than older
patients.
Risk factors for developing post-infectious IBS
prolonged duration of initial illness,
 toxicity of infecting bacterial strain
 smoking
 mucosal markers of inflammation,
 female gender
 depression
 Hypochondriasis , and adverse-life events in the
preceding 3 months
 treatment with antibiotics has been associated with
increased risk
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Approach to the Patient: Irritable Bowel Syndrome
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diagnosis relies on recognition of positive clinical
features and elimination of other organic diseases.
A careful history and physical examination are
frequently helpful in establishing the diagnosis.
Clinical features suggestive of IBS include:
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recurrence of lower abdominal pain with altered
bowel habits over a period of time without progressive
deterioration
onset of symptoms during periods of stress or
emotional upset
absence of other systemic symptoms such as fever and
weight loss, and small-volume stool without any
evidence of blood.
against the diagnosis of IBS
the appearance of the disorder for the first time in old
age
 progressive course from time of onset
 persistent diarrhea after a 48-h fast
 presence of nocturnal diarrhea
 steatorrheal stools
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Pain due to IBS that occurs in the epigastric or
periumbilical area must be differentiated from biliary
tract disease, peptic ulcer disorders, intestinal
ischemia, and carcinoma of the stomach and
pancreas.
 If pain occurs mainly in the lower abdomen, the
possibility of diverticular disease of the colon,
inflammatory bowel disease (including ulcerative
colitis and Crohn's disease), and carcinoma of the
colon must be considered.
 Postprandial pain accompanied by bloating, nausea,
and vomiting suggests gastroparesis or partial
intestinal obstruction.
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Giardia lamblia or other parasites may cause similar
symptoms.
When diarrhea is the major complaint(must be ruled out)
lactase deficiency
laxative abuse
malabsorption
celiac sprue
hyperthyroidism
inflammatory bowel disease
infectious diarrhea
constipation may be a side effect of many
different drugs, such as
anticholinergic
 antihypertensive
 antidepressant medications.
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Endocrinopathies such as
 hypothyroidism
 hypoparathyroidism
Thus, a younger individual with mild symptoms
requires a minimal diagnostic evaluation, while an older
person or an individual with rapidly progressive
symptoms should undergo a more thorough exclusion of
organic disease.
 Most patients should have a complete blood count and
sigmoidoscopic examination
 stool specimens should be examined for ova and
parasites in those who have diarrhea.
 In patients with persistent diarrhea not responding to
simple anti-diarrhea agents, a sigmoid colon biopsy
should be performed to rule out microscopic colitis.
 In those aged >40 years, an air-contrast barium enema
or colonoscopy should also be performed
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If the main symptoms are diarrhea and increased gas,
the possibility of lactase deficiency should be ruled out
with a hydrogen breath test or with evaluation after a
3-week lactose-free diet.
Some patients with IBS-D may have undiagnosed
celiac sprue.
In patients with concurrent symptoms of dyspepsia,
upper GI radiographs or esophagogastroduodenoscopy
may be advisable.
In patients with postprandial right upper quadrant
pain, an ultrasonogram of the gallbladder should be
obtained.
Laboratory features that argue against IBS
include
1:anemia
2:elevated sedimentation rate(ESR)
3: presence of leukocytes or blood in stool
4:stool volume >200–300 mL/d
INITIAL THERAPY
In patients with mild and intermittent symptoms that
do not impair quality of life
initially recommend lifestyle and dietary modification
alone rather than specific pharmacologic agents
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In patients with mild to moderate symptoms who fail to
respond to initial management and in patients with
moderate to severe symptoms that affect quality of life,
we suggest pharmacologic therapy as adjunctive
treatment
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Education and reassurance — It is important to
establish a therapeutic clinician-patient
relationship to validate the patient's symptoms.
Patients should also be counseled that although
IBS does not increase their risk of malignancy, it
is a chronic disease.
Both a low FODMAP diet and a strict traditional IBS
diet (regular meal pattern; avoidance of large meals;
reduced intake of fat, insoluble fibers, caffeine, and gasproducing foods such as beans, cabbage, and onions)
improve IBS symptoms.
 Exclusion of gas-producing foods — Patients with IBS
should be advised to exclude foods that increase
flatulence (eg, beans, onions, celery, carrots, raisins,
bananas, apricots, prunes, Brussels sprouts, wheat
germ, pretzels, and bagels), alcohol, and caffeine
 ‫ کلم‬،‫ آلو‬،‫ زردآلو‬،‫ موز‬،‫ کشمش‬،‫ هویج‬،‫ کرفس‬،‫ پیاز‬،‫ لوبیا‬،‫(به عنوان مثال‬
‫ الکل و کافئین‬،)‫ و شیرینی‬،‫ چوب شور‬،‫ جوانه گندم‬،‫بروکلی‬
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LACTOSE AVOIDANCE
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Patients with known lactose intolerance should be
placed on a lactose-restricted diet.
We also suggest an empiric trial of a lactose-free diet
in patients who complain of persistent abdominal
bloating despite exclusion of gas-producing foods.
GLUTEN AVOIDANCE
We suggest a two-week trial of a gluten-free diet in
patients with diarrhea-predominant IBS (IBS-D) with
significant abdominal bloating and flatulence whose
symptoms have failed to improve with a low FODMAP
diet and avoidance of gas-producing foods.
 However, there is limited evidence to support gluten
avoidance in patients with IBS.
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Physical activity should be advised in patients
with IBS given a potential benefit with regard to
IBS symptoms and the general health benefits of
exercise
ADJUNCTIVE PHARMACOLOGIC THERAPY
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We treat patients with moderate to severe symptoms
of irritable bowel syndrome (IBS) that impair quality
of life with pharmacologic agents.
Since IBS generally presents as a complex of
symptoms , treatment should be based on the
predominant symptom and subtype.
We make incremental changes in therapy at two- to
four-week intervals
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Reassurance and careful explanation of the
functional nature of the disorder
Excessive fructose and artificial sweeteners, such as
sorbitol or mannitol, may cause diarrhea, bloating,
cramping or flatulence.
Stool-Bulking Agents
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High-fiber diets and bulking agents.
Fiber supplementation with psyllium has been shown to
reduce perception of rectal distention As some patients may
experience increased bloating and gas, we suggest a starting dose of psyllium of
one-half to one tablespoon daily. The dose should then be slowly titrated up based
on response to treatment.
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most gastroenterologists consider stool-bulking agents
worth trying in patients with IBS-C.
In patients with IBS with constipation (IBS-C)
who have failed a trial of soluble fiber (eg,
psyllium/ispaghula), we suggest polyethylene
glycol (PEG).
 We treat patients with persistent constipation
despite treatment with PEG with lubiprostone or
linaclotide
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Osmotic laxatives — PEG is inexpensive, widely available, and has
fewer side effects as compared with other osmotic laxatives (eg,
lactulose, milk of magnesia). We initially start with 17 g of powder
dissolved in 8 ounces of water once daily and titrate up or down (to a
maximum of 34 g daily) to effect. However, side effects of bloating and
abdominal discomfort limit the use of PEG.
Chloride Channel Activators
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Lubiprostone is a bicyclic fatty acid that stimulates
chloride channels in the apical membrane of intestinal
epithelial cells. We use lubiprostone in women with IBS with
persistent constipation despite PEG.
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Chloride secretion induces passive movement of
sodium and water into the bowel lumen and improves
bowel function.
Oral lubiprostone was effective in the treatment of
patients with constipation-predominant IBS
lubiprostone 8 g twice daily for 3 months
Linaclotide is a guanylate cyclase agonist that
stimulates intestinal fluid secretion and transit.
As the long-term risks of linaclotide are
unknown, its role in the treatment of IBS-C is
limited to patients with persistent constipation
despite treatment with PEG
 Linaclotide is used for treatment of IBS-C at a
dose of 290 micrograms daily . Patients who
received linaclotide also demonstrated a
significant improvement in secondary endpoints
of abdominal pain/discomfort, bloating, straining,
stool consistency
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In a randomized crossover trial in which 120 patients with
IBS-D were assigned to treatment with ondansetron
(starting dose 4 mg) or placebo for five weeks, ondansetron
significantly improved stool consistency, frequency, and
urgency but was not associated with a significant
improvement in abdominal pain
Abdominal pain and bloating — In patients with abdominal
pain due to IBS, we use antispasmodics on an as-needed
basis. In patients with IBS with constipation, we initiate
antispasmodics only if the abdominal pain persists despite
treatment of constipation.
In patients with persistent abdominal pain despite
antispasmodics, we recommend a trial of antidepressants..
ANTISPASMODIC AGENTS
Antispasmodics should be administered on an
as-needed basis and/or in anticipation of
stressors with known exacerbating effects.
Antispasmodics provide short-term relief in
symptoms of abdominal pain in patients with
IBS, but their long-term efficacy has not been
established .
 Antispasmodic include those that directly affect
intestinal smooth muscle relaxation (eg,
mebeverine and pinaverine), and those that act
via their anticholinergic or antimuscarinic
properties (eg, dicyclomine and hyoscyamine)
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Antispasmodics
anticholinergic drugs may provide temporary relief for
symptoms such as painful cramps related to intestinal
spasm.
anticholinergic drugs inhibit the gastrocolic reflex; hence,
postprandial pain is best managed by giving
antispasmodics 30 min before meals
 (Dicyclomine that have less effect on mucous membrane
secretions and produce fewer undesirable side effects)
Dicyclomine 20 mg orally four times daily as needed
 Hyoscyamine 0.125 to 0.25 mg orally or sublingually three
to four times daily as needed
 Sustained release hyoscyamine 0.375 to 0.75 mg orally
every 12 hours
Antidiarrheal Agents
Peripherally acting opiate-based agents are the initial
therapy of choice for IBS-D.
 When diarrhea is severe, especially in the painless
diarrhea variant of IBS,
 we suggest loperamide 2 mg 45 minutes before a meal on
regularly scheduled doses . in patients with alternating diarrhea and
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constipation (maximum daily dose 16 mg/day).
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Eluxadoline is an agent that combines a mu-opioid
receptor agonist and a delta-opioid receptor antagonist; it
has been approved for treatment of IBS with diarrhea
but is not commercially available
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Bile acid sequestrants — In patients with persistent
diarrhea despite antidiarrheals
we use bile acid sequestrants (eg, cholestyramine,
colestipol, colesevelam). However, their use is limited by
associated gastrointestinal side effects including bloating, flatulence,
abdominal discomfort, and constipation.
ANTIDEPRESSANTS
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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
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For the treatment of abdominal pain in IBS,
antidepressants should be started at low doses. The
initial dose should be adjusted based upon tolerance
and response. Due to the delayed onset of action of
antidepressants, three to four weeks of therapy
should be attempted before increasing the dose.
Amitriptyline, nortriptyline, and imipramine can be
started at a dose of 10 to 25 mg at bedtime.
Desipramine should be started at a dose of 12.5 to 25
mg at bedtime. If the patient is intolerant of one TCA,
another may be tried. For patients with IBS in whom
depression is a cofactor, serotonin reuptake inhibitors
(SSRIs) can also be used
the selective serotonin reuptake inhibitor (SSRI)
paroxetine accelerates orocecal transit, raising the
possibility that this drug class may be useful in IBS-C
patients.
The SSRI citalopram blunts perception of rectal
distention
Antiflatulence Therapy
The management of excessive gas is seldom
satisfactory, except when there is obvious aerophagia or
disaccharidase deficiency.
 Patients should be advised to eat slowly and not chew
gum or drink carbonated beverages.
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Bloating may decrease if an associated gut syndrome
such as IBS or constipation is improved.
 If bloating is accompanied by diarrhea and worsens
after ingesting dairy products, fresh fruits, vegetables,
or juices, further investigation or a dietary exclusion
trial may be worthwhile.
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Avoiding flatogenic foods, exercising, losing excess
weight, and taking activated charcoal are safe but
unproven remedies.
Data regarding the use of surfactants such as
simethicone are conflicting.
Other therapies — Other therapies have been
evaluated in patients with IBS (eg, herbs,
acupuncture, enzyme supplementation, and mast cell
stabilizers [eg:ketotifen]) but their role in the
treatment of IBS remains uncertain Pancreatic enzymes
reduce bloating, gas, and fullness during and after high-calorie, highfat meal ingestion.
Modulation of Gut Flora
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Antibiotic treatment benefits a subset of IBS patients.
Rifaximin is the only antibiotic with demonstrated
sustained benefit beyond therapy cessation in IBS
patients
 In patients with moderate to severe IBS without
constipation, particularly those with bloating, who have
failed to respond to other therapies, we suggest a twoweek trial of rifaximin
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Serotonin Receptor Agonist and Antagonists
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5-HT3 receptor antagonist such as alosetron reduces
perception of painful visceral stimulation in IBS.
It also induces rectal relaxation, increases rectal
compliance, decreasing colonic motility and
secretion. Itis approved for the treatment of severe diarrheapredominant IBS in female patients whose symptoms have lasted for
six months and who have failed to respond to all other conventional
treatment
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Side effects of ischemic colitis and complications of severe constipation led to
the withdrawal of alosetron from the market in the United States. However,
following evaluation of postmarketing data, alosetron is now available in the
United States but can be prescribed under restricted conditions, at a lower
starting dose than previously approved, and by physicians enrolled in the
alosetron prescribing program
Novel 5-HT4 receptor agonists such as tegaserod
exhibit prokinetic activity by stimulating peristalsis.
In IBS patients with constipation, tegaserod
accelerated intestinal and ascending colon transit..
Diarrhea is the major side effect.
However, tegaserod has been withdrawn from the
market; a meta-analysis revealed an increase in
serious cardiovascular events
 Probiotics
— Probiotics are not routinely
recommended in patients with IBS. Although
they have been associated with an improvement
in symptoms, the magnitude of benefit and the
most effective species and strain are uncertain
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Bifidobacterium ,Lactobacillusinfantis showed
significant improvement in the composite score for abdominal pain,
bloating/distention, and/or bowel movement/nist hzf
ANXIOLYTICS
The use of anxiolytic agents in patients with IBS
should be limited to short-term (less than two
weeks) reduction of acute situational anxiety that
may be contributing to symptoms .
 Side effects of anxiolytics include the risk of
habituation, rebound withdrawal, and drug
interactions.
 Furthermore, benzodiazepines may lower pain
thresholds by stimulating gamma aminobutyric
acid (GABA) receptors, thereby decreasing brain
serotonin.
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THANK YOU
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The selective inhibition of gastrointestinal
smooth muscle by antispasmodics and
peppermint oil reduce stimulated colonic motor
activity and may be beneficial in patients with
postprandial abdominal pain, gas, bloating, and
fecal urgency