1. 1- Irritable Bowel Syndrome (IBS) 2- Constipation
By Dr. Zahoor

2. Irritable Bowel Syndrome (IBS)
Irritable bowel syndrome or spastic colon, is functional bowel disorder and symptom based diagnosis
It is commonest Functional Gastrointestinal Disorder (FGID)
Why we say functional?
Because symptoms occur in the absence of any demonstrable abnormalities in the digestion, absorption of nutrients, fluid and electrolyte. There is no structural abnormality in GIT.
IBS has no known organic cause

3. Irritable Bowel Syndrome (IBS)
Symptoms
Chronic abdominal pain
Abdominal discomfort, blotting
Alteration of Bowel habits
Rectal mucus
Diarrhea or constipation may predominate or they may alternate (IBS-D, IBS-C or IBS-A)
Nocturnal symptoms are rare

4. Irritable Bowel Syndrome (IBS)
Onset of IBS Symptoms
Symptoms usually occurs after infection – post infection bile salt mal absorption
Use of antibiotic
Alteration in immune system
Emotions, depression, anxiety can effect GIT function
Psychological stress can increase GIT symptoms

5. Irritable Bowel Syndrome (IBS)

6. Biopsychosocial Concept of GIT disorders

7. Irritable Bowel Syndrome (IBS)
In western world, 1 in 5 people report symptoms consistent with IBS
Up to 40% of all patient seen in specialist gastroenterology clinic will have IBS
Female patients out number male patient

8. Irritable Bowel Syndrome (IBS)
IBS is multi system disorder
IBS patient suffer from many non intestinal symptoms

9. Irritable Bowel Syndrome (IBS)
Diagnostic Criteria
In preceding 3 months, there should be at least 3 days per month of recurrent abdominal pain or discomfort associated with
1. Improvement with defecation
2. On set associated with a change in frequency of stool
3. Change in form (appearance) of stool
Note – Rule out other condition that produce IBS – like symptoms e.g. parasitic infection, celiac disease, lactose intolerance , inflammatory bowel disease

10. Irritable Bowel Syndrome (IBS)
Investigation
Investigations are done to exclude other conditions
Stool microscopy and culture (to exclude infectious conditions)
Blood test – full blood examination, ESR, LFT
Abdominal ultrasound (to exclude Biliary tract disease)
Endoscopy and biopsy (to exclude celiac disease, inflammatory bowel disease)

11. Irritable Bowel Syndrome (IBS)
IBS Treatment
Therapies target central and end organ pathways
End organ treatment ( GIT )
- Diet - High fiber diet
- Anti diarrheal drugs e.g. Loperamide
- Treat constipation – 5HT4 receptor agonist e.g. prucalopride
- Smooth muscle relaxant for pain e.g. mebeverine hydrochloride

12. Irritable Bowel Syndrome (IBS)
Central Treatment
- Psychotherapy
- Anti depressant e.g. Amitriptylline, Clomipramine

13. Management of Irritable Bowel Syndrome

14. FUNCTIONAL DIARRHOEA

15. FUNCTIONAL DIARRHOEA
In this form of functional bowel disease, symptoms occur in the absence of abdominal pain
Symptoms commonly are
- Passage of several stools in rapid succession usually first thing in the morning
- No further motion may occur that day or defecation occurs after meals

16. FUNCTIONAL DIARRHOEA
Symptoms (cont) - The first stool of the day is usually formed, later ones are mushy, loose or watery - Urgency of defecation - Anxiety - Exhaustion after defecation

17. FUNCTIONAL DIARRHOEA Treatment Loperamide
Tricyclic antidepressant at night e.g. Clomipramine mg
Note – If there are atypical features e.g. large volume stool, rectal bleeding, weight loss, nutritional deficiency then more investigations should be done

18. CONSTIPATION

19. We will study Colon & Rectum first
The colon and rectum
Structure (important points)
The large intestine starts at caecum
Colon is made up of ascending, transverse, descending and sigmoid colon which join the rectum

20. Structure of Large Intestine

21. Colon and Rectum
The mucosa of colon is lined by epithelial cells with crypts but no villi, so that surface is flat
Mucosa is full of goblet cells
Colon is innervated by enteric nervous system with input from parasympathetic and sympathetic pathways

22. Colon and Rectum Physiology of colon
Main role of colon is absorption of water and electrolytes
Propulsion of contents from caecum to the anorectal region
Peristalsis is induced by release of serotonin (5-HT) from neuroendocrine cells in response to luminal distension
Normal colonic transit time is 24 to 48 hours with normal stool weight up to 250 g/day

23. Colon and Rectum Physiology of defecation Role of rectum and anus
Rectum is normally empty
Stool is propelled into the rectum by colonic contraction
Desire to defecate and urgency to defecate are experienced with increasing volume of rectal content (threshold 100ml)

24. Colon and Rectum Physiology of defecation ( cont)
These sensation are associated with rectal contraction and relaxation of internal anal sphincter, both of which push the stool down in to the proximal anal canal
This increases the defecation urge, which can be suppressed by vigorous contraction of external sphincter and Puborectalis muscle

25. Constipation
Constipation is very common symptom, particularly in women and elderly
Constipation is defined as
- infrequent passage of stool - less than 3 times per week
- passage of hard stools – straining more than 25% of time
- incomplete evacuation

26. Constipation
Constipation may affect more than 1 in 5 of the population
Patient may attribute many symptoms to constipation e.g. headache, malaise, nausea, bad taste in mouth
Other symptoms abdominal blotting or discomfort, perianal pain

27. Causes of Constipation

28. Constipation Assessment of Constipation
Constipation can be classified into Three broad categories:
1. Normal transit through colon (59%)
2. Defecatory Disorder (25%)
3. Slow transit (13%)

29. Constipation 1- Normal Transit Constipation
Stool traverses the colon at normal rate but there is passage of hard stool
2. Defecatory Disorder
They are mainly due to dysfunction of anal sphincter and pelvic floor e.g. mucosa of anterior rectal wall prolapses downward during straining
3. Slow Transit
Occurs predominantly in young women who have infrequent bowel movement

30. Constipation Treatment Treat the underlying cause
In Normal and Slow transit constipation, the main focus should be on increasing fiber content of the diet and increase fluid intake

31. Constipation Treatment ( cont ) Laxative and Enemas
1. Bulk forming laxative
- Dietary fiber
- Methyl cellulose
- Ispaghula husk
2. Stimulant laxative (stimulate gut motility)
- Bisacodyl
- Phenolphthalein
3. Osmotive Laxative
- Lactulose

32. Constipation Treatment ( cont) Suppositories Bisacodyl Glycerol Enemas
Arachis oil

33. Thank you