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Irritable Bowel Syndrome
Dr Max Groome Consultant Gastroenterologist Ninewells Hospital, Dundee
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Irritable Bowel: Outline
What is the best way to identify IBS patients? What are the minimum number of relevant Ix? What is the best management?
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IBS: Background Chronic, relapsing problem Abdo pain Bloating
Change in bowel habit 10-20% population Peaks in 30’s – 40’s Females >males (2:1)
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Pathophysiology of IBS
Genes + Environment Disturbed GI motility; high-amplitude propagating contractions - exaggerated gastro-colic reflex, pain Visceral hypersensitivity
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Visceral pain sensation
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Descending inhibitory pathways
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Visceral hypersensitivity
Seen in 2/3 patients (gut distension studies) Mechanisms Peripheral sensitisation: Inflammatory mediators up-regulate sensitivity of nociceptor terminals Central sensitisation: Increased sensitivity of spinal neurones
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Evidence of hypersensitivity?
Peripheral: Up to 20% recall onset after infectious gastroenteritis Central: Increased pain radiation to somatic structures eg fibromyalgia
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Rome III criteria Recurrent abdo pain/discomfort for at least 3 days per month for 3 months + 2 or more of: Improvement with defecation Onset assoc. with ∆ stool frequency Onset assoc. with ∆ stool form (appearance)
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Additional clues... Bloating Urgency Sensation of incomplete emptying
Mucus per rectum Nocturia (and poor sleep) Aggravated by stress
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Association with other illnesses
Fibromyalgia Chronic fatigue syndrome Temporomandibular joint dysfunction Chronic pelvic pain Overlap cases likely to have more severe IBS, psychiatric problems
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Psychological features
At least 50% are depressed/anxious/hypochondriacal In tertiary centres, 2/3 have depression/anxiety
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Irritable Bowel Concept
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What is best way to identify IBS patients?
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History A good history will make the diagnosis: Bowel habit
Bloating, nocturia Diet (bread, fibre, meal times, bizarre exclusions) Trigger factors (infection, menstruation, drugs) Opiate use (codeine and Opiate/Narcotic bowel syndrome) Psychosocial factors (stress) Underlying fears (‘cancer’)
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Alarm features Age > 50 Short duration of symptoms
Woken from sleep by altered bowel habit Rectal bleeding Weight loss Anaemia FH of colorectal cancer Recent antibiotics
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What are the minimum number of relevent investigations?
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Investigations FBC ESR / plasma viscosity CRP
Antibody testing for coeliac disease (TTG) Lower GI tests if aged >50 or strong FH of CRC
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What is the best management plan?
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Treatment of IBS Diet Regular meal times Reduce fibre Drugs:
Stop opiate analgesia anti-diarrhoeals Anti-spasmodics Anti-depressants
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Fibre and IBS NICE guidance 2008:
Evidence for ‘weak’ , ‘inconclusive’, ‘may be detrimental’ Suggest: ‘review fibre intake, adjusting (usually reducing) while monitoring symptoms. If fibre is necessary – suggest oats’
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Stop opiates With prolonged use can lead to ‘opiate/narcotic bowel syndrome’: Worsening pain control despite escalating dose Reliance on opiates Progression of frequency, duration and intensity of pain No GI explanation for pain
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Anti-spasmodics (Mebeverine, Hyoscine)
Poor quality studies Metanalysis:* Global benefit vs placebo (NNT 5.5) Relief of pain vs placebo (NNT 8.8) No benefit for diarrhoea / constipation *Poynard T Alimentary Pharm & Ther 2001
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Laxatives Fibre aggravates pain
Stimulant laxatives eg Senna not a long-term solution (tachyphylaxis) Lactulose promotes flatulence PEG-based laxatives > lactulose* *Attar A Gut 1999
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Anti-diarrhoeals Loperamide (tablets or syrup) Opiate analogue
inhibits peristalsis, gut secretions Benefits diarrhoea. No effect on pain. No dependency Use PRN / prophylactic Cann P 1984 Dig Dis Sci.
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Anti-depressants Tricyclics eg Amitriptyline Reduce diarrhoea
Reduce afferent signals from gut (‘central analgesics’) Helps restore sleep pattern Fits with ‘neuroplasticity’ theories: Loss of cortical neurones in psychiatric trauma Brain-derived neurotrophic factor increases with Rx (pre-cursor of neurogenesis) Low dose 10 – night (NNT 5.2)* Side effects limit use (NNH 22) *Drossman DA 2003 Gastroenterology
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Psychological treatment
If severe anxiety / depression If no response to empiric anti-depressants Options: Relaxation therapy Cognitive Behavioural therapy Hypnosis (moderate efficacy)
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Irritable Bowel: Conclusions
What is the best way to identify IBS patients? What are the minimum number of relevant Ix? What is the best management?
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What does the patient want?
Support and understanding Clear explanation that IBS is an illness Symptoms can be controlled by the patient There is no miracle cure There will be good days and bad Explanation of treatment options BSG IBS Guidelines 2007
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Loperamide / movicol / anti-spasmodic
Summary of management Careful history Positive diagnosis of IBS Simple management plan: Diet Symptom relief: Loperamide / movicol / anti-spasmodic Amitriptyline
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Further reading BSG IBS Guidelines 2007 NICE IBS Guidance 2008
AGA technical review 2002
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