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Irritable Bowel
Syndrome
HeeJae Hyun
2011.6.20
CASE


28-year-old woman
7-month history
– Recurrent, crampy pain in LLQ
– Bloating with abdominal distention
– Frequent, loose stools


Similar but milder symptoms since childhood
Long times in the bathroom
– Because she is worried about uncontrollable
discomfort and fecal soiling
CASE



Feel anxious and fatigue
She is frustrated that her previous physician did
not seem to take her distress seriously.
Physical examination is unremarkable except for
tenderness over the LLQ
 How
should her case be
evaluated and treated?
Irritable Bowel Syndrome

Character
– Chronically recurring abdominal pain or discomfort
– Altered bowel habits
– In the absence of any organic cause

Functional disorder
– By symptom-based diagnostic criteria

One of several functional gastrointestinal
disorders

In the absence of any organic cause
Irritable Bowel Syndrome

One of the most common syndromes

Worldwide prevalence : 10 to 15%
– Only about 15% of affected people actually seek
medical help

Prevalence
– Woman 7-24% > Man 5-19% in USA , UK
– But, Woman 6.0%, Man 7.1% in Korea
Irritable Bowel Syndrome

Health care costs
– Twice that of an asymptomatic person
– More appendectomies, cholecystectomies and hysterectomies in those with
IBS
– The direct medical costs of IBS are US 8 billion in the US each year
– Impairment of QOL: worse than in patients with DM or CRF
Gralneck etal (2000) Gastroent 119:654
– Time off work: 3 times more often than that for an asymptomatic
– Restriction of activities: by 145 days per year
Creed etal (2001) Ann Int Med 134:860
Diagnostic criteria

1978년

32명의 IBS환자, 33명의 기질환자
 15개의 복부증상 중 IBS환자에서 보다 많은 나타나는 6개의 증상

제한점: 증상의 지속기간, 빈도에 대한 규정 없음, 몇 가지 이상의 증상?

574명 대상의 4개의 연구 – 3가지 증상 이상있을 때
 Sensitivity 78%, Specificity 72%
Diagnostic criteria

1988년 multinational working team committee가 로마에서 열려
FGID 진단기준 만들었기에 붙여진 이름

22년간 3차례 개정

Rome I
 Sensitivity 67-83%, Specificity 33-85%
Rome II
 Sensitivity 31-65%, Specificity 30-100%

Rome III
Functional Gastrointestinal
Disorders (FGID)

A. Functional esophageal disorders
– A1. Functional heartburn
– A2. Functional chest pain of presumed
esophageal origin
– A3. Functional dysphagia
– A4. Globus

–
–
–
–
–


B. Functional gastroduodenal disorders
– B1. Functional dyspepsia

B1a. Postprandial distress
syndrome

B1b. Epigastric pain syndrome
– B2. Belching disorders

B2a. Aerophagia

B2b. Unspecified excessive
belching
– B3. Nausea and vomiting disorders

B3a. Chronic idiopathic nausea

B3b. Functional vomiting

B3c. Cyclic vomiting syndrome
– B4. Rumination syndrome in adults
C. Functional bowel disorders

D. Functional abdominal pain syndrome
E. Functional gallbladder and Sphincter of
Oddi (SO) disorders
–
–
–

C1. Irritable bowel syndrome
C2. Functional bloating
C3. Functional constipation
C4. Functional diarrhea
C5. Unspecified functional bowel disorder
E1. Functional gallbladder disorder
E2. Functional biliary SO disorder
E3. Functional pancreatic SO disorder
F. Functional anorectal disorders
–
–
–
F1. Functional fecal incontinence
F2. Functional anorectal pain
F2a. Chronic proctalgia


–
–
F2a1. Levator ani syndrome
F2a2. Unspecified functional anorectal
pain
F2b. Proctalgia fugax
F3. Functional defecation disorders


F3a. Dyssynergic defecation
F3b. Inadequate defecatory propulsion
Drossman D, Corazziari E, Spiller R, Talley N, Thompson W, Whitehead W,
eds. Rome III.
The Functional Gastrointestinal Disorders. 3rd ed. McLean, VA 2006
Rome III
Functional Gastrointestinal
Disorders (FGID)


G. Functional disorders: neonates and
toddlers
– G1. Infant regurgitation
– G2. Infant rumination syndrome
– G3. Cyclic vomiting syndrome
– G4. Infant colic
– G5. Functional diarrhea
– G6. Infant dyschezia
– G7. Functional constipation
H. Functional disorders: children and
adolescents
– H1. Vomiting and aerophagia
 H1a. Adolescent rumination
syndrome
 H1b. Cyclic vomiting
syndrome
 H1c. Aerophagia
–
H2. Abdominal pain-related
functional gastrointestinal
disorders
 H2a. Functional dyspepsia
 H2b. Irritable bowel
syndrome
 H2c. Abdominal migraine
 H2d. Childhood functional
abdominal pain
– H2d1. Childhood
functional abdominal
pain syndrome
– H3. Constipation and
incontinence
 H3a. Functional constipation
 H3b. Nonretentive fecal
incontinence
LIFE
Genetics
Environment
Social Context
Outcome
•Medications
• MD visits
•Daily
function
•Quality of
life
Drossman, DA; Gastro 2006
Diagnostic criteria

Rome III (2006)
– Recurrent abdominal pain or discomfort three
days per month in the last three months
associated with two or more of :
– Improvement with defecation
– Onset associated with a change in frequency of stool
– Onset associated with a change in form of stool
CLINICAL MANIFESTATIONS

Chronic abdominal pain
– Crampy sensation with variable intensity, periodic
exacerbations
– Location, character: widely variable
– Factor: emotional stress, eating, defecation...
CLINICAL MANIFESTATIONS

Altered bowel habits
– Diarrhea
Frequent loose stools
 Generally during waking hours

– Morning or after meals
Lower abdominal cramps, urgency
 Not associated

– Large volume diarrhea, bloody stools, nocturnal diarrhea,
greasy stools
– Constipation
Last from days to months
 Sense of incomplete evacuation

CLINICAL MANIFESTATIONS

Other GI Sx
– Gastroesophageal reflux, dysphagia, early satiety,
intermittent dyspepsia, nausea, non-cardiac chest
pain
– Abdominal bloating
– Increased gas production


Flatulence, belching
Extraintestinal Sx
– Impaired sexual function, dysmenorrhea,
dyspareunia, increased urinary frequency, urgency,
fibromyalgia Sx
Overlapping Upper GI
Symptoms in Patients with IBS
Symptoms
Number of symptoms
IBS with constipation
(n =76)
IBS with diarrhea
(n =64)
6.67
4.62
Lower abdominal pain (%)
40.8
24.4
Upper abdominal pain (%)
36.8
24.4
Bloating (%)
75.0
40.9
Indigestion (%)
48.7
36.4
Nausea (%)
46.1
47.7
Early satiety (%)
42.7
25.0
Heartburn (%)
32.9
40.9
Talley et al. Am J Gastroenterol 2003;98:2454–9
4 SUBTYPEs of IBS

IBS with constipation (IBS-C)
– Hard or lumpy stools > 25%
– Loose or watery stools < 25%

IBS with diarrhea (IBS-D)
– Loose or watery stools >25%
– Hard or lumpy stools <25%

Mixed IBS (IBS-M)
– Hard or lumpy stools > 25%
– Loose or watery stools > 25%

Unsubtyped IBS
– Insufficient abnormality of stool consistency
DIAGNOSTIC APPROACH

It is important to exclude other causes

“Alarm” or atypical symptoms
–
–
–
–
Rectal bleeding
Nocturnal or progressive abdominal pain
Weight loss
Lab. Abnormalities

Anemia, elevated inflammatory markers, electrolyte
disturbances
– Family history of colon cancer, IBD, Nontropical sprue
– Onset of first symptom after 50yr of age
– Major change in symptoms

Routine lab : normal in IBS
DIAGNOSTIC APPROACH
DIAGNOSTIC APPROACH

Diarrhea predominant IBS
– Stool culture
 Little
role in patients with chronic diarrhea
 Giardia in patient’s clinical history
– Celiac disease screening
 Serum
IgA antibody to tissue transglutaminase
 In a meta-analysis of 14 studies
– 4%, Four times than controls without IBS
– 24hr stool collection
 If
osmotic or secretory diarrhea or malabsorption
is suspected
– Colonoscopy or flexible sigmoidoscopy and
biopsy
DIAGNOSTIC APPROACH

Constipation predominant IBS
– Radiography
 Detect
retained stool
– Flexible sigmoidoscopy and colonoscopy
 If
a structural lesion is suspected
 Older than 50 because of the increased risk of
colon cancer
Usefulness of Warning Signs

Onset of first symptom after 50yr of age
– Odds ratio (OR) : 2.65 (95% confidence interval 1.4-5.0)
Gut 2004;53:666-672

Rectal bleeding
– Sensitivity 64% (95% CI=55-73%), Specificity 52% (95%
CI=42-63%)
Am J Gastroenterol 2002;97:S7-S26

Anemia
– Sensitivity 19% (95% CI=5.5-33%), Specificity 90% (95%
CI=87-92%)
과민성 장증후군의 진단: 체계적인 문헌고찰 Korean J Gastroenterol 2010;55:308-315
Usefulness of Warning Signs

Weight loss
– Sensitivity 22% (95% CI=14-31%), Specificity 89% (95% CI=8195%)
Am J Gastroenterol 2002;97:S7-S26

Family history of colon cancer, IBD, Nontropical sprue
– Association of colon cancer risk
Gastroenterology 2003;124:544-560
N Eng med 2002;347:417-429

Nocturnal abdominal pain
– Not association of organ disease
Gut 2004;53:666-672
과민성 장증후군의 진단: 체계적인 문헌고찰 Korean J Gastroenterol 2010;55:308-315
Usefulness of Warning Signs

Accuracy of warning sign
– Not as satisfactory as expected
– Rectal bleeding, nocturnal symptom
– Anemia, weight loss
IBS Sx (0) + Anemia, Weight loss, Family Hx (X)
= IBS (?)
PATHOPHYSIOLOGY of IBS
uncertain
PATHOPHYSIOLOGY of IBS

Gastrointestinal motility

Visceral hypersensitivity

Intestinal inflammation

Postinfectious

Alteration in fecal microflora

Bacterial overgrowth

Food sensitivity

Genetics

Psychosocial dysfunction
PATHOPHYSIOLOGY of IBS

Gastrointestinal motility
– No predominant pattern of motor activity
– In some patients
Frequency and irregularity of luminal contractions
 Prolonged transit time
 Exaggerated motor response to
– Cholecystokinin and meal ingestion

– Pharmacologic stimulation of gut motility

Reduce gas retention
 Improve
symptom
PATHOPHYSIOLOGY of IBS

Gastrointestinal motility
– Pre-prandial colonic tone and motility is increased
in IBS patients
Vassallo, MJ; Mayo Clinic Proc 1992
– Functional GI disease patients like IBS have greater
motility response to stressors- both physiologic and
psychologic when compared to normal
Drossman, DA; Gastro 2002
PATHOPHYSIOLOGY of IBS

Visceral hypersensitivity
(increased sensation in response to stimuli)
– Nerves in the bowels are overactive in people with IBS

Normal amounts of gas or movement are perceived as excessive and
painful
– Several studies


Selective hypersensitization of visceral afferent verves in the gut, triggered
by bowel distention or bloating
Repetitive rectal balloon inflations lead to a progressive increase in pain
that occurs longer and with greater intensity than controls
Munakata K; Gastro 1997
– ?




By local GI nervous system
By central modulation from the brain
By some combination
By specific GI mediators (serotonin, kinins)
PATHOPHYSIOLOGY of IBS

Intestinal inflammation
– Mucosal immune system activation
– Lymphocytes, mast cells
– Proinflammatory cytokines
– 50% IBS patients have increased activated mucosal
inflammatory cells
Chadwick, VS; Gastro 2002
– 33% pts with IBS can correlate symptoms to an enteric
infection
– 25% of pts with an acute enteric infection go on to develop IBS
like or dyspeptic symptoms
Gwee, KA; Gut 1999
– Meta-analysis of post-infectious IBS
Halvorson, HA; Am J Gastro 2006
PATHOPHYSIOLOGY of IBS

Postinfectious
–
–
–
–
Malabsorption
Increase in enteroendocrine cells/lymphocytes
Antibiotic use
Review of 18 studies


IBS incidence 10%, increased sixfold after an acute GI infection
Risk factor: young age, prolonged fever, anxiety, depression
PATHOPHYSIOLOGY of IBS

Alteration in fecal microflora
– Fecal microflora in individuals with IBS differ from
healthy controls
– Eradication of small intestinal bacterial overgrowth
reduces symptoms of IBS
Anderson, ML; Am J Gastro 2000
– Normalization of lactulose breath testing correlates
with symptomatic improvement in IBS
Pimentel, M; Am J Gastro 2003
PATHOPHYSIOLOGY of IBS

Bacterial overgrowth
– In some studies



Abnormal breath hydrogen levels in IBS
Improvement in symptoms after erdication of the overgrowth
Food sensitivity
– Food allergy : food specific antibodies
– Carbohydrate malabsorption
– Gluten sensitivity
PATHOPHYSIOLOGY of IBS

Genetics
– Several twin studies
– Associations between specific genes and IBS
PATHOPHYSIOLOGY of IBS

Psychosocial factors
– Psychosocial factors may influence the expression of IBS
symptoms
– Anxiety, depression, phobias, somatization in IBS Pts.
– History of physical, verbal, or sexual abuse
– Psychological stress exacerbates GI symptoms in everyone- but
to a greater degree in patients with IBS
– 50% of patients with IBS seen at referral centers meet the criteria
for a psychological disorder
– Chronic illness such as IBS has psychosocial consequences
Drossman, DA; Gastro 2006
PATHOPHYSIOLOGY of IBS

Brain Gut Interaction
– Brain and gut are hardwired bidirectionally
– Anxiety is associated with increased anterior cingulate
cortex activity during rectal pain in IBS
Morgan, V; Gastro 2001
– IBS and history of abuse have synergistic effects on
cingulate activation in response to rectal distention
Ringel Y; Gastro 2003
TREATMENT of IBS

RELIEF
 Relationship
 Education
 Diet
 Fiber
 Medication
 Probiotics
 Psychosocial
 Alternative-
Gut directed hypnotherapy,
acupuncture, herbal medicine, peppermint oil,
melatonin, extract of artichoke
TREATMENT of IBS

Therapeutic physician-patient relationship
– Most important component

Patients with a strong positive therapeutic
relationship with their physician have fewer IBS
related office visits
Owens, W; Annals IM 1995

262 pts with IBS
–
–
–
–
Group 1 control
Group 2 sham acupuncture and little provider interaction
Group 3 sham acupuncture and high provider interaction
Level of improvement Group 3 >>Group 2 >> Group 1
Kaptchuk M; BMJ 2008
TREATMENT of IBS

Patient education
– Review elements of the pathophysiology
 May I explain your problem?
– Clearly convey “You have IBS”
– This is a chronic disease and benign nature
– There is help with management but no known cure
– This disease will not shorten your life span or lead to
any other complicating illness
TREATMENT of IBS

Dietary modification
– Lactose

Lactose intolerance
– The similarity in Sx of IBS
– Undiagnosed
– Exclusion of gas-producing foods

Increase flatulense
– Beans, onions, celery, carrots, raisins, bananas, apricots, prunes,
brussel sprouts, wheat, prtzels, bagels
– Visceral hyperalgesia in IBS
• Exaggerated discomfort
– Food allergy
– Gluten sensitivity
– Carbohydrate malabsorption
: unclear, trial
TREATMENT of IBS

Fiber
– An increase in the intake of fiber
– But not all authorities agree

British guideline: up to 12 g per day , particularly insolube fiber
such as bran
– Mechanisms
Enhancement of water holding properties of the stool
 Formation of gells to provid lubrication
 Binding fo agents such as bild

– Systematic review: no convincing evidence
Am J Gastro 2009
TREATMENT of IBS

Fiber
– Synthetic fiber such as polycarbophil, methylcellulose
 More soluble
 Less bloating
 But, not determined
– A trial of fiber is reasonable
 In
all patients with IBS
 Especially constipation predominant IBS
TREATMENT of IBS

Psychosocial therapies
– Behavioral treatments, Hypnosis, Biofeedback, Psychotherapy

2009 meta-analysis
– Psychological therapy were significantly more effective than control therapy for at
least a 50 % reduction in symptoms
Am J Gastroenterol 2009; 104 suppl 1:S1

Cognitive behavioral therapy is more effective than patient
education and desipramine and placebo
Drossman DA; Gastro 2003

Cognitive behavioral therapy improves symptoms but no
better than standard care or relaxation therapy.
Boyce, PM; American J of Gastro 2003
TREATMENT of IBS

Medications
– Only an adjunct to treatment in IBS
– Drug chosen varies depending on the patient’s major
symptoms
– Chronic use of drugs : Minimized or avoided


Lifelong nature of this disorder
Lack of convincing therapeutic benefit
– Difficulty in demonstrating efficacy



Heterogeneous population diagnosed with IBS
The lack of disease markers
High placebo response rates
MEDICATIONS

Antispasmodic agents
– Directly affect intestinal smooth muscle relaxation

Mebeverine, pinaverine
– Via anticholinergic or antimuscarinic propeties

Dicyclomine, hyoscyamine
– Meta-analysis of 23 controlled trials of smooth muscle
relaxants



More effective than placebo
41 % improvement in pain with placebo
53% improvement in pain with antispasmodic
Aliment Pharm Ther 2001
– ACG 2009 review showed little evidence for efficacy
MEDICATIONS

Antidepressants
– Analgesic properties
– Beneficial in patients with neuropathic pain
– TCA



Via anticholinergic properties
Slow intestinal transit time : diarrhea-predominant IBS
Low doses than required for treatment of depression
– Delayed onset of action, three to four weeks of therapy
MEDICATIONS

Antidepressants
– TRICYCLICS
 Pain
benefit
 Desipramine/ nortriptyline have fewer side effects
 Start low 10-20mg qhs and increase to 50-75
 Efficacy of desipramine in moderate to severe IBS
over placebo: 73% response vs 50%
Drossman, D; Am J Gastro 2009
MEDICATIONS

Antidepressants
– Less published experience (SSRI, SNRI)

A meta-analysis concluded that overall treatment effects were similar to TCA
Gut 2009;58:367

SSRI
– Use for anxiolysis
–

Not much pain benefit
Paroxetine (Paxil) better than placebo
Tabas G; Am J Gastro 2004

Fluoxetine (Prozac) better than placebo in IBS-C
Vahedi H; Alim Pharm Ther 2005

Citalopram (Celexa) efficacious in nondepressed IBS
Tack J; Gut 2006

Psychotherapy and Paroxetine cost effective when compared to routine care for
severe IBS
Creed, F; Gastro 2003
MEDICATIONS

Antidiarrheal agents
– Loperamide




More effective than placebo for treatment of IBS-C
Not for treatment of global IBS symptoms or abdominal pain
Preferred to a regular scheduled dosing
Not be used in patients with constipation
MEDICATIONS

Benzodiazepines
– Anxiolytic agents

Of limited usefulness in IBS
– Risk of drug interactions, habituation, rebound withdrawal

Useful for short term reduction of acte situational anxiety
MEDICATIONS

Serotonin modulators
– Serotonin





A monoamine neurotransmitter
Found in cardiovascular tissue, the peripheral nervous
system, blood cells, and the CNS
95 % resides in the GI tract
The function of serotonin is exerted upon its interaction with
specific receptors.
7 distinct families of 5HTreceptors; 5HT1, 5HT2, 5HT3, 5HT4,
5HT5, 5HT6, and 5HT7
– Serotonin plays a major role in modulating intestinal movement
and perception of pain. Helps to soften stools by releasing water.
Am J Gastroenterol 2000; 95(10): 2698
MEDICATIONS

Serotonin modulators
– 5HT3 antagonists




Slow intestinal transit
Decrease intestinal secretions
Decrease the water content of stool
Diminish colonic pain
– 5HT4 agonists



Accelerate gastric emptying
Accelerate small and large bowel transit
Increase stool water content
MEDICATIONS

5HT3 antagonists
– Alosetron, cilansetron, ondansetron, granisetron
– Meta-anlysis
 A benefit in global improvement in IBS
 Relief of abdominal pain and discomfort
Clin Gastroenterol Hepatol 2008;6:545
– Alosetron (Lotronex)
 Effective in female patients with IBS-C
 FDA approved 2000
 Withdrawn 2000 Ischaemic colitis (1:1000)
 A few deaths attributed to it
 Reintroduced 2002
 Reduced dose
 Severe restrictions (counselling, consent)
MEDICATIONS

5HT4 agonists
– Rationale for use in IBS-D
– Tegaserod (Zelnorm)

Removed from the market in March 2007 because of
cardiovascular side-effects
MEDICATIONS

Lubiprostone
– Locally acting chloride channel activator



Enhances choride-rich intestinal fluid secretion
For Tx of chronic idiopathic constipation
Later for Tx of IBS-C in women 18 yrs and older
– Multicenter placebo-controlled trials




1154 (92% women) with IBS-C
Ramdom lubiprostone or placebo for 12 weeks
Response 18 vs 10%
Adverse events : similar to placebo
Aliment Pharmacol Ther 2009;29:329
MEDICATIONS

Antibiotics
– Rifaximin 400 mg tid for 10 days better than placebo in IBS- 36%
vs 21%
Pimentel, M; Ann Int Med 2006
– Rifaximin 550mg tid for 14 days decreased IBS symptoms
including bloating and pain. Effects lasted for 10 week study
period -41% vs 31%
NEJM 2011;364;22
– Modest benefit and relatively short-term F/U
– Not suggest the routine use of antibiotics
– But if failed to respond to all other therapies, reasonable to
consider two-week trial of rifaximin
IBS: Symptomatic Therapy
Smooth muscle relaxants
5-HT agonists/antagonists
TCAs, SSRIs
Smooth muscle relaxants
5-HT agonists/antagonists
Antiflatulents
Abdominal
pain/
discomfort
CONSTIPATION
Fibres
Osmotic agents
5-HT4 agonists
Prokinetics
Bloating
Altered bowel
function
DIARRHEA
Loperamide
Cholestyramine
5-HT3 antagonists
 None of these medications effectively treat the multiple symptoms of IBS.
May exacerbate individual symptoms e.g., fiber and bloating; antispasmodics and constipation
MEDICATIONS

Alternative therapies

–
–
–
–
Their role remains uncertain
Herbs
Probiotics
Acupuncture
Enzyme
치료
권고 등급
약제의 조합:
‘과민성 장증후군은 여러 가지 병태생리가 관여되어 다양
한 증상 양상을 보이는 이질적인 질환군이며 각각의 증상
에 대한 약제를 조합하는 것이 치료에 효과적이다’
Grade 1B, 권고수준: 강함, 증거수준: 중등
도
진경제:
‘진경제는 과민성 장증후군 환자에서 복통 및 복부 불편감
의 치료에 효과적이다’
Grade 1B, 권고수준: 강함, 증거수준: 중등
도
선택적 염소통로활성제:
‘선택적 염소통로활성제는 변비형 과민성 장증후군 환자의
치료에 효과적이다’
Grade 1B, 권고수준: 강함, 증거수준: 중등
도
항우울제:
‘삼환계 항우울제와 선택적 세로토닌 재흡수 억제제는 일
부 과민성 장증후군 환자의 치료에 도움을 준다’
Grade 2A, 권고수준: 약함, 증거수준: 높음
세로토닌 3형 수용체 길항제:
‘세로토닌 3형 수용체 길항제는 설사형 과민성 장증후군의
치료에 도움을 준다’
Grade 2A, 권고수준: 약함, 증거수준: 높음
세로토닌 4형 수용체 작용제:
‘세로토닌 4형 수용체 작용제는 변비형 과민성 장증후군
환자의 치료에 도움을 준다’
Grade 2A, 권고 수준: 약함, 증거수준: 높음
과민성 장증후군 치료에 관한 임상진료지침 Korean J Gastroenterol 2011;57(2):82-99
치료
권고 등급
부피형성 하제:
‘부피형성 하제는 과민성 장증후군의 일부 증상의 치료에
도움을 준다’
Grade 2B, 권고수준: 약함, 증거수준: 중등
도
지사제:
‘지사제는 과민성 장증후군에서 배변 형태를 호전시키고
배변 횟수를 줄이는데 도움을 준다’
Grade 2B, 권고수준: 약함, 증거수준: 중등
도
비흡수성 경구용 항생제:
‘비흡수성 경구용 항생제의 단기간 사용은 일부 과민성 장
증후군 환자의 치료에 도움을 준다’
Grade 2B, 권고수준: 약함, 증거수준: 중등
도
정신과적 치료(인지행동치료 등):
‘인지-행동 요법, 역동정신요법, 최면요법은 일부 과민성
장증후군 환자의 치료에 도움을 준다’
Grade 2B, 권고수준: 약함, 증거수준: 중등
도
삼투성 하제:
‘변비형 과민성 장즈후군 환자에서 삼투성 하제는 배변 횟
수를 증가시키는데 도움을 줄 수 있다’
Grade 2C, 권고수준: 약함, 증거수준: 낮음
프로바이오틱스:
‘프로바이오틱스는 일부 과민성 장증후군 환자의 치료에
도움을 줄 수 있다’
Grade 2C, 권고수준: 약함, 증거수준: 낮음
과민성 장증후군 치료에 관한 임상진료지침 Korean J Gastroenterol 2011;57(2):82-99
Augmentation Therapy
for Refractory Abdominal Pain

Use more than one treatment to enhance benefit

Remember lower doses to minimize side effects

Examples:
– Add buspirone to SSRI
– Add SNRI to tricyclic
– Add mood stabilizer lamotrigine (lamictal) to
antidepressant
Drossman, DA; Am J Gastro 2009