IRRITABLE BOWEL SYNDROME Kimberly M. Persley, MD.
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Transcript of IRRITABLE BOWEL SYNDROME Kimberly M. Persley, MD.
Earliest descriptions Earliest descriptions of symptoms defining IBSof symptoms defining IBS
1849 – W Cumming1849 – W Cumming11
““The bowels are at The bowels are at one time constipated, one time constipated, at another lax, in the at another lax, in the same person.same person.How the disease has How the disease has two such different two such different symptoms I do not symptoms I do not profess to explain. . . .”profess to explain. . . .”
IBS – HistoryIBS – History
Other historical termsOther historical terms–– mucous colitis mucous colitis –– colonic spasm colonic spasm –– neurogenic mucous colitis neurogenic mucous colitis –– irritable colon irritable colon –– unstable colon unstable colon–– nervous colon nervous colon–– spastic colon spastic colon–– nervous colitis nervous colitis–– spastic colitis spastic colitis
1962 – Chaudhary & Truelove1962 – Chaudhary & Truelove22
Irritable colon syndromeIrritable colon syndrome
1966 – CJ DeLor1966 – CJ DeLor33
Irritable bowel syndromeIrritable bowel syndrome
References: 1. Cumming. Lond Med Gazette. 1849;NS9;969-973. 2. Chaudhary and Truelove. Q J Med. July 1962;31:307-322. 3. DeLor. Am J Gastroenterol. May 1967;47:427-434.
Historical perspectiveHistorical perspective Long dismissed as a psychosomatic conditionLong dismissed as a psychosomatic condition11
–– no clear etiology no clear etiology – – affects predominantly women affects predominantly women
((~70%~70% of sufferers are women)of sufferers are women)22 –– condition not fatalcondition not fatal
Attitudes now changingAttitudes now changing
Incidence and prevalence not extensively Incidence and prevalence not extensively monitored in pastmonitored in past
IBS – HistoryIBS – History
References: 1. Maxwell et al. Lancet. December 1997;350:1691-1695. 2. Sandler. Gastroenterology. August 1990;99:409-415.
Hallmark symptoms of IBSHallmark symptoms of IBS
Chronic or recurrent GI symptomsChronic or recurrent GI symptoms
–– lower abdominal pain/discomfortlower abdominal pain/discomfort
–– altered bowel function (urgency, altered stool altered bowel function (urgency, altered stool consistency, altered stool frequency, incomplete consistency, altered stool frequency, incomplete evacuation)evacuation)
–– bloatingbloating
Not explained by identifiable structural or Not explained by identifiable structural or biochemical abnormalitiesbiochemical abnormalities
IBS IBS –– Signs and symptoms Signs and symptoms
Reference: Thompson et al. Gut. 1999;45(suppl 2):1143-1147.
Key facts about IBSKey facts about IBS
Up to 20% of the US population report symptoms Up to 20% of the US population report symptoms
consistent with IBSconsistent with IBS11
The most common GI diagnosis among The most common GI diagnosis among
gastroenterology practices in the US gastroenterology practices in the US22
One of the top 10 reasons for PCP visitsOne of the top 10 reasons for PCP visits33
Affects predominantly females (~70% of sufferers)Affects predominantly females (~70% of sufferers)44
The most common functional bowel disorderThe most common functional bowel disorder55
IBS IBS –– Overview Overview
References: 1. Camilleri and Choi. Aliment Pharmacol Ther. 1997;11:13-15. 2. Everhart and Renault. Gastroenterology. April 1991;100:998-1005. 3. Physician Drug & Diagnosis Audit (PDDA), April 1999, Scott-Levin. 4. Sandler. Gastroenterology. August 1990;99:409-415. 5. Thompson et al. Gastroenterol Int. 1992;5:75-91.
Key facts about IBS Key facts about IBS (cont.)(cont.) Can cause great discomfort, sometimes intermittent Can cause great discomfort, sometimes intermittent
or continuous, for many decades in a patient’s lifeor continuous, for many decades in a patient’s life11
Can significantly disrupt daily lifeCan significantly disrupt daily life22
Can have negative impact on quality of lifeCan have negative impact on quality of life22 Current treatment optionsCurrent treatment options33
–– dietary modificationdietary modification–– fiber supplementsfiber supplements–– pharmacologic agentspharmacologic agents–– psychotherapypsychotherapy
Success of current treatment options in addressing Success of current treatment options in addressing multiple symptoms of IBS has been limitedmultiple symptoms of IBS has been limited44
IBS IBS –– Overview Overview
References: 1. Hahn et al. Dig Dis Sci. December 1998;43:2715-2718. 2. Hahn et al. Digestion. 1999;60:77-81. 3. Drossman. Aliment Pharmacol Ther. 1999;13(suppl 2):3-14. 4. Klein. Aliment Pharmacol Ther. 1999;13(suppl 2):15-30.
IBS consultation patternIBS consultation patternSpecialistsSpecialists11
Primary carePrimary care11
~25%~25%ConsultersConsulters11
~75%~75%NonconsultersNonconsulters11
~70% ~70% FemaleFemale22
~30%~30%MaleMale22
IBS IBS –– Epidemiology Epidemiology
References: 1. Drossman and Thompson. Ann Intern Med. June 1992;116(pt 1):1009-1016. 2. Sandler. Gastroenterology. August 1990;99:409-415.
IBS vs other IBS vs other important disease statesimportant disease states
US prevalence up to 20%US prevalence up to 20%11
US prevalence rates for other common US prevalence rates for other common diseasesdiseases22::
–– diabetesdiabetes 3% 3%
–– asthmaasthma 4%4%
–– heart diseaseheart disease 8% 8%
–– hypertensionhypertension 11%11%
IBS IBS –– Epidemiology Epidemiology
References: 1. Camilleri and Choi. Aliment Pharmacol Ther. 1997;11:3-15. 2. Adams and Benson. Vital Health Stat 10. December 1991:83. DHHS publication no (PHS)92-1509.
Productivity burdenProductivity burden
IBS IBS –– Burden of disease Burden of disease
00
22
44
66
88
1010
1212
1414
IBSIBS Non-IBSNon-IBS
Da
ys
pe
r y
ea
rD
ay
s p
er
ye
ar
PP=0.0001=0.0001
Absenteeism from work or school Absenteeism from work or school during the last 12 monthsduring the last 12 months
Reference: Drossman et al. Dig Dis Sci. September 1993;38:1569-1580.
Irritable Bowel SyndromeIrritable Bowel Syndrome
Biopsychosocial DisorderBiopsychosocial Disorder– PsychosocialPsychosocial– MotilityMotility– SensorySensory– ? Infectious? Infectious
Prevalence 10%, Incidence 1-2% per YearPrevalence 10%, Incidence 1-2% per Year Disturbs QOL, Social Function, Healthcare UtilizationDisturbs QOL, Social Function, Healthcare Utilization
PsychosocialFactors
AlteredMotility
S2,3,4
Vagal nuclei
Sympathetic
AlteredSensation
IBS: Current thinking on pathophysiologyIBS: Current thinking on pathophysiology
Visceral hypersensitivityVisceral hypersensitivity11
–– Increased visceral afferent response to normal as well as Increased visceral afferent response to normal as well as noxious stimulinoxious stimuli
–– Mediators include 5-HT, bradykinin, tachykinins, CGRP, and Mediators include 5-HT, bradykinin, tachykinins, CGRP, and neurotropinsneurotropins
Primary motility disorder of GI tractPrimary motility disorder of GI tract22
–– Mediated by 5-HT, acetylcholine, ATP, motilin, nitric oxide, Mediated by 5-HT, acetylcholine, ATP, motilin, nitric oxide, somatostatin, somatostatin, substance P, and VIP substance P, and VIP
IBS IBS –– Pathophysiology Pathophysiology
References: 1. Bueno et al. Gastroenterology. May 1997;112:1714-1743. 2. Goyal and Hirano. N Engl J Med. April 1996;334:1106-1115.
Defects in the enteric nervous system may lead Defects in the enteric nervous system may lead to the hallmark symptoms of IBS.to the hallmark symptoms of IBS.
Physiological Physiological distribution of 5-HTdistribution of 5-HT
CNS – 5%CNS – 5%
– enterochromaffin cellsenterochromaffin cells– neuronalneuronal
IBS IBS –– Pathophysiology Pathophysiology
GI tract – 95% GI tract – 95%
Reference: Gershon. Aliment Pharmacol Ther. 1999;13(suppl 2):15-30.
5-HT5-HT receptor effectsreceptor effects
Mediate reflexes controlling gastrointestinal Mediate reflexes controlling gastrointestinal
motility and secretionmotility and secretion
Mediate perception of visceral painMediate perception of visceral pain
IBS IBS –– Pathophysiology Pathophysiology
Reference: Gershon. Aliment Pharmacol Ther. 1999;13(suppl 2):15-30.
20 60 100 140 180
Comparison of pain thresholds Comparison of pain thresholds of IBS patients and controlsof IBS patients and controls
IBS IBS –– Physiology Physiology
% R
epo
rtin
g P
ain
% R
epo
rtin
g P
ain
Rectosigmoid balloon volume (mL)Rectosigmoid balloon volume (mL)
Reference: From Whitehead et al. Dig Dis Sci. June 1980;25:404-413. With permission.
0
20
40
60
IBSIBS
NormalNormal
Pain produced by rectosigmoid balloon distensionPain produced by rectosigmoid balloon distension
Comparison of pain thresholdsComparison of pain thresholds
IBS IBS –– Physiology Physiology
Colonic DistensionColonic Distension Ice Water ImmersionIce Water Immersion
IBSIBS
NormalNormal
Reference: Whitehead et al. Gastroenterology. May 1990;98:1187-1192.
Make a positive diagnosisMake a positive diagnosis1,21,2
IBS – IBS – DiagnosisDiagnosis
Identify abdominal pain as dominant Identify abdominal pain as dominant symptom with altered bowel functionsymptom with altered bowel function
Perform diagnostic tests/physical exam Perform diagnostic tests/physical exam to rule out organic diseaseto rule out organic disease
Initiate treatment program as part Initiate treatment program as part of diagnostic approachof diagnostic approach
Follow up in 3 to 6 weeksFollow up in 3 to 6 weeks
Look for “red flags”Look for “red flags”
References: 1. Paterson et al. Can Med Assoc J. July 1999;161:154-160. 2. American Gastroenterological Association. Gastroenterology. June 1997;112:2120-2137.
Make/confirm diagnosisMake/confirm diagnosis
IBS ROME II CRITERIAIBS ROME II CRITERIA
At Least 12 Weeks, Which Need Not Be At Least 12 Weeks, Which Need Not Be Consecutive, in the Preceding 12 Consecutive, in the Preceding 12 Months, of Abdominal Discomfort or Months, of Abdominal Discomfort or Pain That Has Two of Three Features:Pain That Has Two of Three Features:
1. Relieved with Defecation; and/or1. Relieved with Defecation; and/or2. Onset Associated with a Change 2. Onset Associated with a Change
in Frequency of Stool; and/orin Frequency of Stool; and/or3. Onset Associated with a Change 3. Onset Associated with a Change
in Form (Appearance) of Stoolin Form (Appearance) of Stool
ConstipationConstipation DiarrheaDiarrhea
““Red flags” may suggest an Red flags” may suggest an alternative or coexisting diagnosisalternative or coexisting diagnosis
AnemiaAnemia
FeverFever
Persistent diarrheaPersistent diarrhea
Rectal bleedingRectal bleeding
Severe constipationSevere constipation
Weight lossWeight loss
IBS – IBS – DiagnosisDiagnosis
Reference: Paterson et al. Can Med Assoc J. July 1999;161:154-160.
Additional diagnostic screening needed for atypical Additional diagnostic screening needed for atypical presentations such aspresentations such as
Nocturnal symptoms of pain Nocturnal symptoms of pain and abnormal bowel functionand abnormal bowel function
Family history of GI cancer, Family history of GI cancer, inflammatory bowel disease, inflammatory bowel disease, or celiac diseaseor celiac disease
New onset of symptoms in New onset of symptoms in patients 50+ years of agepatients 50+ years of age
Diagnostic tests—What? When? Who?Diagnostic tests—What? When? Who?
If patient has typical features of IBS:If patient has typical features of IBS:
If If 50 years of age, order CBC, electrolytes, LFTs, 50 years of age, order CBC, electrolytes, LFTs, screen stool for occult blood, and consider screen stool for occult blood, and consider sigmoidoscopy.sigmoidoscopy.11
If If 50 years of age, order CBC, electrolytes, LFTs, 50 years of age, order CBC, electrolytes, LFTs, and perform a colonoscopy or air-contrast barium and perform a colonoscopy or air-contrast barium enema with sigmoidoscopy.enema with sigmoidoscopy.1,21,2
IBS – IBS – DiagnosisDiagnosis
References: 1. American Gastroenterological Association. Gastroenterology. June 1997;112:2120-2137. 2. Paterson et al. Can Med Assoc J. July 1999;161:154-160.
Differential diagnosisDifferential diagnosis
MalabsorptionMalabsorption11
Dietary factorsDietary factors11
InfectionInfection11
Inflammatory bowel diseaseInflammatory bowel disease11
Psychological disordersPsychological disorders11
Gynecological disordersGynecological disorders22
MiscellaneousMiscellaneous11
IBS – IBS – DiagnosisDiagnosis
References: 1. Drossman. Aliment Pharmacol Ther. 1999;13(suppl 2):3-14. 2. Moore et al. Br J Obstet Gynaecol. December 1998;105:1322-1325.
CurreCurrentnt management of IBS management of IBS
Establish a Establish a positivepositive diagnosis diagnosis11
Reassure patient that there is no serious Reassure patient that there is no serious organic disease or alarming symptomsorganic disease or alarming symptoms11
Success of current treatment options in Success of current treatment options in addressing multiple symptoms of IBS has addressing multiple symptoms of IBS has been limitedbeen limited22
IBS – IBS – DiagnosisDiagnosis
References: 1. Drossman. Aliment Pharmacol Ther. 1999;13(suppl 2):3-14. 2. Klein. Gastroenterology. July 1988;95:232-241.
Current management Current management components of IBScomponents of IBS
EducationEducation ReassuranceReassurance Dietary modificationDietary modification FiberFiber Symptomatic treatmentSymptomatic treatment Psychological/behavioral optionsPsychological/behavioral options Realistic goalsRealistic goals
IBS – IBS – ManagementManagement
Reference: Drossman. Aliment Pharmacol Ther. 1999;13(suppl 2):3-14.
Currently available Currently available Rx treatments for IBSRx treatments for IBS
Dicyclomine HClDicyclomine HCl11
Hyoscyamine sulfate Hyoscyamine sulfate (± other anticholinergics/sedatives)(± other anticholinergics/sedatives)22
Belladonna and phenobarbitalBelladonna and phenobarbital11
Clidinium bromide with chlordiazepoxideClidinium bromide with chlordiazepoxide11
TegaserodTegaserod
AlosetronAlosetron
IBS – IBS – ManagementManagement
References: 1. PDR® Generics™. 1998:314, 559-561, 873-875. 2. Physicians’ Desk Reference®. 1999:2910-2911.
Antispasmodics/anticholinergicsAntispasmodics/anticholinergics
Symptomatic treatment—painSymptomatic treatment—pain11
Smooth muscle relaxants via Smooth muscle relaxants via anticholinergic effects and/or direct anticholinergic effects and/or direct action on smooth muscleaction on smooth muscle22
IBS – IBS – ManagementManagement
References: 1. Drossman. Aliment Pharmacol Ther. 1999;13(suppl 2):3-14. 2. Drug Facts and Comparisons®. 1999:298-298c.
AntidiarrhealsAntidiarrheals
Symptomatic treatment—dSymptomatic treatment—diarrheaiarrhea
Increase stool firmnessIncrease stool firmness
Decrease stool frequencyDecrease stool frequency
– Examples: loperamide, diphenxylate-atropineExamples: loperamide, diphenxylate-atropine
IBS – IBS – ManagementManagement
Reference: Drug Facts and Comparisons®. 1999:324b.
Laxatives and bulking agentsLaxatives and bulking agents
Symptomatic treatment—constipationSymptomatic treatment—constipation
IBS – IBS – ManagementManagement
References: 1. American Gastroenterological Association. Gastroenterology. June 1997;112:2120-2132. 2. Camilleri and Choi. Aliment Pharmacol Ther. 1997;11:3-15. 3. Drug Facts and Comparisons®. 1999:316-317a.
Increased dietary fiber or psylliumIncreased dietary fiber or psyllium11
Osmotic laxatives (MgSOOsmotic laxatives (MgSO44, lactulose), lactulose)22
Stimulant laxativesStimulant laxatives33
Some laxatives and bulking agents can Some laxatives and bulking agents can exacerbate abdominal pain and bloatingexacerbate abdominal pain and bloating33
Tricyclic antidepressants Tricyclic antidepressants and SSRIsand SSRIs
Symptomatic treatment—painSymptomatic treatment—pain
Reserved for patients with severe Reserved for patients with severe or refractory painor refractory pain
IBS – IBS – ManagementManagement
Reference: Drossman and Thompson. Ann Intern Med. 1992;116(pt 1):1009-1016.
Multiple medications needed Multiple medications needed to treat multiple symptomsto treat multiple symptoms
IBS – IBS – ManagementManagement
AnticholinergicsAnticholinergics11 XX XX
TricyclicTricyclicantidepressantsantidepressants XX and SSRIsand SSRIs22
AntidiarrhealsAntidiarrheals11 XX XX XX
Bulking agentsBulking agents11 X X XX XX
LaxativesLaxatives33 XX XX
Lower Lower abdominal painabdominal pain BloatingBloating
Altered Altered stool formstool form
Altered Altered stool passagestool passage UrgencyUrgency
References: 1. American Gastroenterological Association. Gastroenterology. June 1997;112:2120-2137. 2. Drossman and Thompson. Ann Intern Med. 1992;116(pt 1):1009-1016. 3. Drug Facts and Comparisons®. 1999:316.
INITIAL MANAGEMENT OF IBSINITIAL MANAGEMENT OF IBS
Review Diet History Review Diet History Re: Fiber IntakeRe: Fiber Intake
YesYes
Increase Fiber (20g),Increase Fiber (20g),Osmotic LaxativeOsmotic Laxative
YesYes
H2 Breath TestH2 Breath TestCeliac panelCeliac panel
AntidiarrhealAntidiarrheal
YesYes
Abdominal X-ray Abdominal X-ray (KUB During Pain)(KUB During Pain)
AntispasmodicAntispasmodic++ Antidepressant Antidepressant
NoNo
Camilleri & Prather. 1992Camilleri & Prather. 1992
Additional TestsAdditional Tests
Therapeutic TrialTherapeutic Trial
Constipation Diarrhea Pain/Gas/Bloat
Symptom Features
Tegaserod (Zelnorm)Tegaserod (Zelnorm)(serotinin 4 receptor agonist)(serotinin 4 receptor agonist)
Approved for constipation predominant Approved for constipation predominant IBSIBS
1 pill given twice daily1 pill given twice daily Improvement of symptoms in women Improvement of symptoms in women
but not menbut not men Use up to 12 weeksUse up to 12 weeks Mild side effects: diarrhea the most Mild side effects: diarrhea the most
prominent side effectprominent side effect
Non-Traditional RemediesNon-Traditional Remedies
Chinese Herbal MedicineChinese Herbal Medicine– 116 pts randomized to CHM did better than pts 116 pts randomized to CHM did better than pts
receiving placeboreceiving placebo Peppermint OilPeppermint Oil
– Relaxation of GI smooth muscleRelaxation of GI smooth muscle– Meta-analysis showed significant improvement Meta-analysis showed significant improvement
of IBS symptomsof IBS symptoms AcupuntureAcupunture ProbioticsProbiotics AntibioticsAntibiotics Benoussan A. JAMA 1998Benoussan A. JAMA 1998
Pittler M. AJG 1998Pittler M. AJG 1998
Surgical Therapy for IBSSurgical Therapy for IBS
IBS symptoms may be attributed to:IBS symptoms may be attributed to:– Non-functioning gallbladder disease, Non-functioning gallbladder disease,
chronic appendicitis, uterine fibroids, chronic appendicitis, uterine fibroids, tortuous colontortuous colon
IBS symptoms rarely improve after IBS symptoms rarely improve after surgerysurgery
IBS patients 2 to 3 times more likely to IBS patients 2 to 3 times more likely to undergo unnecessary surgeryundergo unnecessary surgery
Take Home PointsTake Home Points
IBS is a chronic medical condition IBS is a chronic medical condition characterized by abdominal pain, characterized by abdominal pain, diarrhea or constipation, bloating, diarrhea or constipation, bloating, passage of mucus and feelings of passage of mucus and feelings of incomplete evacuationincomplete evacuation
Precise etiology of IBS is unknown and Precise etiology of IBS is unknown and therefore treatment is focused on therefore treatment is focused on relieving symptoms rather that “curing relieving symptoms rather that “curing disease”disease”
Take Home PointsTake Home Points
Although many IBS patients complain Although many IBS patients complain of symptoms after eating, true food of symptoms after eating, true food allergies are uncommonallergies are uncommon
Specific therapies are determined by Specific therapies are determined by individual patient symptomsindividual patient symptoms
Life-style modifications and possible Life-style modifications and possible alternative therapies may relieve alternative therapies may relieve symptomssymptoms
Surgery has NO Role in treatment of IBSSurgery has NO Role in treatment of IBS