Download Irritable Bowel Syndrome (IBS)

Management of Irritable Bowel
Syndrome (IBS) in Family Medicine
Meera Kaur, PhD, RD, CDE
Assistant Professor, Family Medicine
University of Manitoba, Canada
http://home.cc.umanitoba.ca/~kaur/
What is IBS?
IBS is defined as “abdominal pain or discomfort that
occurs in association with altered bowel habits over a
periods of at least three months.” 1
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Probably the most challenging of all functional GI
disorders
7-10% people worldwide have IBS
Prevalence in N. America is 3-20% with an average
range of 10-15%
Peaks in the 3rd and 4th decades of life and declines in
6th and 7th decades
Patients with IBS consumes 50%more health care
resources than those without it.
1 Brandt et al., Am. J.Gastro, 2009;104:SI-S-35
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Pathophysiology
• IBS is characterized by changes in motility in
response to environmental or enteric stimuli
• Visceral hypersensitivity is well documented in IBS
patients
• Serotonin, which has both motility and sensory
modulating properties, could represent a common
factor linking the symptoms of IBS
• Mucosal inflammatory process
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Symptoms
• Loose stool
• Constipation
• Alternating Diarrhea and Constipation
• Urges to move bowel again immediately following a
bowel movement
• Mucus in stool
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Subtypes
• Diarrhoea predominant (IBS-D)
• Constipation predominant (IBS-C)
• Pain predominant (IBS-P)
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Diagnosis….
• Approach: Before doing any test…
– Gain the confidence of the patient at the first
consultation, let them talk and just listen
– Remain aware that some IBS patients have a
hidden agenda
– Do not say to the patient what some FPs say,
namely, “I don’t know what is wrong with you.”
– Do not say what some Specialists say, namely:
“There is nothing wrong with you” or “it is in your
head.”
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Diagnosis….
• Approach: Before doing any test
– Get all the test reports from the other MDs files
and
– Show & discuss those test results with the patient
– In those below 55 yrs. and in the absence of
“alarm symptoms”, if “routine” blood tests +
ESR/CRP are normal, diagnosis of IBS has:
- 83% sensitivity
- 97% specificity
- 100% PPV
Therefore, please consider doing these tests
Tolliver et al (1994) Amer J Gast 89:176
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Diagnostic Criteria
1. Manning
2. Kruls
3. Rome
J Jailwala An Int Med 2000;133:136-147
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Differential Diagnoses
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Dietary – e.g. lactose intolerance, ↑ caffeine etc.
Infections – Giardia, Bacterial Overgrowth Syndrome
Inflammatory Bowel Disease – UC, CD,
Microscopic Colitis
Malabsorption syndrome – Celiac Disease
Pancreatic Insufficiency
Psychological – Depression Anxiety, Somatization
Other - Neuroses
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“Red Flags’” - Alarm Symptoms/Signs
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Onset after 55 years
Persistent anorexia & weight loss > 10 lbs
Persistent “fever” in the evening
Pain – changing pattern or increasing after food
and persisting for a few hours
Awakened by pain &/or diarrhea at night
Rectal bleeding, not just on wiping
Stools “like malabsorption syndrome”
P/E: palpable mass in the abdomen
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Diagnosis Summary
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IBS remains a clinical diagnosis
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In those below 55 years and in the absence
of alarm symptoms, Rome II Criteria (Clinical)
has:
- Sensitivity → 65%
- Specificity → 100%
- PPV →
100%
Vanner et al (1999) Amer J Gast 94:2912
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Traditional therapies focused on
individual symptoms of IBS with constipation
Bloating and distention
Abdominal pain / discomfort
 Antispasmodics
Abdominal
 Tricyclics
 Analgesics
pain /
discomfort
Irregular Bowel
Habit
Bloating /
distention
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Dietary modifications
Antispasmodics
Antiflatulants
Digestive enzymes
Antibiotics
Constipation
or Diarrhea
 Fiber
 Laxatives
 Imodium
 None of these medications effectively treat the multiple symptoms of IBS.
May exacerbate individual symptoms e.g., fiber and bloating; antispasmodics and constipation
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IBS: Symptomatic Therapy
Smooth muscle relaxants
5-HT agonists/antagonists
TCAs, SSRIs
Abdominal
pain/
discomfort
Smooth muscle relaxants
5-HT agonists/antagonists
Antiflatulents
Bloating
Altered bowel
function
CONSTIPATION
Fibres
Osmotic agents
5-HT4 agonists
Prokinetics
DIARRHEA
Loperamide
Cholestyramine
5-HT3 antagonists
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Alternative/Complementary Approach
1. Herbal
– Peppermint oil capsule
– Turmeric Extract
– Artichoke leaf Extract
2.
Mind-Body Therapies
– Hypnotherapy
– Cognitive-behavioral Therapy (CBT)
3.
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Relaxation Technique
Acupuncture and Moxibustion
Diet, lifestyle
Probiotics
Yoon et al, Altern Med Rev, 2011; 16(2): 134-151
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Evidence-Based Position Statement on
Management of IBS
• Summary (Grades of Evidence)
– IBS defined by abdominal discomfort plus altered
bowel habits (C)
– IBS significantly decrease quality of life (QOL) of
most patients seeking care (C)
– Treatment indicated when patient & physician
believe QOL is diminished (C)
– IBS therapies should improve global symptoms
including discomfort, bloating, and altered bowel
habits (C)
Am J Gastro 2002; 97:S1-S5
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Management - Summary
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Lifestyle (poor data)
Diet (poor data)
Pain management (meta-analysis)
Antidiarrheals (db, pc trials)
Osmotic laxatives (poor data)
Psychotherapy (no good data)
Antidepressants (meta-analysis)
Probiotics (poor data)
Others - Alternative Medical Therapies (poor
data)
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Concluding Statements
IBS is a benign condition without benign
effects. We should keep an open mind while
managing IBS.
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References
• Books
• Journal articles published during 1990-2012
• International, National and Provincial governments’
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relevant websites
Regulatory organizations’ websites and reports
Other relevant organizations’ publications/reports
Evidence-based Guidelines
References are available on request
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Questions?
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