1. Focus on Irritable Bowel Syndrome (IBS)
(Relates to Chapter 43, “Nursing Management: Lower Gastrointestinal Problems,” in the textbook)
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Description
Common problem affecting 10% to 15% of Western populations
Affects twice as many women as men
Characterized by intermittent and recurrent abdominal pain and stool pattern irregularities
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3. Etiology and Pathophysiology
Pain/discomfort from visceral hypersensitivity
Stool or gas in GI tract stimulates visceral afferent fibers.
Neurochemicals involved in bowel symptoms
Serotonin
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4. Etiology and Pathophysiology
Altered motility
Altered intestinal and colonic motility
Altered response to stress
Postinfectious IBS
For some patients, psychologic factors such as depression, anxiety, and posttraumatic stress disorder play a role in the pathophysiology of IBS.
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5. Clinical Manifestations
Symptoms
Diarrhea
Constipation
Alternating diarrhea/constipation
Abdominal distention
Excessive flatulence
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6. Clinical Manifestations
Symptoms (cont’d)
Bloating
Continual defecation urge, urgency
Sensation of incomplete evacuation
Fatigue
Sleep disturbances
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7. Psychosocial Factors in IBS
Common in patients with IBS
Anxiety, panic disorder
Depression
Posttraumatic stress disorder
Abuse history
Stress, psychologic factors, prior gastroenteritis, and specific food intolerances have been identified as major factors that precipitate IBS symptoms.
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8. Psychosocial Factors in IBS
Stress can exacerbate stress symptoms.
May influence health care–seeking behavior
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9. Problems Not Associated With IBS
Anemia
Fever
Persistent diarrhea
Rectal bleeding
Severe constipation
Weight loss
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10. Differential Diagnoses
Malabsorption (gluten intolerance, lactose intolerance)
Dietary factors
Infection
Colorectal cancer
Inflammatory bowel disease
Diagnostic tests are used selectively to rule out more serious disorders with symptoms similar to those of IBS.
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11. Differential Diagnoses
Psychologic disorders
Gynecologic disorders
Peptic ulcer disease
Celiac disease
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Diagnostic Studies
No specific physical findings
Diagnosis made on the basis of symptoms and by ruling out other conditions
Physical examination
Past health history
Psychosocial factors
Family history
Drug/diet history
No specific physical findings are associated with IBS. The key to accurate diagnosis is a thorough history and physical examination.
Emphasis should be placed on symptoms, past health history (including psychosocial factors such as physical or sexual abuse), family history, and drug and diet history.
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Diagnostic Studies
Standardized symptom-based criteria (Rome III criteria)
At least 3 months, with onset at least 6 months previously of recurrent abdominal pain or discomfort associated with two or more of the following:
Pain relieved by defecation
Onset of pain related to a change in stool frequency
Onset of pain related to a change in stool appearance
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Collaborative Care
Patients do better with therapy if they have
A trusting relationship with care provider
Coping mechanisms
Symptoms that are less severe/frequent
Treatment is directed at psychologic and dietary factors, and also includes medications to regulate stool output.
Encourage the patient to verbalize concerns.
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Collaborative Care
Based on dominant symptoms and their severity and on psychosocial factors
Medical management
Diet
Psychologic or behavioral options
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Collaborative Care
Consider predominant symptom pattern.
Diarrhea
Constipation
Pain
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Collaborative Care
Diet modification
Fiber therapy (20 g/day)
Antispasmodics
Antidiarrheals
Laxatives
Serotonergic agents
Antidepressants
Because treatment is often focused on symptoms, patients may benefit from keeping a diary of symptoms, diet, and episodes of stress to help identify factors that seem to trigger the IBS symptoms.
Increases in dietary fiber should be instituted gradually to avoid bloating and intestinal gas pains.
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18. Nonpharmacologic Treatments
Education and reassurance
Relaxation
Stress management techniques
Alternative therapies
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Nutritional Therapy
Eliminate gas-producing foods.
Brown beans
Brussel sprouts, cabbage, cauliflower, raw onions
Grapes, plums, raisins
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Nutritional Therapy
Eliminate fructose, sorbitol.
Determine if lactose intolerant.
Advise patient to substitute yogurt for milk products to help determine if lactose intolerance is present. Probiotics may be given, because alterations in intestinal bacterial are believed to influence symptoms.
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21. Drug Therapy: Antispasmodics
Anticholinergics
Dicyclomine (Bentyl)
Reduce colonic motility after meals.
Take before meals.
Side effects
Dry mouth, urinary retention, tachycardia
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22. Drug Therapy: Antidiarrheals
Loperamide (Imodium)
Decreases intestinal transit
Enhances intestinal water absorption and sphincter tone
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Drug Therapy
Lubiprostone (Amitiza)
For treatment of women with IBS-constipation
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24. Drug Therapy: Serotonin Agonists
5-HT3 receptor blockers
↓ Urgency, pain, and diarrhea in diarrhea-prominent women
Alosetron (Lotronex)
FDA approved for women only
Must be monitored because of potential side effects
Because of serious side effects (e.g., severe constipation, ischemic colitis), alosetron is available only through a restricted access program for women who have not responded to other IBS therapies, and in whom other anatomic and chemical abnormalities have been ruled out.
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25. Psychologic Therapies
Cognitive-behavioral therapy
Stress management techniques
Acupuncture
Hypnosis
No single therapy has been found to be effective for all patients with IBS.
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Case Study
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Case Study
31-year-old woman is seen in an outpatient clinic for abdominal pain, discomfort, bloating.
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Case Study
She has had intermittent abdominal pain for approximately 6 months.
She often misses work, where she is an administrative assistant, because of her GI symptoms, as well as fatigue.
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Case Study
She eats irregularly and often in a hurry.
She is anxious about her symptoms and is worried that she may have colon cancer, because her grandmother died of cancer.
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Case Study
She has a very stressful lifestyle.
She denies any blood in stool or diarrhea.
No change in body weight is noted, and appetite is good.
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Case Study
She states that abdominal pain and bloating are relieved by having a bowel movement.
She is often constipated, for which she takes laxatives.
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Case Study
On examination, bowel sounds are present, and her physical (BP, heart rate, temperature) and laboratory findings (WBC) are normal.
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Discussion Questions
What problems do her history and symptoms suggest?
What important teaching topics should you discuss with her?
What nutritional recommendation could you make?
1. History and symptoms are suggestive of irritable bowel syndrome (constipation type).
2. Need for education and reassurance. Keep a symptom and stool pattern diary for 1 month. Discuss strategies for reducing stress at work. Teach relaxation strategies, particularly before meals.
3. Increase fiber intake, limit gas-producing foods. Increase fiber in diet, and eliminate gas-forming foods. Follow up with health care provider to evaluate symptoms.
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