Download 1- Irritable Bowel Syndrome (IBS) 2

By Dr. Zahoor
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 Irritable bowel syndrome or spastic colon, is functional
bowel disorder and symptom based diagnosis
 It is commonest Functional Gastrointestinal Disorder
(FGID)
Why we say functional?
 Because symptoms occur in the absence of any
demonstrable abnormalities in the digestion,
absorption of nutrients, fluid and electrolyte. There is
no structural abnormality in GIT.
 IBS has no known organic cause
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Symptoms
 Chronic abdominal pain
 Abdominal discomfort, blotting
 Alteration of Bowel habits
 Rectal mucus
 Diarrhea or constipation may predominate or they
may alternate (IBS-D, IBS-C or IBS-A)
 Nocturnal symptoms are rare
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Onset of IBS Symptoms
 Symptoms usually occurs after infection – post
infection bile salt mal absorption
 Use of antibiotic
 Alteration in immune system
 Emotions, depression, anxiety can effect GIT function
 Psychological stress can increase GIT symptoms
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Biopsychosocial Concept of GIT disorders
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 In western world, 1 in 5 people report symptoms
consistent with IBS
 Up to 40% of all patient seen in specialist
gastroenterology clinic will have IBS
 Female patients out number male patient
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 IBS is multi system disorder
 IBS patient suffer from many non intestinal symptoms
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Diagnostic Criteria
 In preceding 3 months, there should be at least 3 days
per month of recurrent abdominal pain or discomfort
associated with
1. Improvement with defecation
2. On set associated with a change in frequency of stool
3. Change in form (appearance) of stool
Note – Rule out other condition that produce IBS – like
symptoms e.g. parasitic infection, celiac disease,
lactose intolerance
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Investigation
Investigations are done to exclude other conditions
 Stool microscopy and culture (to exclude infectious
conditions)
 Blood test – full blood examination, ESR, LFT
 Abdominal ultrasound (to exclude Biliary tract
disease)
 Endoscopy and biopsy (to exclude celiac disease,
inflammatory bowel disease)
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IBS Treatment
 Therapies target central and end organ pathways
 End organ treatment
- Diet - High fiber diet
- Anti diarrheal drugs e.g. Loperamide
- Treat constipation – 5HT4 receptor agonist e.g.
prucalopride
- Smooth muscle relaxant for pain e.g. mebeverine
hydrochloride
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 Central Treatment
- Psychotherapy
- Anti depressant e.g. Amitriptylline, Clomipramine
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Management of Irritable Bowel Syndrome
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 In this form of functional bowel disease, symptoms
occur in the absence of abdominal pain
 Symptoms commonly are
- Passage of several stools in rapid succession usually
first thing in the morning
- No further motion may occur that day or defecation
occurs after meals
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Symptoms (cont)
- The first stool of the day is usually formed, later ones
are mushy, loose or watery
- Urgency of defecation
- Anxiety
- Exhaustion after defecation
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Treatment
 Loperamide
 Tricyclic antidepressant at night e.g. Clomipramine 1030 mg
Note – If there are atypical features e.g. large volume
stool, rectal bleeding, weight loss, nutritional
deficiency then more investigations should be done
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 The colon and rectum
Structure (important points)
 The large intestine starts at caecum
 Colon is made up of ascending, transverse, descending
and sigmoid colon which join the rectum
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Structure of Large Intestine
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 The mucosa of colon is lined by epithelial cells with
crypts but no villi, so that surface is flat
 Mucosa is full of goblet cells
 Colon is innervated by enteric nervous system with
input from parasympathetic and sympathetic
pathways
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Physiology of colon
 Main role of colon is absorption of water and
electrolytes
 Propulsion of contents from caecum to the anorectal
region
 Peristalsis is induced by release of serotonin (5-HT)
from neuroendocrine cells in response to luminal
distension
 Normal colonic transit time is 24 to 48 hours with
normal stool weight up to 250 g/day
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Physiology of defecation
Role of rectum and anus
 Rectum is normally empty
 Stool is propelled into the rectum by colonic
contraction
 Desire to defecate and urgency to defecate are
experienced with increasing volume of rectal content
(threshold 100ml)
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Physiology of defecation ( cont)
 These sensation are associated with rectal contraction
and relaxation of internal anal sphincter, both of
which push the stool down in to the proximal anal
canal
 This increases the defecation urge, which can be
suppressed by vigorous contraction of external
sphincter and puborectalis
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 Constipation is very common symptom, particularly in
women and elderly
 Constipation is defined as
- infrequent passage of stool - less than 3 times per
week
- passage of hard stools – straining more than 25% of
time
- incomplete evacuation
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 Constipation may affect more than 1 in 5 of the
population
 Patient may attribute many symptoms to constipation
e.g. headache, malaise, nausea, bad taste in mouth
 Other symptoms abdominal blotting or discomfort,
perianal pain
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Causes of
Constipation
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Assessment of Constipation
 Constipation can be classified into Three broad
categories:
1. Normal transit through colon (59%)
2. Defecatory Disorder (25%)
3. Slow transit (13%)
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1- Normal Transit Constipation
 Stool traverses the colon at normal rate but there is passage
of hard stool
2. Defecatory Disorder
 They are mainly due to dysfunction of anal sphincter and
pelvic floor e.g. mucosa of anterior rectal wall prolapses
downward during straining
3. Slow Transit
 Occurs predominantly in young women who have
infrequent bowel movement
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Treatment
Treat the underlying cause
 In Normal and Slow transit constipation, the main
focus should be on increasing fiber content of the
diet and increase fluid intake
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Treatment
 Laxative and Enemas
1. Bulk forming laxative
- Dietary fiber
- Methyl cellulose
- Ispaghula husk
2. Stimulant laxative (stimulate gut motility)
- Bisacodyl
- Phenolphthalein
3. Osmotive Laxative
- Lactulose
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Treatment
Suppositories
 Bisacodyl
 Glycerol
Enemas
 Arachis oil
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