Transcript Sometimes, it is more important to know what person has

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.
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
Mayer EA, Gebhart GF, Gastroenterology 1994;107:271
IBS
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
30
15
0
NORMAL
IBD
IBS
IBS = IBD > Normal; F=7.7; p=0.001.
URINARY SYMPTOMS
40
20
0
NORMAL
IBD
IBS
IBS > IBD = normal; F=8.7; p<0.001.
SLEEP DISTURBANCES
40
20
0
NORMAL
IBD
IBS
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
Lower GI tract
Functional abdominal
pain
IBS
Functional
constipation/diarrhea
Heartburn
Gastroesophageal reflux
disease (GERD)
Functional
dyspepsia
(FD)
IBS: Additional Clinical Features
•Non-Digestive Symptoms;
•Association with other functional GI
disorders;
•Relationship to enteric infections;
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
•Biological
•Psychological
PATHOGEN FACTORS
Postinfectious IBS (PI-IBS):
PATHOGEN FACTORS
• The risk varies with the pathogen.
• The risk associated with infections with
shigella or campylobacter jejuni is 10fold 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
8-14 days
15-21 days
>22 days
1.0
2.9
6.5
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 Tlymphocyte 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
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;
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.
Management of Refractory Patients
• Antidepressants
• Psychological Treatments:
• Hypnotherapy
• Cognitive Behavioral Therapy (CBT)
HYPNOTHERAPY FOR IBS
HYPNOTHERAPY IN IBS
LONG-TERM RESULTS
GAS-PAIN
DIARRHEA
50
50
25
25
0
PRE
POST Tx
0
1 Year Post
CONSTIPATION
PRE
POST Tx
PSYCHOLOGICAL DISTRESS
60
50
30
25
0
0
PRE
POST Tx
1 Year Post
1 Year Post
PRE
POST
1 Year Post
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)