1. Changes in bowel movement-IBS Mohammed Alwahibi Khalid Alsadhan Walid Alkhamis

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9. Page  9 Changes in bowel movement: Abnormal changes in the frequency, consistency and the color of the stool Irritable bowel syndrome (IBS) is a chronic, relapsing and often life-long disorder. Symptoms may include disordered defaecation (constipation or diarrhoea or both) and abdominal distension, usually referred to as bloating. People with IBS present to primary care with a wide range of symptoms, some of which they may be reluctant to disclose without sensitive questioning.

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11. Page  11 Altered GI motility includes distinct aberrations in small and large bowel motility. Psychopathology is the 2 nd aspect. Associations between psychiatric disturbances and irritable bowel syndrome pathogenesis are not clearly defined.

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14. Page  14 Gender differences: Affects up to 20% of adults (70% of them are women). Age: Young Psychopathology: High prevalence of psychiatric disorders (anxiety and depression were the most common). Only 25% of persons with this condition seek medical care.

15. Page  15 Irritable bowel syndrome in secondary school male students in AlJouf Province, north of Saudi Arabia (2011 Nov)

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19. Page  19 The primary aim should be to establish the person's symptom profile, with abdominal pain or discomfort being a key symptom. It is also necessary to establish the quantity and quality of the pain or discomfort, and to identify its site (which can be anywhere in the abdomen) The primary aim should be to establish the person's symptom profile, with abdominal pain or discomfort being a key symptom. It is also necessary to establish the quantity and quality of the pain or discomfort, and to identify its site (which can be anywhere in the abdomen)

20. Page  20 Healthcare professionals should consider assessment for IBS if the person reports having had any of the following symptoms for at least 6 months: 1-Abdominal pain or discomfort 2-Bloating 3-Change in bowel habit.

21. Page  21 A diagnosis of IBS should be considered only if the person has abdominal pain or discomfort that is either relieved by defaecation or associated with altered bowel frequency or stool form. This should be accompanied by at least two of the following four symptoms: altered stool passage symptoms worse by eating passage of mucus abdominal bloating Other features such as lethargy, nausea, backache and bladder symptoms are common in people with IBS Other features such as lethargy, nausea, backache and bladder symptoms are common in people with IBS

22. Page  22 In people who meet the IBS diagnostic criteria, the following tests should be undertaken to exclude other diagnoses: 1) full blood count (FBC) 2) erythrocyte sedimentation rate (ESR) or plasma viscosity 3) c-reactive protein (CRP) 4) antibody testing for coeliac disease - endomysial antibodies [EMA] or tissue 5) transglutaminase [TTG].

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24. Page  24 Dietary and lifestyle advice People with IBS should be given information that explains the importance of self-help in effectively managing their IBS. This should include information on general lifestyle, physical activity, diet and symptom-targeted medication 1

25. Page  25 Healthcare professionals should assess the physical activity levels of people with IBS and for the People with low activity levels should be given brief advice and counselling to encourage them to increase their activity levels.

26. Page  26 Diet and nutrition should be assessed for people with IBS and the following general advice given: * Have regular meals and take time to eat. * Avoid missing meals or leaving long gaps between eating. * Drink at least 8 cups of fluid per day, especially water or other non-caffeinated drinks, for example herbal teas. * Restrict tea and coffee to 3 cups per day. Diet and nutrition should be assessed for people with IBS and the following general advice given: * Have regular meals and take time to eat. * Avoid missing meals or leaving long gaps between eating. * Drink at least 8 cups of fluid per day, especially water or other non-caffeinated drinks, for example herbal teas. * Restrict tea and coffee to 3 cups per day.

27. Page  27 2 Pharmacological therapy Decisions about pharmacological management should be based on the nature and severity of symptoms. The recommendations made below assume that the choice of single or combination medication is determined by the predominant symptom(s).

28. Page  28 - Antispasmodic (Dicyclomine hydrochloride) agents should be taken as required, alongside dietary and lifestyle advice. -Laxatives (Methylcellulose) should be considered for the treatment of constipation in people with IBS, but people should be discouraged from taking lactulose.

29. Page  29 # Consider linaclotide (Linzess) for people with IBS only if: - optimal or maximum tolerated doses of previous laxatives from different classes have not helped - they have had constipation for at least 12 months. - Follow up people taking linaclotide after 3 months.

30. Page  30 - Loperamide (Imodium) should be the first choice of antimotility agent for diarrhoea in people with IBS

31. Page  31 - Consider tricyclic antidepressants (TCAs) (Imipramine) as second-line treatment for people with IBS if laxatives, loperamide or antispasmodics have not helped. Start treatment at a low dose (5–10 mg equivalent of amitriptyline), taken once at night, and review regularly. Increase the dose if needed, but not usually beyond 30 mg.

32. Page  32 - Consider selective serotonin reuptake inhibitors (SSRIs) for people with IBS only if TCAs are ineffective.

33. Page  33 3 Psychotherapy o Cognitive behavioral therapy (perceptions of illness), was reportedly to be effective. o A review of psychological treatments for IBS reported positive responses to psychotherapy o Psychotherapy is considered useful for those who have relatively severe or refractory symptoms o Small studies have shown that tricyclic compounds in low doses relieve unexplained abdominal pain.

34. Page  34 Psychological interventions 4 Referral for psychological interventions (cognitive behavioural therapy [CBT], hypnotherapy and/or psychological therapy) should be considered for people with IBS who do not respond to pharmacological treatments after 12 months and who develop a continuing symptom profile (described as refractory IBS).

35. Page  35 Patient education remains the cornerstone of successful treatment of irritable bowel syndrome. Teach the patient to acknowledge stressors and to develop avoidance techniques. Many patients successfully manage their symptoms with attention to dietary triggers.

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37. Page  37 if they have any of the following 'red flag' indicators and should be referred to secondary care for further investigation if any are present: - unintentional and unexplained weight loss - rectal bleeding - a family history of bowel or ovarian cancer - anaemia - abdominal masses - rectal masses - inflammatory markers for inflammatory bowel disease

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41. Page  41 Lactose intolerance is a common disorder and is due to the inability to digest lactose into its constituents, glucose and galactose, secondary to low levels of lactase enzyme in the brush border of the duodenum.

42. Page  42 loose stools abdominal bloating flatulencenausea borborygmi

43. Page  43 A diagnosis or even the suggestion of lactose intolerance leads many people to avoid milk

44. Page  44 Rome III criteria is a diagnostic criteria for IBS red flag Symptoms include unintentional and unexplained weight loss, rectal bleeding, family history, anaemia, abdominal masses, rectal masses, inflammatory markers for inflammatory bowel disease Treatment of IBS include Dietary and lifestyle advice, antispasmodic, Laxatives, Loperamide, TCAs, SSRIs

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52. Page  52 Irritable bowel syndrome in adults: diagnosis and management of irritable bowel syndrome in primary care NICE clinical guideline http://www.medscape.org/viewarticle/439588 http://emedicine.medscape.com/article/187249-differential http://emedicine.medscape.com/article/180389-medication#7 http://www.ncbi.nlm.nih.gov/pubmed/22125990

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