1. Shad Johnson MPAS, PA-C Southeast Idaho Gastroenterology

5. Gain an appreciation for the nonspecific nature of the symptoms of irritable bowel syndrome (IBS) Be able to make use of judicious diagnostic testing when suspicious of IBS Choose from the many therapeutic options available for the treatment of IBS Understand the importance of psychosocial factors which affect symptoms of IBS

6. The most commonly diagnosed gastrointestinal disorder ~10-20% of the population meet diagnostic criteria ~1/3 of referrals to gastroenterologists More common in young people and women (2:1 female predominance) Major cause of absence from work Estimated annual cost in the billions

7. Chronic abdominal pain Diarrhea Constipation Diarrhea and constipation may be mixed Associated symptoms Nausea, chest pain, bloating, flatulence, and eructation Dysmenorrhea, dyspareunia, urinary frequency and urgency, and fibromyalgia symptoms

8. Symptoms/signs which should prompt investigation for other diagnosis Pain with anorexia/weight loss Progressive pain, pain which wakes a patient from sleep or prevents sleep Rectal bleeding Iron deficiency anemia or other nutritional deficiencies

9. Recurrent abdominal pain or discomfort at least three days per month in the last three months associated with two or more of the following: Improvement with defecation Onset associated with a change in frequency of stool Onset associated with a change in form (appearance) of stool Criteria fulfilled for the last three months with symptom onset at least six months prior to diagnosis

10. Abnormal motility Increased frequency of luminal contractions Decreased transit time Visceral hypersensitivity Balloon distension of the rectum/colon causes pain at lower volume than in controls Sometimes observed during colonoscopy Intestinal inflammation/Postinfectious Increased mast cell/lymphocytes in tissue samples and/or proinflammatory interleukins in serum Postinfectious IBS symptoms occur following acute

11. Alteration in fecal microflora Fecal bacteria may differ in IBS patients Some studies show improvement with probiotics Food sensitivity?? Carbohydrate malabsorption Improvement in symptoms upon withdrawal of certain types of carbohydrates Food allergy Greater number of positive skin reactions in IBS patients Genetics Higher concordance rates in some twin studies

12. Lactose intolerance Celiac disease Inflammatory bowel disease Infectious diarrhea (giardia) Small bowel bacterial overgrowth Pancreatic insufficiency Microscopic colitis Medications (metformin, magnesium) Postcholecystectomy diarrhea

13. Is there evidence of inflammatory diarrhea Test for celiac disease Consider lactose intolerance Decide if colonoscopy is necessary When you and the patient are satisfied that other entities have been ruled out, provide reassurance and make a treatment plan

14. Education and Reassurance Dietary Modification Minimizing alcohol and caffeine intake Exclusion of gas producing foods (low FODMAP diet) Food journal Lactose avoidance Increased fiber intake (especially with mixed diarrhea and constipation) Physical activity

15. FODMAP: Fermentable Oligo-Di-Monosaccharides and Polyols The goal is reduction, not elimination https://stanfordhealthcare.org/content/dam/SHC/for-patients-component/programs- services/clinical-nutrition-services/docs/pdf-lowfodmapdiet.pdf

16. Constipation predominant IBS Osmotic laxatives polyethylene glycol milk of magnesia lactulose (fermentable carbohydrate) Amitiza® (lubiprostone) Major adverse effect: nausea $$$ Linzess® (linaclotide) Major adverse effect: diarrhea $$$

17. Diarrhea predominant IBS loperamide (Imodium®) Bile acid sequestrants cholestyramine (Questran®), colestipol (Colestid®), Welchol® Antispasmodics dicyclomine (Bentyl®) hyoscyamine (Levsin®) glycopyrolate (Robinul®) Adverse effects: dry mouth, difficulty urination, constipation, Tricyclic antidepressants amitriptyline, nortriptyline, imipramine Can take several weeks to gain full effect

18. Diarrhea predominant IBS (cont.) Lotronex® Severe diarrhea predominant IBS in women who have failed conventional treatments Prescriber must be enrolled in a special prescribing program Ischemic colitis! Xifaxan® Non-absorbable antibiotic, $$$ Viberzi® Mu-opioid receptor agonist and delta-opioid receptor antagonist, $$$ Adverse effects: nausea, constipation, abdominal pain, PANCREATITIS Probiotics???

19. Stress Clinician-Patient relationship Validation of patient symptoms Setting expectations Involving patients in the decision making process

20. www.uptodate.com Sleisenger & Fordtran’s Gastrointestinal and Liver Disease, 7 th Edition, Feldman, Friedman, Sleisenger www.stanfordhealthcare.org Mayo Clinic Gastroenterology and Hepatology Board Review, Hause