Presentation on theme: "IRRITABLE BOWEL SYNDROME-DIARRHEA"— Presentation transcript:
1 IRRITABLE BOWEL SYNDROME-DIARRHEA A NEW LOOK AT AN OLDPROBLEMMeritus Medical CenterCommunity Education SeminarsAugust 18, 2011M. E. Money, M.D., FACPClinical Associate Professor Department of MedicineUniversity of Maryland School of MedicineMeritus Medical Staff
2 IRRITABLE BOWEL SYNDROME-DIARRHEA What is the irritable bowel syndrome?What are the symptoms?Why does it occur?What are the treatments?Are there any tests that can definitely “prove”a person's symptoms are IBS-D?M. E. Money. M.D.
3 Definition of IBSIBS is a functional bowel disorder in which abdominal pain or discomfort is associated with defecation or a change in bowel habit. Bloating, distension, and disordered defecation are commonly associated features.Irritable bowel syndrome: a global perspective. World Gastroenterology Organizational Global Guideline. April 20, 2009M. E. Money. M.D.
4 Mainstream concepts about IBS Exact cause of irritable bowel syndrome not known.Multiple factors thought to contribute to etiology.To date an 'IBS gene' has not been identified.The concept of IBS as a diagnosis of exclusion is not acceptable any more.The treatment of IBS is targeted at symptom relief.Cognitive behavioral therapy is very beneficial.M. E. Money. M.D.
5 Diagnostic criteria (Rome III) Onset of symptoms at least 6 months before diagnosisRecurrent abdominal pain or discomfort for >3 days per month during the past 3 monthsAt least two of the following features:Improvement with defecationAssociation with a change in frequency of stoolAssociation with a change in stool formNB: What precedes the symptoms is not included.WGO Practice Guidelines Irritable bowel syndrome 2009M. E. Money. M.D.
6 Accuracy of symptom-based criteria for diagnosis of IBS in primary care1 Reviewed 25 primary diagnostic studies.2 research questions:Performance of symptom-based criteria in excluding organic GI disease.Performance of signs and symptoms in identifying IBSConclusion: “organic disease cannot be accurately excluded by symptom-based IBS criteria alone.”1Jellema, P. et al. Systematic review: accuracy of symptom-based criteria for diagnosis of irritable bowel syndrome in primary care. Alimentary Pharmacology & Therapeutics DOI: /jM. E. Money, MD
7 Irritable bowel syndrome impact Estimated: 15 Million people in the U.S.Prevalence 10-20% of adults$2 Billion in direct annual costs$20 Billion in indirect annual costsEstimated only 1/3 patients seek medical attention for condition.Laudanum, U. Irritable Bowel Syndrome. Advanced Studies in Medicine. Vol. 4, No. 3. March PagesExecutive Summary: IBS in Women: The Unmet Needs. Society for Women’s Health Research.2003.M. E. Money. M.D.
8 IBS-diarrhea and constipation 35% Sub types of IBSIBS-Diarrhea33%IBS-Constipation32%IBS-diarrhea and constipation 35%Executive Summary: IBS in Women: The Unmet Needs. Society forWomen’s Health Research. 2003M. E. Money. M.D.
9 Patient #1Has had intermittent increased loose stools after meals for 11 yrs, sometimes at night if eats late. She wonders if she has IBS. Symptoms may last for weeks once it gets started, otherwise only when eats out in restaurants. Worse with spicy foods, onions, garlicky Italian meals and tomatoes.Exam entirely normal. 64” tall, 161#Chronic medical problems other than above: AsthmaCurrent meds: Zyrtec, Advair Diskus, Ventolin inhalerMother has similar digestion problem.Patient had never had a colonoscopy.9M. E. Money. M.D.
10 Patient #1 continuedPatient referred to gastroenterologist who wrote: “Patient states she has cramping, watery diarrhea alternating with constipation, up to 10x/day, mild in nature…..symptoms are suggestive of IBS.”Investigation by gastroenterologist:Colonoscopy negativeX-rays for the stomach and small intestine were normalBlood tests for Celiac disease was normalBiopsy of colon negative for pathologyTreatment: Patient encouraged to try probiotics by gastroenterologist.M. E. Money. M.D.
11 Patient #211 year old maleFather has trouble eating certain foods: gets abdominal pain and urgent diarrhea if eats out in restaurant and avoids onions at any time.Son observed to get extremely nervous and sweaty (clammy) when eating out in a restaurant. Would refuse to eat with the family sometimes. Didn't want to go with friends to parties. Frequently complained of having cramping stomach pains.M. E. Money. M.D.
12 Patient #376 yr old femaleHas had “food allergies” for decades. Predominantly if she eats spagetti will get moderate cramping and has to find the bathroom really fast. Sometimes will have 3-4 loose stools (which may become all liquid) within minutes after eating. The episodes will cause her to feel quite weak, sweaty, and one time she fainted while sitting on the commode. She rarely has any nausea and has never had any hives, trouble breathing, or vomiting.M. E. Money. M.D.
13 Patient #4 55 year old construction worker. Has had frequent bowel movements for the last years. May have 4-6 medium soft to loose stools daily. Will have to be close to a bathroom while on the job. A couple of times almost didn't make it. Has more bowel movements after eating rich, fatty foods, or if sometime is fried.M. E. Money. M.D.
14 Incidence of diarrhea occurring after eating 50% of patients suffering with the diarrhea or mixed form of IBS related symptoms to eating.However, the current definition of IBS does not encourage nor require the physician to inquire about any precipitating factor such as the condition occurring ONLY after eating.M. E. Money. M.D.
15 Differential diagnosis for IBS Celiac Sprue/gluten enteropathyLactose intolerance (inherited or 2nd to mucosal damage)Inflammatory bowel diseaseColorectal carcinomaLymphocytic and collagenous colitisAcute diarrhea due to protozoa or bacteriaSmall-intestinal bacterial overgrowth (SIBO)DiverticulitisEndometriosisPelvic inflammatory diseaseOvarian cancerWGO Practice Guideline IBS 2009M. E. Money. M.D.
16 What is missing from this differential diagnosis? Conditions that causeMALDIGESTIONM. E. Money. M.D.
17 Common conditions that cause maldigestion 1. Diarrhea due to excess bile acids.2. Diarrhea due to lack of digestive enzymes from the pancreas.3. Diarrhea due to insufficient enzymes from the small intestine that digest starches and milk.Alpha glucosidases deficiencies (disaccharidases)Beta glucosidase deficiency (lactase)M. E. Money. M.D.
18 Bile acid malabsorption Bile acid malabsorption can occur in patients with or without an intact gall bladderBile acid malabsorption(BAM) may affect up to % of patients with chronic diarrheaCan be treated with bile acid binding agents: Welchol, Cholestyramine, QuestranA blood test can now prove this problem but is not currently available for routine testing.Recent studies now suggest that bile can bind to starch and prevent its digestion.M. E. Money. M.D
19 Pancreatic insufficiency Pancreatic insufficiency was found in 6.1% (19/314) patients who had been diagnosed as having IBS-D by the Rome Criteria. This was determined by the measurement of the fecal elastase-1 concentration in the stool. Patients were then treated with pancreatic enzyme supplements with a statistical improvement in stool frequency, consistency, and abdominal pain.Some Patient With Irritable Bowel Syndrome May Have Exocrine Pancreatic Insufficiency. Leeds, J et al, Clinical Gastroenterology and Hepatology 2010; 8:M. E. Money. M.D
20 Carbohydrate malabsorption “Carbohydrate malabsorption and intolerance is suggested by the patient’s clinical history. The relation of symptoms to feeding and the occurrence of remission while fasting are crucial to the history. In older children and adults the symptoms can resemble those of dyspepsia or irritable bowel syndrome (IBS)…The diagnosis of functional bowel disease usually is made without evaluation of carbohydrate digestion… symptoms from IBS and carbohydrate intolerance can be confused easily”.Disaccharide Digestion: Clinical and Molecular Aspects. Robayo-Torres, C. et al; Clinical Gastroenterology and Hepatology. 2006;4:M. E. Money. M.D.
21 Digestion of starches: alpha-glucosidases Starch digestion begins in the mouth by salivary amylase, which breaks the starch into smaller units called disaccharides. These are then broken down to glucose by enzymes in the small intestine known as “alpha-glucosidases:”MaltaseIsomaltaseSucraseTrehalaseGluco-amylaseM. E. Money. M.D.
22 Carbohydrate malabsorption syndromes Milk-Lactose MaldigestionDue to Lactase deficiency,(a beta-glucosidase)Symptoms after the ingestion of milk products:Abdominal painCrampsUrgent diarrheaTime of onset: variable depending upon quantity and sensitivity of patientStarch MaldigestionDue to alpha- glucosidase(s) deficiencySymptoms after the ingestion of carbohydrates(lettuce, beans, corn, etc)Abdominal painCrampsUrgent diarrheaTime of onset: variable depending upon quantity and sensitivity of patientM. E. Money. M.D.
23 What is the current evidence for maldigestion due to alpha-glucosidases deficiency or inhibition? M. E. Money. M.D.
24 Inherited alpha-glucosidase deficiency in children 1-2% of children with severe diarrhea from birth are found to have an inherited sucrase-isomaltase disaccarhidase deficiencyRecent research by Dr. Buford Nichols (Baylor College, Houston, Texas) in collaboration with Dr. Susan Baker ( Woman and Children Hospital of Buffalo, NY ) have found 26% of children with digestion symptoms have difficulty digesting starch due to a deficiency of glucoamylase.M. E. Money. M.D.
25 Alpha-glucosidase deficiency in adults 4 papers from reported the identification of sucrase-isomaltase enzyme deficiency in adults. Symptoms were quite variable from none to constant diarrhea.Sonntag, W. M. et al, 1964, Gastroenterology 47:18.McNair, et al. 1972, Sucrose malabsorption in Greenland, Br. Med J. 2:19.Ringrose (1980) Dig. Dis. Sci. 25:384Gudmand-Høyer E.Sucrose malabsorption in children: a report of thirty- one Greenlanders.J Pediatr Gastroenterol Nutr Dec;4(6):873-7.M. E. Money. M.D.
26 Alpha-Glucosidases deficiency in patients with chronic diarrhea compared to those with indigestion In Indonesia, biopsies taken from the small intestine were examined for concentration of Lactase, Sucrase, and Maltase from 13 patients with chronic diarrhea, and compared to biopsies from 34 patients with “dyspepsia”.Results: All of enzyme concentrations from the patients with chronic diarrhea were statistically lower than those with dypepsia.Examination of small bowel enzymes in chronic diarrhea. J Gastroenterol Hepatol. Simadibrata, m., et al.18(1):M. E. Money. M.D.
27 Low carbohydrate diet and diarrhea symptoms A very low-carbohydrate diet improves symptoms and quality of life in IBS-D patientsProspective Study17 enrolled with moderate to severe IBS-DInitially had 2 weeks of standard diet, then 4 weeks of very low (20gm carbohydrate/day).13 completed the study. 10 (77%) reported adequate relief for all 4 weeks on the low carb diet; stool number decreased, QOL improved, and decrease in pain.Clin Gastroenterol Hepatol. Austin, GL; Dalton, CB; et.al June; 7(6) el.doi: /j.cghM. E. Money. M.D.
28 Alpha-glucosidase inhibition by foods and spices Laboratory studies have demonstrated glucosidase inhibition with common food substances such as cinnamon extract , certain tropical pepper spices , basil extract , certain strains of maize , certain Indian spices , the Welch onion , the Maitake mushroom, (Grifola frondosa) and chamomile tea . A consequence of glucosidase inhibition may be abdominal symptoms such as bloating and postprandial diarrhea.Quercetin (found in onions and garlic, 5x more potent than acarbose)M. E. Money. M.D.
29 Examples of food triggers among 49 “users” #%Mexican Food3674%Green Peppers1837%Cajun3367%Oranges1633%Iceberg Lettuce2755%OnionItalianBroccoliChineseGarlic1327%Ice Cream2653%BeansMilk2041%ApplesCorn1939%Tomatoes1225%
30 Alpha-glucosidase inhibition by drugs Drugs: Acarbose ( a diabetic medication to reduce absorption of carbohydrates by preventing absorption).Side effect: >30% patients experience diarrheaThe STOP-Noninsulin Dependent Diabetes Mellitus international trial from 1995 to 2001 clearly demonstrated the benefits of α-glucosidase inhibition in patients with impaired fasting blood sugar, by demonstrating a 49% relative risk reduction in the development of cardiovascular events among the acarbose users compared to the placebo group. However, 29.5% of patients assigned to acarbose, compared to 18.2% using placebo, discontinued the drug because of adverse gastrointestinal tract effects: flatulence, diarrhea, and abdominal pain .M. E. Money. M.D.
31 Mainstream treatment options for IBS-Diarrhea AntidepressantsAnticholinergics (Bentyl, Levsin, etc)Bulking agents (metamucil, etc)Chinese Herbal therapiesCholestyramineAntispasmodicsLactase supplementationAntibioticsSerotonin modulatorsAntidiarrheals drugs (Lomotil, etc)Deodorized tincture of opiumM. E. Money. M.D.
32 Potential treatment options for patients with diarrhea after meals Over the counter agents:Fiber capsules (which absorbs extra liquids)Calcium (which slows down the motility naturally),Enzyme supplement: Essential Enzymes 500 mg (by Source Natural), an over the counter supplement (1-3) before eating any “trigger meal” or daily as needed.Prescription medications from a physician:Pancreatic enzymes: examples: ZenPep 20,000 lipase, Creon 24 (1-3capsules) before eating any “trigger meal” or daily as needed.Bile acid binding drugs: Questran 1-2 packages/day; Welchol 625 mg (1-3) before eating any trigger meal or daily as needed.M. E. Money. M.D.
33 Effectiveness of pancreatic enzymes A retrospective review was recently completed of all of the patients in my practice who had the diagnosis of IBS and had been treated by me from to evaluate the effectiveness of the enzymes.278 patients had received a diagnosis of spastic colon or IBS134 excluded since they had been treated by another practitioner144 seen by me, and 104 had been offered PEZ86/104 patients returned for follow-up, and 82.5% (71) reported positive improvementM. E. Money. M.D.
34 Diarrhea predominant IBS (IBS-D): fact or fiction Dr. Saad Habba, gastroenterologist in NY, analyzed all patients seen by him over the last 8 yrs for “IBS-D”.575 patients seen, only 303 patients completed all of the studies. Of these 303 patients, 204 (68%) responded to bile acid binding agents with resolution of diarrhea.Diarrhea Predominant Irritable Bowel Syndrome-Diarrhea: Fact or Fiction. Habba,S., Medical Hypotheses 76(2011)M. E. Money. M.D
35 Working hypothesisDiarrhea occurring after meals may actually be a subclinical form of inherited or acquired maldigestion, possibly related to a bile acid malabsorption or a mild deficiency, relative ineffectiveness or suppression of one or more enzymes: amylase, lipase, the alpha-glucosidases, or others.M. E. Money. M.D.
36 SummaryThe current Rome Criteria may be limiting appropriate research and treatment for a subset of IBS-D patients who recognize the direct association of symptoms with meals or triggering foods. The relationship to meals should be sought in obtaining the history from patients.A high percentage of these patients probably have a subclinical form of maldigestion which may be substantially improved by the use of enzymes or bile acid binding agents when taken immediately before eating the “triggering meal.”M. E. Money. M.D.