IBS

Dr. Matt Johnson BSc MBBS MRCP MD

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Specialty Areas of Interest

• • • •

EofE Train the Trainers in Constipation Management Inflammatory Bowel Disease

– including tertiary referral clinics at St. Mark’s and St. Thomas’s hospitals. •

Surgical Gastroenterology

- National Referral Unit for ileoanal pouches, faecal incontinence, complex anorectal fistula disease at St. Mark’s

Small bowel pathology + Coeliac disease tertiary referral clinics

responsive cases.

for complicated and non-

Hepatology

(General hepatopancreatobiliary medicine, Hepatitis clinics, Liver ITU, pre/post liver transplant medicine) 2

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St. Thomas’s Hospital

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St. Mark’s

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Research Fellowship

•

St. Marks’ and St. Thomas’ Hospital

• The Bacterial Pathogenesis of Pouchitis and Development of Novel Probiotic Therapies • • Prof PJ. Ciclitira, Prof RJ. Nicholls and Prof A. Forbes

MD

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18 Publications

Management of colonic diverticulosis. Coeliac disease in the elderly. Nat Clin Pract Gastroenterol Hepatol. 2008 Dec; 5(12): 697-706 Bacterial community diversity in cultures derived from healthy and inflamed ileal pouches after restorative proctocolectomy. IBD. 2009 Nov The bacteriology of pouchitis: A molecular phylogenetic analysis. GUT. 2009. Dec The prevalence of osteoporosis and osteopenia in ileal pouch patients post-restorative proctocolectomy. IBD. 2009. Sept Prolonged toxic megacolon secondary to Salmonella. [Submitted to Diseases of the Colon and Rectum] Coeliac disease in the older patient: Are we ageist in our practice. [Awaiting publication in Gastroenterolgy CME Journal] The medical management of patients with an ileal pouch anal anastomosis after restorative proctocolectomy. EJoGH. Faecal M2-pyruvate kinase; a novel, non-invasive marker of ileal pouch inflammation. EJoGH Faecal calprotectin: A non-invasive diagnostic tool and marker of severity in pouchitis. Eur J Gastroentero Hepatol. 2008 March; 20(3): 174-179 Hyperbaric oxygen as a treatment for malabsorption in a radiation damaged short bowel. June 2006; 18(6):685-688 Risk of dysplasia and adenocarcinoma following restorative procto-colectomy for ulcerative colitis. Colorectal Disease. CDI 00256-2005.R1. 03/05/06 Use of fecal lactoferrin to diagnose irritable pouch syndrome: A word of caution. Gastroenterology. 2004. 127(5):1647-8 Presentation, diagnosis and management of inflammatory bowel disease in older people. CME Geriatric Medicine, 2005; 7(3): 149 153 The pathogenesis of coeliac disease. Molecular Aspects of Medicine, Dec 2005: 26 (6); 421-458 11th International Symposium on Coeliac Disease: A report. Gastroenterology Today. Summer 2004; 14 (2): 46-7 Clinical toxicity of HMW glutenin subunits of wheat to patients with celiac disease. Proceedings of the 19th Meeting of the Working Group on the prolamin analysis and toxicity, 2004; III Symposium: 147-9 Malaria: The dilemmas of malarial diagnostics. J R Army Med Corps 2002; 148: 122-126 7

L&D

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Graham Holland’s ‘the optimism and the frustration of living in a metropolis’ 9

IBS

• Rome Criteria 3 • 3m of Abdominal Pain / Discomfort • Associated with 2 of 3 – Altered frequency – Altered consistency – Improves with defaecation 10

IBS - Associated symptoms

• Tiredness / lethargy • Poor sleep • Backpain • Fybromyalgia • Urinary urgency and frequency • Dysguesia - Unpleasant taste in mouth 11

IBS

• 9-12% of adult population • 40-60% of all Gastro OPA referrals • 1M : 2.5F

• Aetiology – Psychological (Increased incidence of Psych Hx) – Stress (ppt in 50%) – Post infective (ppt in 10-20%) – Consulting behaviour / Abnormal illness behaviour – Gut motility (no consistent evidence) – Visceral hypersensitivity – Diet (lactose + wheat intolerance) 12

IBS - Investigation

• FBC + ESR (1%) • TFT (6%) • Coeliac (2-15%) • Ca + Albumin • Stool MCS + COP • Faecal elastase • US (incidental gallstones and fibroids 8%) • Lactose intolerance testing (21-25%) • Flexible sig / BaEnema / Colonoscopy • SeHCAT scan - Bile acid malabsorption (8%) 13

IBS Management

• Positive diagnosis • Listen • Lifestyle advice • Placebo (50%) • Dietary advice – (exclude lactulose,wheat, caffeine, CHO) • Psychological therapies – Diagnosis + Psych referral – Relaxation / Biofeedback, Hypnotherapy, Cognitive behavioural, Psychotherapy • Pharmacological Rx – PTO 14

IBS Treatment

• Pain – Anticholinergics – Antispasmodics – Tricyclic antidepressants • Urgency + Diarrhoea – Loperamide – Codeine • Constipation – Increased fibre – Ispaghula • Others = Placebo 15

Gastro Psychiatrist

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Give me a Gastro patient that doesn’t fit these criteria !

• Rome Criteria 3 - Surely we can all relate !

3m of Abdominal Pain / Discomfort Associated with 2 of 3 – Altered frequency – Altered consistency – Improves with defaecation 17

IBS - What does it mean to me?

• Non-organic disorder • Functional bowel symptoms (FBS) • Talk to your patients about their life and their bowel habits

“Don’t treat the symptoms Treat the cause”

• Anyone with chronic diarrhoea need full Ix 18

FBS - What are the main symptoms

• Chronic Diarrhoea (rare) • Pain – Faecal loading (Left Vs Right or Pan-colonic) – Bloating / Aerophagia • Bloating • Constipation • Constipation Cycle functional bowel symptoms – Diverticulosis, Coeliac – Right sided faecal loading 19

Chronic Diarrhoea

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Chronic Diarrhoea

• Lactose Intolerance • Infection eg Giardia • Bile acid malabsorption • Coeliac disease • Small bowel bacterial overgrowth (SBBO) • Inflammatory bowel disease (UC / Crohn’s) • All patients need to be actively investigated • All should be referred in to a gastroenterologist 21

Left sided Constipation

• 1) RIF pain (exclude DD) • 2) Reduced frequency • 3) Harder consistency with Straining +/ Haemorrhoids or Fissure • Mx • 1) Increase fluid intake >2L/day • 2) High fibre diet (not if DD present) • 3) Laxatives • 4) Stimulants 22

Right sided faecal loading

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Right sided faecal loading

• 1) Altered bowel habits = Hard pellets + episodic loose • 2) Bloating / Flatulence / Borborygmi • 3) Sense on incomplete emptying • 4) Straining +/- Haemorrhoids • Mx • 1) Increase fluid intake >2L/day • 2) Low residue (high soluble fibre) diet • 3) Osmotic agents (Movicol) +/- Laxatives • 4) Stimulants +/- 5HT4 agonists (Prucalopride) 24

Osmotic agents: polyethylene glycol

Higher stool frequency with PEG vs lactulose after 1 month 1

P<0.005

Less straining with PEG vs lactulose after 1 month 1

P<0.0001

25 1.

2.

3.

4.

Attar et al. Gut. 1999.44.226-30 Andorsky & Goldner. Am J Gastroenterol. 1990;85(3):261-5 Corazziari et al. Dig Dis Sci. 1996;41(8):1636-42 Di Palma et al. Am J Gastroenterol. 2007;102(9):1964-71 25

Idiopathic Slow Transit Constipation

Day 5 after taking markers

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Abdominal Pain

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Abdominal Pain

• Faecal Loading – Left sided – Right sided – Pan-colonic • Diverticulosis • Bloating – Aerophagia 28

Bloating

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3 Main Causes

• 1) Air swallowed = Aerophagia • 2) Gas production = SBBO • 3) Air trapped = Faecal Loading • Mx • 1) Awareness / Exercise / Positional deflation /Anti-anxiety agents • 2) H2 Lactulose breath test + Abs • 3) Rx to soften and shift the bowel 30

Aerophagia

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Low FODMAP Diet

• • FODMAPs =

F

ermentable

A

nd

P

olyols.

O

ligo-,

D

i-, and

M

ono-saccharides, • Typical symptoms would include – abdominal bloating – excessive gas – chronic diarrhea or constipation • Strict FODMAP avoidance 32

Low FODMAP Diet

Oligo saccharides Fructans

white bread pasta pastries cookies onions artichokes asparagus leeks garlic chicory roots

Galactans

cabbage brussel sprouts soy beans chickpeas lentils

Di saccharides Lactose

mil k butter cheese yoghurt sweets chocolate beer pre-prep soups pre-prep sauce

Mono saccharides Fructose

honey dried fruits apples pears cherries peaches agave syrup watermelon corn syrup

Polyols Sorbito l

sugar free gum low cal foods stone fruits peaches apricots plums

Xylitol

berries chewing gum 33

One remedy

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• Matt Johnson + David Dewar • Professor Paul Ciclitira • St Thomas’s Hospital, London 36

AD and age at diagnosis:

Group A1 – age<2yrs A2 – age 2-10yrs A3 – age>10yrs Prevalence AD 5.1% 17% 23.6% • Prevalence of autoimmune disease is related to duration of gluten exposure

Osteoporosis

• 47% women < 50% men on GFD have osteopenia / osteoporosis a • Improvement 1 year post treatment b a McFarlane (1995) Gut 36:710-14 b Valdimarsson (1996) Gut 38:322-7 38

Diverticulosis

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Physiology and Anatomy

•Terminal arterial branches •Penetrate circular muscle •Often lie adjacent to taenia 40

Complications

• Bleeding (15%) • 40% of all LGIBleeds • Assoc colitis • Stricture Obstruction • Diverticulitis inflammation “itis” – Fistula – Sepsis – Perforation 41

DD Re-Bleeding Rates Year 1 2 3 4 Percentage 9% 10% 19% 25%

1 Longstreth Am J Gastro 1997 42

Use of surrogate markers of inflammation and Rome criteria to distinguish organic from non organic intestinal disease Tibble J. Gastro. 2002; (123): 450-460 • • • • 602 new referrals with bowel symptoms All patients had FC, intestinal permeability studies and either Ba enema or colonoscopy 263 had organic disease, 339 diagnosed with IBS FC OR=27.8 p<0.0001

FC Sensitivity 89% Specificity 79% IP Rome I 63% 44 85% 87% 71%

BMJ Meta-analysis

Rheenen P.F. BMJ. 2010;341:c3369 • • • • • • 13 studies = 670 adults + 371 children Sensitivity = 0.93 (0.85-0.97) in adults Specificity = 0.96 (0.79-0.99) similar in kids Screening potential IBD patients would reduce 67% of colonoscopy 6% false negative = delayed diagnosis 9% may have a non-IBD pathology 45

Can FCalp reduce unnecessary colonoscopy in IBS

Whitehead SJ. GUT. 2010; (59): A36 • • • • • 2419 patients 1750 -ives 669 +ives (FC > 50mcg/g) = 58% pathology Cheaper + more effective at differentiating between IBS and IBD

Faecal Calprotectin

• Business Case as a QUIPP Project • 1 year • Cost = 2600 colonoscopies = 2600 x £394 = £1,020,240 • Normals = 40% • Cost of FC in those 40% = £13,000 • Cost of colonoscopy in those 40% = £409,760 – +/- the additional complications • Ease pressure on our colon lists + BCS lists • Increase OGD capacity, when Community Endo Unit closes

Graham Holland’s Vision of Luton 48

Further Information

• www.drmattwjohnson.com

• Oesophageal Laboratory • Small bowel capsule enteroscopy • Faecal calprotectin • IBD-SSHAMP • Spire - 07889 219806 • L&D - 01582 497242