1. Irritable Bowel Syndrome Bill Cayley, Jr MD

2. Objectives Participants will have the medical knowledge to Describe the Irritable Bowel Syndrome Discuss the use of diagnostic criteria in evaluating a patient for the Irritable Bowel Syndrome Discuss evidence for management of the Irritable Bowel Syndrome

3. Violet R 35 year female  “Upset stomach for one year, now increased rumblings, looser and more frequent stools with leakage, cramping.”  PMH: On Serzone for anxiety.  FH: Depression.  SH: Stressful office work, no tobacco.  What else would you like to know?

4. Violet R Physical exam  WD WN NAD  Vitals normal, weight up and down past year  Heart RRR, Lungs CTA  Abdomen is soft, a bit tympanic, diffuse discomfort w/ palpation  Extremities benign  What else would you like to know?

5. Violet R What could she have?  Assessment and differential diagnosis

6. Violet R What could she have?  Assessment and differential diagnosis What should we do next?  Plan

7. Irritable Bowel - What is it?

8. "The bowels are at one time constipated, another lax, in the same person. How the disease has two such different symptoms I do not profess to explain.” (Cumming, London Med Gaz, 1849.) Other names:  Mucous colitis  Spastic colitis  Nervous colon  Irritable colon

9. Irritable Bowel - What is it? Abdominal discomfort that is  Relieved with defecation  Associated with altered stool frequency  Associated with altered stool consistency

10. Possible Causes Altered Bowel Motility  Abnormal timing & pattern of contractions w/ food or stress Visceral Hypersensitivity  Abnormal excitability of neurons & pathways Psychosocial Factors  May affect perceptions or central signal processing Neurotransmitter Imbalance  Increased serotonin levels? Infection/Inflammation  Inflammatory cytokines may affect bowel sensitization

11. Possible Causes “To date, no single conceptual model can explain all cases of the syndrome.” NEJM 2001; 344:1846-1850

12. What is a “Syndrome?”

13. “Syndrome” “A pattern of symptoms indicative of some disease”  Different causes for same problem?  Different problems with similar manifestations?

14. IBS – Does it exist? Irritable Bowel Syndrome Defined by Factor Analysis. Dig Dis Sci 1995; 40: 2647-55. Six Manning criteria:  Frequent stools with abdominal pain  Looser stools with pain  Relief of pain with defecation  Abdominal distension  Passage of mucus  A feeling of incomplete evacuation after defecation Validation study  1344 students  Measured prevalence of 22 GI Sx in past 6 months Factor analysis: 3 three Manning symptoms clustered together among both sexes and racial groups  More frequent bowel movements with the onset of pain  Looser stools with the onset of pain  Relief of pain with defecation 3 Manning symptoms did not cluster with each other or with the first three symptoms.  Bloating  Mucus  Feeling of incomplete evacuation

15. Epidemiology Incidence/prevalence  Prevalence 3 - 22% world-wide  Reason for 20 - 50% of gastroenterology visits  $8 billion in medical expenses per year in the USA  26% prevalence among children with recurrent abdominal pain Predominant age  40% onset before age 35  50% onset age 35 - 50 Predominant gender  Female > Male (2:1) in the US

16. Irritable Bowel - Diagnosis

17. Differential Diagnosis What is the differential diagnosis for IBS?

18. Differential Diagnosis Inflammatory bowel disease  Crohn's disease or ulcerative colitis Medications  Laxatives  Constipating medications Infections  Parasitic, bacterial, viral, and opportunistic Malabsorption syndromes  Celiac disease  Pancreatic insufficiency Endocrine disorders  Hypothyroidism  Hyperthyroidism  Diabetes  Addison's disease Endocrine tumors (very uncommon)  Gastrinoma  Carcinoid Colorectal carcinoma  Adenocarcinoma  Villous adenoma Intestinal pseudo-obstruction  Diabetes  Scleroderma Lactose intolerance Psychiatric disorders  Depression  Anxiety  Somatization disorder

19. Diagnostic Criteria Manning IBS diagnosed if 3 of the following are present:  Abdominal pain  Pain relief with defecation  Increased stool frequency with pain  Looser stools with pain  Mucus in stools  Feeling of incomplete evacuation Rome III Abdominal pain or discomfort for at least 3 days per month for the past 3 months, with at least two of:  Improved with defecation  Onset associated with change in stool frequency  Onset associated with change in stool form

20. Diagnostic Red Flags Further evaluation is mandated: Weight loss Evidence of bleeding or anemia Signs of infection Age over 50 at the onset of symptoms

21. Diagnostic Sensitivity and Specificity Manning Criteria:  2 of 6 present 84-94% Sensitivity & 55-76% Specificity  3 of 6 present 63-90% Sensitivity & 70-93% Specificity Rome 1:  65% Sensitivity & 100% Specificity

22. Symptom Patterns Constipation Predominant Diarrhea Predominant Abdominal Pain Predominant Severity  Mild Can be ignored if the patient does not think about it  Moderate Cannot be ignored but does not affect patient's lifestyle  Severe/very severe Affects patient's lifestyle

23. Investigations What tests are needed for IBS?

24. Investigations Constipation predominant IBS  CBC, TSH, Electrolytes, Sigmoidoscopy Diarrhea predominant IBS  CBC, TSH, ESR, Electrolytes, Sigmoidoscopy Abdominal pain predominant IBS  CBC

25. When can you stop the tests? Meta-analysis of 6 studies Prevalence of disease if IBS criteria met:  Colitis/inflammatory bowel disease = 0.5% - 1.0%  Colorectal cancer = 0% - 0.5%  Celiac disease = 4.7%  Gastrointestinal infection = 0% - 1.7%  Thyroid dysfunction = 6%  Lactose malabsorption = 22% - 26% Endoscopy, ultrasound, and barium studies only detected organic disease in 1% of patients. CBC and chemistries were unhelpful.  Am J Gastroenterol 2002; 97:2812-9.

26. Red Flags… Warrant a more thorough diagnostic evaluation.  Weight loss  Evidence of bleeding or anemia  Signs of infection  Age over 50 at the onset of symptoms

27. When can you stop the tests? Bottom line:  “There is insufficient evidence to recommend the routine performance of a standardized battery of diagnostic tests in patients who meet symptom- based criteria for IBS.  Am J Gastroenterol 2002; 97:2812-9.

28. Evaluation Positive Manning or Rome 3? Absence of alarm symptoms? Symptom Pattern? Also explore…  Dietary fiber and food intolerances  Family history of intestinal disease or malignancy  Family stress  Abuse history?  Depression or anxiety  Effect of symptoms on daily life

29. Irritable Bowel - Management

30. What are important parts of the management of IBS?

31. Irritable Bowel - Management Strong physician-patient relationship  Education, reassurance Dietary  Reduce EtOH, caffeine, fat (?????) Explore triggers  Life stresses  Foods Symptom-specific medications  Pain predominant  Diarrhea predominant  Constipation predominant

32. Behavior Therapy for IBS 1. Provide information about IBS and normal GI functioning, discuss the role of stress. 2. Analyze the patient's illness in terms of symptoms, circumstances of first onset, symptom triggers, contributing factors, and consequences. 3. Teach relaxation techniques. 4. Teach patients to identify irrational thoughts regarding their GI problems. 5. Discuss ways people cope with the problems that chronic illness brings to daily life. 6. Discuss ways to manage difficulties the individual may have in social situations caused by GI problems.

33. Pharmacologic Treatment - Reviews Ann Int Med 133: 136.  Improved Pain Amitryptiline  Improved Constipation Ispaghula (Psyllium) Ondansetron  Improved Diarrhea Ispaghula (Psyllium) Amitryptiline Ondansetron JFP 52: 942  Good evidence for Tegaserod for constipation* Alosetron for women with diarrhea IBS *  Fair evidence for TCA’s for Pain Loperamide for Diarrhea Bulk for Constipation Antispasmodics for Global Symptoms

34. Treatment recommendations Constipation- predominant IBS  Guar gum, fiber, exercise, episodic use of antispasmodics, peppermint oil, and adequate fluid intake. (SOR = B) Diarrhea-predominant IBS  Loperamide, episodic use of antispasmodic agents, peppermint oil, and dietary manipulation (SOR = B). Patients with pain-predominant or severe IBS  TCAs and psychotherapy should be considered. (SOR = B)

35. IBS – what should you do? Perform a symptom-directed history and exam Use lab testing judiciously if indicated Defer further testing or imaging unless clearly indicated Begin education on the interaction of emotional factors, coping styles, environmental stressors and physiologic factors in IBS Begin working to establish a strong physician-patient relationship Consider a trial of dietary adjustments Consider pharmacologic interventions based on the patient’s symptom pattern

36. Resources – for Physicians Mayer EA. Clinical practice. Irritable bowel syndrome. N Engl J Med. 2008 Apr 17;358(16):1692-9. PMID: 18420501 (http://content.nejm.org/cgi/content/full/358/16/1692)http://content.nejm.org/cgi/content/full/358/16/1692 Hadley SK, Gaarder SM. Treatment of irritable bowel syndrome. Am Fam Physician. 2005 Dec 15;72(12):2501-6. PMID: 16370407 (http://www.aafp.org/afp/20051215/2501.html)http://www.aafp.org/afp/20051215/2501.html Cayley WE Jr. Irritable bowel syndrome. BMJ. 2005 Mar 19;330(7492):632. (http://bmj.bmjjournals.com/cgi/content/full/330/7492/632)http://bmj.bmjjournals.com/cgi/content/full/330/7492/632 Holten KB, Wetherington A, Bankston L. Diagnosing the patient with abdominal pain and altered bowel habits: is it irritable bowel syndrome? Am Fam Physician. 2003 May 15;67(10):2157-62. PMID: 12776965. (http://www.aafp.org/afp/20030515/2157.html)http://www.aafp.org/afp/20030515/2157.html Horwitz BJ, Fisher RS. The irritable bowel syndrome. N Engl J Med. 2001 Jun 14;344(24):1846-50. PMID: 11407347 (http://content.nejm.org/cgi/content/full/344/24/1846)http://content.nejm.org/cgi/content/full/344/24/1846 Fass R, Longstreth GF, Pimentel M, Fullerton S, Russak SM, Chiou CF, Reyes E, Crane P, Eisen G, McCarberg B, Ofman J. Evidence- and consensus-based practice guidelines for the diagnosis of irritable bowel syndrome. Arch Intern Med. 2001 Sep 24;161(17):2081-8. Review. PMID: 11570936 (http://archinte.ama-assn.org/cgi/content/full/161/17/2081)http://archinte.ama-assn.org/cgi/content/full/161/17/2081

37. Resources – for Patients What I need to know about Irritable Bowel Syndrome (Patient information). National Digestive Diseases Information Clearinghouse. http://digestive.niddk.nih.gov/ddiseases/pubs/ibs/index.htm http://digestive.niddk.nih.gov/ddiseases/pubs/ibs/index.htm Irritable Bowel Syndrome: Tips on Controlling Your Symptoms (Patient information). Family Doctor.org. http://familydoctor.org/online/famdocen/home/common/digestive/dis orders/112.html http://familydoctor.org/online/famdocen/home/common/digestive/dis orders/112.html IBS--What You Need to Know (Patient information). Am Fam Physician 2002. http://www.aafp.org/afp/20021115/1880ph.htmlhttp://www.aafp.org/afp/20021115/1880ph.html Irritable Bowel Syndrome (IBS) Self Help and Support Group (Support Group Website). http://www.ibsgroup.org/http://www.ibsgroup.org/