IRRITABLE BOWEL SYNDROME Joseph Zimmerman MD Gastroenterology Hadassah-Hebrew University Medical Center Jerusalem, Israel

The Irritable Bowel Syndrome (IBS) “IBS is defined by abdominal discomfort associated with altered bowel habits not explained by structural or known biochemical abnormality” ACG Position Statement 2002

IBS: The Rome III Criteria for Diagnosis Recurrent abdominal pain or discomfort at least 3 days/month in the last 3 months associated with 2 or more of the following: Improvement with defecation; Onset is associated with a change in the frequency of stool; Onset is associated with a change in form (appearance) of stool. The Rome III criteria are accepted as the diagnostic criteria for IBS. However, other diagnostic criteria were developed and used in the past. The Rome III criteria were published in 2006.

OTHER BOWEL SYMPTOMS IN IBS Abnormal stool passage (straining etc.); Passage of mucus; Bloating or feeling of abdominal distention.

IBS: Clinical Subtypes IBS is sub-classified into three types based on the primary bowel symptom: constipation: IBS-C diarrhea: IBS-D alternation between constipation and diarrhea: IBS-A Patients may shift between the various types.

EPIDEMIOLOGY OF IBS

The Irritable Bowel Syndrome Symptoms compatible with IBS are present in 7-15% of the general population. Females predominate 2:1. Most of the people who meet diagnostic criteria for IBS have never consulted a doctor for bowel symptoms (IBS nonpatients).

IBS: A Multidimensional Disorder BIOLOGICAL PSYCHOLOGICAL BEHAVIORAL

IBS is a Syndrome of Visceral Hyperalgesia Low visceral pain threshold; Normal compliance of the bowel wall; Normal threshold for SOMATIC pain (in most but not all studies); May we widespread;

CONTROLS IBS Mayer EA, Gebhart GF, Gastroenterology 1994;107:271

Is It in the Brain? Some studies have shown that IBS patients differ from control subjects in the pattern of brain activation as a response to balloon distention in the distal colon. The reported findings are inconsistent.

ABNORMAL GAS PROPULSION IN IBS Abdominal girth normally swells during the day, peaking in the late evening. This phenomenon is exaggerated in IBS. Studies using infusion of gas into the small intestine have shown that IBS patients retain more gas than controls, indicating abnormal gas propulsion.

BLOATING AND DISTENTION IN IBS During gas infusion, IBS patients, in contrast to healthy controls, involuntarily suppress their abdominal wall muscle contraction, reflecting an abnormal intestinal somatic reflex response.

IBS: Additional Clinical Features Non-Digestive Symptoms; Association with fibromyalgia. Association with other functional GI disorders; Relationship to enteric infections;

SOMATIC PAIN SCORE IBS = IBD > Normal; F=7.7; p=0.001.

URINARY SYMPTOMS SCORE IBS > IBD = normal; F=8.7; p<0.001.

SLEEP DISTURBANCES SCORE IBS = IBD > Normal; F=5.5; p<0.001

IBS: Additional Clinical Features Non-Digestive Symptoms; Association with other functional GI disorders; Relationship to enteric infections;

GI disorders of function commonly co-exist Upper GI tract Non-cardiac chest pain Heartburn Lower GI tract Gastroesophageal reflux disease (GERD) Functional abdominal pain Functional dyspepsia (FD) IBS Functional constipation/diarrhea

IBS: Additional Clinical Features Non-Digestive Symptoms; Association with other functional GI disorders; Relationship to enteric infections;

New onset of IBS symptoms following an episode of infectious enteritis Post Infectious IBS New onset of IBS symptoms following an episode of infectious enteritis

Postinfectious IBS (PI-IBS): CLINICAL FEATURES Usually diarrhea predominant; The duration of PI-IBS spans months and years following the episode of acute infectious enteritis.

Postinfectious IBS (PI-IBS): EPIDEMIOLOGY Has been described following dysentery (bacillary or amebic), campylobacter infections and salmonellosis. PI-IBS developed in 7-31% of cases.

Postinfectious IBS (PI-IBS): PATHOGENESIS HOST FACTORS PATHOGEN FACTORS Biological Psychological

Postinfectious IBS (PI-IBS): PATHOGEN FACTORS The risk varies with the pathogen. The risk associated with infections with shigella or campylobacter jejuni is 10-fold higher than that associated with salmonella.

Postinfectious IBS (PI-IBS): Risk Factors for its Development (1) FACTOR ODDS RATIO Female gender 3.4 Duration of diarrhea 0-7 days 1.0 8-14 days 2.9 15-21 days 6.5 >22 days 11.4

Postinfectious IBS (PI-IBS): HOST FACTORS Psychometric testing of patients admitted for acute gastroenteritis revealed that those who scored higher on anxiety, depression, somatization and neurotic traits during the acute illness were more likely to develop a PI-IBS. Gwee et al, Lancet 1996;347:150-53

Postinfectious IBS (PI-IBS): MUCOSAL ABNORMALITIES1 Campylobacter infection may cause mucosal changes that persist for months. These include enterochromaffin cell hyperplasia and an increase in mucosal T-lymphocyte counts. Both changes tend to be more severe in patients with PI-IBS. 1. Dunlop et al. Gastroenterology 2003;125:1651-59

Prevalence of IBS in community-based populations IBS features are highly prevalent in the population. Yet, most people with this “trait” do not consult a doctor for bowel symptoms.

WHAT MAKES A PERSON WITH THE IBS ”TRAIT” BECOME AN IBS PATIENT?

PSYCHOLOGICAL FACTORS; STRESSFUL LIFE EVENTS; BEHAVIORAL FACTORS;

The Irritable Bowel Syndrome: Psychological Profile of Patients No pattern of psychological symptoms is unique to patients with IBS. IBS patients tend to score high in somatization, obsessive-compulsive, depression, anxiety and hostility scales. In some studies, the proportion of patients meeting a criterion for a psychiatric diagnosis is 54-100%.

The Irritable Bowel Syndrome: Stressful Life Events (1) Acute induction of pain or emotional arousal increases the motility of the distal colon under experimental conditions. This response is exaggerated in IBS patients1. Exacerbation of symptoms is frequently associated with psychological stress. 1. Welgan et al., Gastroenterology 94: 1150, 1988

The Irritable Bowel Syndrome: Sressful Life Events (2) Studies of the prevalence of stressful life events in IBS patients have yielded inconsistent results. Loss of a parent in childhood is an important factor1. A history of physical or sexual abuse, particularly at a young age, is significant. 1. Lowman et el. , J Clin Gastroenterol 9:324, 1987

The Irritable Bowel Syndrome: ILLNESS BEHAVIOR IBS PATIENTS: Make 2-3 times as many visits to doctors for non-GI complaints than controls1. Are more likely to have surgery. 1. Drossman et el. , Dig Dis Sci 38:1569 , 1993

IBS and Surgery Of 89,009 HMO members, patients diagnosed with IBS (5.2%) were significantly more likely to undergo the above operations: CHOLECYSTECTOMY: A 3-fold higher rate; APPENDECTOMY: A 2-fold higher rate; HYSTERECTOMY: A 2-fold higher rate; BACK SURGERY: A 50%-fold higher rate. Longstreth GF et al. Gastroenterology 2004:126;1665

IBS: ECONOMIC ASPECTS IBS is associated with costs because of: Days lost from work; Excess physician visits; Excess diagnostic testing; Excess use of medications; In the USA, the estimated annual cost of IBS is 8 billion dollars.

IBS AND QUALITY OF LIFE

A higher score indicates a better health status.

IBS: Differential Diagnosis CHO maldigestion (i.e. lactase deficiency) Inflammatory Bowel Diseases Celiac disease Laxative abuse syndrome Panic disorder Parasitic infections Carcinoma of colon Other conditions

IBS: What is against this diagnosis? Onset after the age of 50; Significant weight loss; Prominent nocturnal symptoms; Rectal bleeding, anemia;

IBS: Clinical Workup Lab: CBC, ESR, CRP, TSH levels; Serological tests for celiac disease; Fecal occult blood; Stool microscopy (in IBS-D) ; Sigmoidoscopy;

Irritable Bowel Syndrome The Management of Irritable Bowel Syndrome (IBS)

IBS Management - General Reassurance and explanation of the nature of the problem: IBS is a recognized clinical entity; symptoms can fluctuate; diet or stress may precipitate symptoms. Dietary counseling (fiber supplementation with psyllium); Symptomatic treatment: antispasmodics (papaverine, mebeverine), anti diarrhea agents etc. Guidelines to assist the physician in the management of the patient with IBS have been presented by the American Gastroenterological Association (AGA) in the form of a Medical Position Statement. As a general approach the recommendations are that the physician should establish an effective therapeutic relationship, educate and reassure the patient, and help with dietary and lifestyle modifications when needed. (Patient Care Committee, AGA, 1997). More specific advice is provided by Drossman et al in their review upon which the Position Statement was based. In addition to carrying out a complete history, physical examination and a cost-efficient investigation, a number of ‘must do’ steps are listed. The following are a couple of examples. The patient’s understanding of IBS and their concerns about the condition should be determined and a thorough explanation of the disorder be given. Education about IBS may, for example, include an explanation that the symptoms are very real. Involving the patient in their treatment by encouraging the keeping of a diary to monitor symptoms can also prove beneficial. In doing so, patients may identify trigger factors, such as diet or some stressful event not previously recognised as being associated with the symptoms of IBS. The physician may then be able to help by reviewing factors that potentiate the condition and, with the patient, consider diet, lifestyle, or behavioural modifications. References: Patient Care Committee, AGA. American Gastroenterological Association Medical Position Statement: Irritable bowel syndrome. Gastroenterology 1997; 112: 2118-9. Drossman DA, Whitehead WE, Camilleri M. Irritable bowel syndrome: A technical review for practice guideline development. Gastroenterology 1997; 112: 2120-37.

Management of Refractory Patients Antidepressants Psychological Treatments: Hypnotherapy Cognitive Behavioral Therapy (CBT) Guidelines to assist the physician in the management of the patient with IBS have been presented by the American Gastroenterological Association (AGA) in the form of a Medical Position Statement. As a general approach the recommendations are that the physician should establish an effective therapeutic relationship, educate and reassure the patient, and help with dietary and lifestyle modifications when needed. (Patient Care Committee, AGA, 1997). More specific advice is provided by Drossman et al in their review upon which the Position Statement was based. In addition to carrying out a complete history, physical examination and a cost-efficient investigation, a number of ‘must do’ steps are listed. The following are a couple of examples. The patient’s understanding of IBS and their concerns about the condition should be determined and a thorough explanation of the disorder be given. Education about IBS may, for example, include an explanation that the symptoms are very real. Involving the patient in their treatment by encouraging the keeping of a diary to monitor symptoms can also prove beneficial. In doing so, patients may identify trigger factors, such as diet or some stressful event not previously recognised as being associated with the symptoms of IBS. The physician may then be able to help by reviewing factors that potentiate the condition and, with the patient, consider diet, lifestyle, or behavioural modifications. References: Patient Care Committee, AGA. American Gastroenterological Association Medical Position Statement: Irritable bowel syndrome. Gastroenterology 1997; 112: 2118-9. Drossman DA, Whitehead WE, Camilleri M. Irritable bowel syndrome: A technical review for practice guideline development. Gastroenterology 1997; 112: 2120-37.

HYPNOTHERAPY FOR IBS

HYPNOTHERAPY IN IBS LONG-TERM RESULTS

GAS-PAIN DIARRHEA CONSTIPATION PSYCHOLOGICAL DISTRESS

Effects of hypnotherapy on colonic motility

Sometimes, it is more important to know what kind of patient has the disease, than what kind of disease the patient has. Sir William Osler (1849-1919)