Transcript Irritable Bowel Syndrome

By Tara Nowakhtar
DidacticsOnline.com
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24 year old female presents with
the following symptoms
 Crampy feeling (abdominal pain),
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varying intensity, intermittent
Stress and eating exacerbate pain
Bowel movement relieves pain
Alternating diarrhea & constipation
Bloated/gassy feeling
Gastroesophageal reflux (“heart
burn”)
Dyspareunia, fatigue
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Pt has had these symptoms for several days a
month in the last 6 months
PMHx: depression, anxiety
SHx: appendectomy
PE:
 Abdomen tender to palpation in all 4 quadrants
with significant guarding
 Abdomen sounds tympanic on percussion
 Global fascial tightness throughout abdomen
 Paraspinal changes at T9-T10
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IBS is an intrinsic colonic motility disorder
with several plausible causes: loss of
tolerance to GI flora, genetic factors,
environmental triggers
MC functional bowel disorder
F>>M
Risk factors:
 Hx of childhood sexual abuse
 Domestic abuse in women
 Increased stress, depression, anxiety
No pathognomonic pattern of gut dysmotility can
be identified with IBS, unlike other functional gut
disorders; however, it is suggested that a motility
disturbance is the underlying issue in IBS patients
 Increased sensitivity in the viscera is commonly
found in IBS patients
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 Distention - Awareness and pain caused by balloon
distention in intestine are experienced at lower
volume than with controls
 Bloating – studies have shown that although there are
similar amounts of gas in IBS vs. control patients,
there is impaired transit of that intestinal gas
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Intestinal Inflammation – mucosal immune
activation has been shown in IBS,
characterized by alterations in immune cells
and markers ; mostly in diarrhea predominant
Lymphocytes – increased numbers reported in
colon and SI in he myenteric plexus
Mast cells – in terminal ileum, jejunum, colon;
some studies have showed a correlation
between abdominal pain and the presence of
activated mast cells around colonic nerves
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Postinfectious IBS – this
has been suspected
based upon a history of
acute diarrheal illness
preceding onset of IBS
symptoms in some
patients
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GI symptoms:
 Chronic abdominal pain (crampy, variable
intensity)
▪ Emotional stress and eating  pain, defecation  pain
 Altered bowel habits
 Other GI symptoms:
▪ GE reflux, dysphagia, early satiety, dyspepsia, nausea,
non cardiac chest pain, abdominal bloating, increased
gas (accompanied by flatulence or belching)
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Non GI symptoms:
 Impaired sexual function, dysmenorrhea,
dyspareunia, increased urinary
frequency/urgency
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Diarrhea
 Frequent loose stools of small volume, with
mucus
 Generally in the morning or after meals
 May be preceded by lower abdominal cramps
and urgency
 May have feeling of incomplete evacuation
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Constipation
 Days to months; may include bouts of diarrhea
or normal bowel function
 Stools often hard and pellet shaped
 May sense incomplete evacuation even with
empty rectum
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There are no biologic disease markers for IBS,
so diagnosis has been standardized with
symptom based criteria
Manning Criteria – 1978, not used as much
anymore
Rome Criteria – 1992, revised 2005, defined
as recurrent abdominal pain/discomfort
associated with altered defecation
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Recurrent abdominal pain/discomfort at least
3 days per month in the last 3 months
associated with 2 or more of the following:
 Improvement with defecation
 Onset associated with change in frequency of
stool
 Onset associated with change in form of stool
(appearance)
IBS with constipation
(hard/lumpy stools
predominant)
 IBS with diarrhea
(loose/watery stools
predominant)
 Mixed IBS (neither
predominates)
 Unsubtyped IBS (insufficient
stool abnormality to meet
the above subtypes)
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Pain associated with: anorexia, malnutrition,
weight loss – these are rare with IBS unless there
is severe psychologic illness
 Progressive pain
 Pain that prevents sleep or wakes patient from
sleep
 Rectal bleeding
 Lab abnormalities: anemia, inflammatory
markers, electrolyte disturbances
 These are “alarm” symptoms and require
additional testing!
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Keep in mind: IBS can look like other
illnesses, and other illnesses can look like IBS!
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Dietary modification: pt may have
food allergies, should exclude gasproducing foods, coffee, fatty foods,
carbohydrates (sx may be related to
impaired absorption of carbohydrates:
FODMAPs enter distal small bowel
and colon when they are fermented,
leading to sx and increased intestinal
permeability, although there have
been few studies to demonstrate this);
Increase fiber intake (say most studies,
although keep in mind that might be
an issue for diarrhea-predominant IBS)
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Patient-physician relationship is important!
Physical activity: in a randomized trial, this
was examined - Physical activity comprised
of 20-6- min of moderate to vigorous activity
3-5x/w – showed improvement in severity of
IBS compared with control group
Psychosocial therapies: behavioral
treatments for those who associate sx with
stressors – the goal being to reduce anxiety,
among other things
**these are to be used as an
ADJUNCT to tx**
Antispasmodics
Antidepressants
Antidiarrheal
agents
 Benzodiazepines
 5-HT 3 receptor
antagonists
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5-HT 4 receptor
agonists
 Lubiprostone
 Guanylate cyclase
agonists
 Mast cell stabilizers
 Antibiotics
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Ex: hyoscine, cimetropium, pinaverium (short
term relief, LT efficacy has yet to be
demonstrated).
Can directly affect intestinal smooth muscle
relaxation, or via
anticholinergic/antimuscarinic properties
They reduce colonic motor activity and may
improve postprandial abdominal pain, gas,
bloating, and fecal urgency.
Independent of their mood improving effects,
antidepressants have analgesic properties, and
therefore may be beneficial in patients with
neuropathic pain
 The assumed MOA with TCA’s and SSRI’s are
facilitation of endogenous endorphin release,
blockade of NE reuptake (leading to
enhancement of descending inhibitory pain
pathways), and blockade of the pain
neuromodulator (5-HT). TCA’s also slow down
intestinal transit time via anticholinergic
properties (helpful in diarrhea predominant IBS)
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Some patients show improvement in sx’s of
bloating, abdominal pain or altered bowel
habits after use of antibiotics
Rifaximin, a nonabsorbable antibiotic,
globally improved IBS symptoms in reports of
two randomized trials
MOA is unclear, may be due to suppression of
gas producing bacteria in the colon
CONS: Usually, pt has to pay out of pocket
due to the outrageous cost of this medication
In a 2007 article in Journal of Gastroenterology &
Hepatology titled “Treatment of Irritable bowel syndrome
with osteopathy: Results of a Randomized controlled pilot
study”, it was found that 13 of 19 patients in the group
receiving osteopathic treatment had overall improvement
of symptoms in 6 months, one was free of symptoms, and
the remaining five showed slight improvement
 In the standard care group, 3/17 subjects noted “definite”
improvement, while 10 showed slight improvement. The
remaining 3 had worsened sx’s
 Improvement was statistically significant in favor of the
osteopathic treatment group with a p value <0.006
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MFR of abdominal fascia
OA decompression
ANS treatments
Treatment of diaphragms (especially thoracoabdominal!)
Treat the whole patient! Listen to the patient,
make sure to get a good hx: remember, these
patients have had it with doctors and are
trying to understand their illness, do your
best to help them!
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