IRRITABLE BOWEL SYNDROME Barbara L. Slee, M.D.

IBS Epidemiology and pathophysiology Symptoms and signs of Dx Appropriate Work-up Treatment

Definition of IBS Benign GI disorder Chronic abdominal pain Altered bowel habits Absence of organic causes

Epidemiology Incidence: 10-15% pop. Most common GI disorder 2:1 female/male Younger patients 2 nd highest cause of missing work $2-8 billion

Pathophysiology Altered GI motility Visceral afferent hypersensitivity Psychosocial dysfunction

Clinical Presentation?

Clinical Presentation Chronic episodic abdominal pain Cramping Pain relieved by defecation Looser, more frequent stools Diarrhea, constipation, or alternating Mucous in stool

Clinical Presentation Bloating, gas Dyspepsia, Nausea Atypical chest pain Symptoms worse during stressful time Normal Exam

Diagnosis Criteria Manning Rome I Rome II –12 or more wks of abd pain –+2 or more of following Relieved by defecation Change in frequency Change in form

Alarm symptoms or Red Flags?

Alarm Symptoms (Red Flags) Anemia Family history colon CA or IBD Fever Nocturnal symptoms

Red Flags (con’t) Bleeding >10 lb wt loss Recent Antibiotic Severe chronic diarrhea > age 50

Work-up for IBS 27 y/o female pt Intermittent, crampy abdominal pain Stool urgency, relief of pain with BM No alarm findings What studies?

REC. W/U for IBS Pretest probability of organic disease <1% Same in healthy controls

Diagnostic Studies in IBS: CBC, Chem 14 Stool O&P – if diarrhea, endemic infection +/- TSH – severe diarrhea +/- hemoccult +/- ESR (younger pt) Colonoscopy – age >50

Screen for Celiac Dz Incidence in IBS = 5% Healthy controls <1% If diarrhea predominant sx - –Antigliadin Ab, antimysial Ab –Upper endoscopy with Biopsy if suspicious and Abs negative

Treatment How do you want to Treat your patient?

Treatment: Doctor –patient relationship Education Reassurance Chronic benign nature

Dietary – Food exclusions Lactose Fructose Foods that increase flatulence Caffeine Any food they find increases their sxs

Medication: Adjunct only Avoid chronic use Use based on predominant symptoms Lack of convincing evidence of efficacy

Pain Sx: Anti-spasmotics –Bentyl –Hyoscymine – Levsin, Symax TCA’s –Low dose –Decrease visceral sensitivity, motility, secretions

Diarrhea predominant sx: Loperimide (lomotil) prn Cholestyramine (questran) Ondansetron (Zofran) 5HT3 antagonist Alosetron (Lotronex) 5HT3 antagonist

Constipation predominant sx: Fiber 25 g/day Tegaserod (Zelnorm) HT4 Agonist –Studies valid for efficacy in women only

Cost of Medication Zelnorm 2mg or 4 mg$100/mo Lotronex 1 mg 252/mo Zofran 8 mg 1277/mo

Pychotherapy: Symptoms unresponsive Impair health related quality of life Co-morbid psychological diagnosis History of Physical or sexual abuse Learned patterns of illness behavior

Psychotherapy Mental health professional part of Treatment Team No one Psych therapy modality superior

Summary Etiology is unclear IBS pathophysiology is multifactorial Diagnosed by H&P Requires minimal lab evaluation in absence of Alarm symptoms

Summary Treatment is first reassurance and non- pharmacological measures Pharmacotherapy is used when needed and for brief periods only

Handouts Text of lecture Criteria for Diagnosis of IBS Treatment Strategy Chart for IBS from NEJM, Irritable Bowel Syndrome: Review Article Nov. 27, 2003 Cover Article from AFP Nov. 15, 2002, Management of Irritable Bowel Syndrome by Anthony Viera and Steve Hoag

References 1. Evidence-Based Position Statement on the Management of Irritable Bowel Syndrome in North America; ACG, American Journal of Gastroenterology, Vol. 97 No. 11 Suppl., Systematic Review on the Management of Irritable Bowel Syndrome in North America; L.J. Brandt, M.D., chairman, David Bjorkman, M.D., M. Brian Fennerty, M.D. et. al, The American Journal of Gastroenterology, Vol. 97, No.11, Suppl., 2002

References 3. Schoenfeld, MD, Philip, Efficacy of Current Drug Therapies in Irritable Bowel Syndrome: What Works and Does Not Work. Gastroenterology Clinics of North America, 34 (2005) Anthony Viera, Steve Hoag, Lt. MC. Management of Irritable Bowel Syndrome, AFP Nov. 15, AGA Guideline: Irritable Bowel Syndrome, Gastroenterology 2002; 123:2105

References 6. Anddrew B. chun, M.D., Steven Desautels, MD, Arnold Wald, MD. Clinical Manifestations and diagnosis of Irritable Bowel Syndrome, UpToDate. Online Sanders DS, Carter MJ, et al. Irritablae Bowel Syndrome Was significantly Associated with Celiac Disease: Update in Gastroenterology and Hepatology. Annals of Internal Medicine, Sept. 7, 2004.

Other Interesting Reading: 1. The Role of Food Intolerance in Irritable Bowel Syndrome, Raichard Lea, Peter Whorwell, MD. Gastroenterology Clinics of North America 34 (2005) Probiotics: An Ideal Anti-inflammatory Treatment for IBS? Editorial, Gastroenterology Vol. 128 No. 3