Presentation is loading. Please wait.

Presentation is loading. Please wait.

Models of care in IBS. Outline Complex aetiology Pain sensitizers Clues to an organic disease: serotonin Other theories Proven therapies FODMAPs NICE.

Similar presentations


Presentation on theme: "Models of care in IBS. Outline Complex aetiology Pain sensitizers Clues to an organic disease: serotonin Other theories Proven therapies FODMAPs NICE."— Presentation transcript:

1 Models of care in IBS

2 Outline Complex aetiology Pain sensitizers Clues to an organic disease: serotonin Other theories Proven therapies FODMAPs NICE guidance Models of care – Expectations of secondary care – Weaknesses of secondary care – Cases

3 Genes Early learning Family influences Susceptible individual External stressors IBS symptoms Psychological disturbance Physiological disturbance Adverse life events Chronic psychological stress Gastrointestinal infection Changes in diet Aetiology:biopsychosocial model Slide courtesy of Prof Robin Spiller

4 Rome III Criteria Recurrent abdominal pain or discomfort at least 3 days/month in the last 3 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 – * Criterion fulfilled for the last 3 months with symptom onset – at least 6 months prior to diagnosis Recurrent abdominal pain or discomfort at least 3 days/month in the last 3 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 – * Criterion fulfilled for the last 3 months with symptom onset – at least 6 months prior to diagnosis

5 Brain functional MRI showing regions activated during endogenous pain modulation by heterotopic stimulation (painful rectal distension with foot cold pain) in healthy controls. Wilder-Smith C H Gut 2011;60: Copyright © BMJ Publishing Group Ltd & British Society of Gastroenterology. All rights reserved. Pain regulation I

6 Pain regulation II “A majority of patients with IBS have diminished pain inhibition or even pain facilitation compared with healthy controls. “ “Brain imaging during specific activation of endogenous pain modulation demonstrates a fairly consistent functional hub of mainly frontal, limbic and brainstem modulatory regions in healthy humans.” “ Patients with IBS have a different pattern of activation and a correlation between the imaging and sensory changes. “ Wilder-Smith C H Gut 2011;60:

7 Factors potentially driving changes in endogenous pain modulation in visceral pain syndromes. Wilder-Smith C H Gut 2011;60: Copyright © BMJ Publishing Group Ltd & British Society of Gastroenterology. All rights reserved. Pain regulation III

8 More than gut

9 The search for an ‘organic’ basis - Serotonin Camilleri Gut 2002;51:i81-i86 doi: /gut.51.suppl_1.i81 Serotonergic modulation of visceral sensation: lower gut

10 Effect of alosetron 1 mg twice daily and placebo on adequate relief of pain (A) and stool consistency (B) in female patients with symptoms of diarrhoea. Camilleri M Gut 2002;51:i81-i86 Copyright © BMJ Publishing Group Ltd & British Society of Gastroenterology. All rights reserved.

11 Effect of alosetron 1 mg twice daily and placebo on adequate relief of pain (A) and stool consistency (B) in female patients with symptoms of diarrhoea. Camilleri M Gut 2002;51:i81-i86 Copyright © BMJ Publishing Group Ltd & British Society of Gastroenterology. All rights reserved. Tegaserod WITHDRAWN 2007 Alosetron WITHDRAWN 2000 (reinstated 2002)

12 Numerous investigations possible IBS-D Bile salt malabsorption – Sehcat scan; present in 10% Small bowel overgrowth – Hydrogen breath test Wedlake et al, APT 2009 (n=1223), 15 trials

13 Candida overgrowth Professor takes an individualised broad-based and holistic approach to each patient.... [However] when this is ineffectual, such as may be the case in patients with the Irritable Bowel Syndrome, then he does not hesitate to try unconventional treatments such as wheat-free diets (effective for bloating in IBS) and mould free diets (effective for the Intestinal Candida Syndrome), etc. In the most resistant cases he has established a sound collaboration with medically-trained homeopaths...

14 What definitely works: TCA Effect of tricyclic antidepressants on “overall symptom improvement with therapy.” Trials included used a validated pain scale to quantify improvement

15 TCA Effect of tricyclic antidepressants on abdominal pain scores

16 Cognitive-Behavioural therapy Meta-analysis of the efficacy of cognitive behaviour therapy: (50% reduction of symptoms) gave an odds ratio of 12 (95% confidence interval 5.56 to 25.96) in favour of cognitive behaviour therapy, with a number needed to treat of 2.16.

17 CBT AuthorsSizeDescriptionResults Bennett and Wilkinson RCT; 12 CBT, 12 usual careEight week package: stress management training, cognitive therapy, and contingency management v medical treatment Anxiety reduced in treatment group but not in control group; both achieved improvement in IBS symptoms, restriction of activities, and fatigue Lynch and ZambleRCT; 12 CBT, 12 waiting listCoping skills, assertiveness training, education, and progressive relaxation v waiting list controls Significantly greater improvement of IBS symptoms and anxiety in treatment group Guthrie et alRCT; n=102Psychotherapy v “supportive listening,” 12 week study. After study, 33 patients from control group accepted Psychotherapy Psychotherapy significantly superior in terms of physical and psychological symptoms. Results sustained at 12 month follow-up Boyce et alRCT; n=105Three arm trial: all groups received standard care, plus either CBT or relaxation training.Patients with “resistant IBS” not included Significant improvements for all groups in IBS symptoms, physical/social functioning and general wellbeing, but no significant differences between groups. Greene and Blanchard RCT; 10 CBT, 10 symptom monitoring Individualised CBT for 10 sessions v daily gastrointestinal symptom monitoring over eight weeks 80% of treatment group showed clinical improvement compared with 10% of controls.

18 CBT AuthorsSizeDescriptionResults Bennett and Wilkinson RCT; 12 CBT, 12 usual careEight week package: stress management training, cognitive therapy, and contingency management v medical treatment Anxiety reduced in treatment group but not in control group; both achieved improvement in IBS symptoms, restriction of activities, and fatigue Lynch and ZambleRCT; 12 CBT, 12 waiting listCoping skills, assertiveness training, education, and progressive relaxation v waiting list controls Significantly greater improvement of IBS symptoms and anxiety in treatment group Guthrie et alRCT; n=102Psychotherapy v “supportive listening,” 12 week study. After study, 33 patients from control group accepted Psychotherapy Psychotherapy significantly superior in terms of physical and psychological symptoms. Results sustained at 12 month follow-up Boyce et alRCT; n=105Three arm trial: all groups received standard care, plus either CBT or relaxation training.Patients with “resistant IBS” not included Significant improvements for all groups in IBS symptoms, physical/social functioning and general wellbeing, but no significant differences between groups. Greene and Blanchard RCT; 10 CBT, 10 symptom monitoring Individualised CBT for 10 sessions v daily gastrointestinal symptom monitoring over eight weeks 80% of treatment group showed clinical improvement compared with 10% of controls.

19 FODMAPs Fermentable, Oligo-, Di- and Mono-saccharides and Polyols, Evidence suggests that reducing global intake of FODMAPs to manage functional gut symptoms provides symptom relief for about 75% of patients with FGDs. Despite its apparent complexity, the FODMAPs approach can be effective when delivered by a dietitian skilled in its intricacies. Patient compliance with this diet is very good, likely due to quality-of-life improvements Gibson PR, Shepherd SJ. Evidence-based dietary management of functional gastrointestinal symptoms: The FODMAP approach. J Gastroenterol Hepatol. 2010;25(2): Shepherd SJ, Parker FC, Muir JG, Gibson PR. Dietary triggers of abdominal symptoms in patients with irritable bowel syndrome: Randomized placebo-controlled evidence. Clin Gastroenterol Hepatol. 2008;6(7):

20 FODMAPs Fructans Oligosaccharides made of fructose molecule chains that are completely malabsorbed Can contribute to bloating, gas, and pain. Wheat accounts for the majority of fructan intake. Galactans Galactans are oligosaccharides containing chains of the sugar galactose. Dietary sources of galactans include lentils, chickpeas, kidney beans, black-eyed peas, broccoli, and soy-based products. Polyols Sugar alcohols. Too large for simple diffusion from the small intestine, creating a laxative effect on the GI tract. They are found naturally in some fruits and vegetables and added as sweeteners to sugar- free gums, mints, cough drops, and medications.

21 NICE guidance - 1 First-line pharmacological treatment – Choose single or combination medication based on the predominant symptom(s). – Consider offering antispasmodic agents - alongside dietary and lifestyle advice. – Laxatives for constipation, but discourage use of lactulose. – Offer loperamide as the first choice of antimotility agent for diarrhoea. – Advise people how to adjust doses of laxative or antimotility agent according to response, shown by stool consistency. The aim is a soft, well-formed stool.

22 NICE guidance - 2 Second-line pharmacological treatment – Consider tricyclic antidepressants (TCAs) for their analgesic effect if first-line treatments do not help. – Start at a low dose (5–10 mg equivalent of amitriptyline) taken once at night and review regularly. – The dose may be increased (but should not usually exceed 30 mg). – Consider selective serotonin reuptake inhibitors (SSRIs) only if TCAs are ineffective. – Take into account the possible side effects of TCAs and SSRIs. – If prescribing these drugs for the first time, follow up after 4 weeks and then every 6–12 months.

23 Expectations of primary care Make positive diagnosis and prescribe trial of first line therapy Clarify the psychological context Identify difficult to treat cases If confident of diagnosis, commence TCA therapy

24 Expectations of secondary care Make a positive diagnosis and be honest Do not over-investigate Set out a management plan to facilitate ongoing care in the community Decide who to refer to psychologist Identify who to refer to tertiary centre

25 Weaknesses of secondary care Not many gastroenterologists are interested in the disease There may be an empathy problem (easy for cancer and Crohn’s, not so for something we can’t see, feel or understand) If psychological support and continuity are important aspects, a ‘normal’ clinic is not the best place to access them

26 So, what do we really think our role is? Exclude ‘serious’ disease Assess severity of the case Deliver a ‘positive’ diagnosis and conceptual model Start the ball rolling and provide a basic route map....and discharge

27 But not: Regular assessments of response Titration of TCA De facto psychological therapy in the clinic

28 Example cases 1 2 3

29 Case 1 20 year old Previously seen at another hospital 2009 Longstanding abdominal pain and bloating Episode gastroenteritis in South America treated with antibiotics (U/S) Sx worse with wheat

30 Case 1 AXR – fecal loading +++ MRI small bowel - normal Treated with Movicol End 2009 – re-referred Long discussion about IBS and laxatives Dietician review

31 Case 1 Review in clinic Now more confident in managing constipation and no need for further follow-up

32 Case 2 Very worried man 2007 – abnormal LFTs, foul wind and abdominal pain. Liver biopsy –nil of concern 2008 – foul wind, something inside – he feels he needs an endoscopy – not organised 2008 – re-referred new consultant - colonoscopy NAD

33 Case 2 New consultant- requesting second opinion – very angry, something is wrong and no-one will help. Wants an MRI abdo. Has been seen by many consultants in more than one hospital.

34 Case 2 Main symptoms: abdominal bloating, worse when walking or lifting and feels that all his symptoms started after he tried herbal body enhancers approximately 4 years ago. Abnormal liver function tests but has had a normal liver biopsy and has found that Amitriptyline, a wheat-free diet, a dairy-free diet and a Dietitian review have been unhelpful. In addition to this 3 ultrasounds, colonoscopy and an OGD that he has had, although they have not revealed any significant abnormality, do still leave him concerned

35 Case 2 Rebook appointment – ask for relative to be present. MRI organised as contract – no further investigations Explain – irritable bowel to both Attitiude starts to change Controlled in secondary care.. for now.

36 Case 3 Mild asthma & bronchomalacia, overweight – bariatric surgery – may help with airway control Background – fibromyalgia, depression, cholecystectomy Post operative C Diff Subsequent severe diarrhoea

37 Case 3 Had already tried – probiotics, loperamide, cholestyramine, some benefit from codeine. Colonoscopy NAD, surgeon says short bowel not possible Extreme distress – over course of time has SeCHAT (borderline but no benefit from treatment), CT, and MRI – all normal

38 Case 3 LFTs obstructive – no suggestion of stones on MRCP, liver fatty on U/S Suggestion post infective irritable bowel – dietician, amitryptilline – do not control UCH suggest creon as stool fatty, with no benefit (fecal elastase normal)

39 Case 3 Extreme distress and some pathology Referral to tertiary centre They say…….. Creon + PPI Treat for bacterial OG Treat with clonidine in case of autonomic dysfunction Try octreotide

40 Summary Can be very challenging Require time that is often not available Try not to over-medicalize Psychological support can help Dietary modification How to deal with false expectations Return onus of control to patient.


Download ppt "Models of care in IBS. Outline Complex aetiology Pain sensitizers Clues to an organic disease: serotonin Other theories Proven therapies FODMAPs NICE."

Similar presentations


Ads by Google