“Functional” Bowel Disorders
Eamonn M M Quigley MD
November 2010
“Functional” Bowel Disorders
• Refer to disorders of gut function
where there is no obvious abnormality
of structure or morphology
– Cause symptoms
– Impair Quality of Life
– Do NOT imply/equate to
psychological/psychogenic!!
A Sub-Classification
• Defined disorders of function; i.e.
motility disorders
• Putative disorders of function;
“functional disorders”
Well-Defined Motility
Disorders
Symptoms
Dysfunction
Pathophysiology
Pathology
Motility Disorders
• Primary
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–
–
–
Achalasia
Diffuse Oesophageal Spasm
Gastroparesis
Acute/Chronic Intestinal Pseudoobstruction
– Megacolon
– Hirschsprung’s disease
Achalasia
• Non-relaxing LOS
– Drop-out of
Inhibitory neurons
(NO, VIP)
• Aperistalsis in the
oesophageal body
• Causes:
– Chagas’ disease
– Pseudo-achalasia
• Cancers
– Idiopathic
Chagas’ Disease
Symptoms
Dysfunction
Pathophysiology
Pathology
Achalasia - Management
• Muscle relaxants
– Ca++ - blockers
– Nitrates
• Dilatation
– Bougie; transient
benefit only
– Balloon forced
dilatation
• Surgery
– Heller myotomy
• Botox
Ineffective
Diffuse Oesophageal Spasm
• True idiopathic
spasm rare; usually
secondary to GORD
• Non-cardiac chest
pain
• Treat:
– Muscle relaxants
– Dilatation
– ? Surgery
Pseudoobstruction
• Rare disorders resulting in diffuse motor
dysfunction:
–
–
–
–
Oesophageal dysmotility
Gastroparesis
Small bowel pseudobstruction
Colonic pseudobstruction
–
–
–
–
Connective tissue diseases
Muscle disease
Neurologic disorders
Metabolic disorders e.g. Diabetes
• Myopathy or Neuropathy
• Congenital or Acquired
• Primary or Secondary
Pseudoobstruction
Presents as acute or recurrent
“obstruction”:
• Small intestine
• Colon
• Acute e.g acute colonic pseudoobstruction (acute megacolon)
• post-op (Ogilvie’s syndrome)
• Chronic
• results in intestinal failure
• small intestinal bacterial
overgrowth
• inability to tolerate p.o.
nutrition
Scleroderma
Symptoms
Dysfunction
Pathophysiology
Pathology
Genetics
Immunology
Neurological Disease:
2.
1. Parkinson’s
Brain StemDisease
Tumor
Symptoms
Dysfunction
Dysphagia
Nausea
Ileus
Constipation
Incontinence
Pathophysiology
Pathology
Hirschsprung’s Disease
• Children; rarely
presents in
adulthood
• Loss of inhibitory
neurons
• Genetics
understood
• Svenson’s pullthrough procedure
Hirschsprung’s Disease
Symptoms
Dysfunction
Pathophysiology
Pathology
“Functional” Disorders
•
•
•
•
•
•
Functional Heartburn
Globus Sensation
Functional Dyspepsia
Irritable Bowel Syndrome
Functional Abdominal pain
Functional Diarrhoea/Constipation
Often overlap; one disorder or a number of discrete disorders
Functional GI Disorders
• Responsible for over 50% of all G.I.
Complaints seen by a G.P.!
How do you make a
diagnosis?
•
•
•
•
Symptoms
No pathology
No abnormal blood tests
No abnormal X Ray’s
Diagnosis
• By exclusion
• Definitive, based on symptoms ( a
consensus approach)
Rome
• Functional Dyspepsia
“ A chronic pain or discomfort centred in
the upper abdomen; may be additional
symptoms such as fullness, bloating,
early satiety, nausea, vomiting”
Rome
• IBS
– “ chronic abdominal pain or discomfort
associated with bowel movement; may be
additional symptoms such as bloating,
distension, constipation, diarrhoea”
IBS
• Abdo Pain +
– Urge to b.m.
– Relief by b.m.
– Alternating diarrhoea and constipation
• Bloating, distension
• Difficult defaecation
Functional Bowel Disorders
Cause(s)
•
•
•
•
•
Motor Dysfunction
Visceral Hypersensitivity
Low-grade inflammation
Central Perception
Psyche
FD – Pathophysiology;
motility
•
•
•
•
•
•
Gastroparesis
Impaired Fundic Accommodation
Antral Dilatation
Gastric Hypersensitivity
Abnormal Cerebral Perception
Helicobacter Pylori
IBS - Pathophysiology
•
•
•
•
Motility
Visceral Hypersensitivity
Central Perception
Inflammation
– Post-infective
– Immune activation
– Microbiota different
• Psyche
Case History
• 24 year-old female graduate student,
volunteers in Africa
• 2000 presented with a 2 year history of abdominal
cramps and constipation
– Went on wheat-free diet
– Substituted soya for cows milk
– Lived in:
» Malawi age 3-10
» Malaysia age 14-16
• December 2003
– Every 2 weeks: diarrhoea, nausea lasting 2-3 days
– Loperamide helped
• April 2004
– Anticholinergic, antispasmodic and antidiarrhoeal: some
help
• July 2004
Case History
• July 2004
• Despite 6 diphenoxylate/day
– Every 3-4 days borborygmi and cramps followed
by diarrhoea (b.o. X 5 in a.m.) and urgency
– Took tinidazole for 4 days – no effect
– Family history of pernicious anaemia, coeliac
disease and Crohn’s disease
Case History
• April 2009
• Intermittent symptoms
– Worse after meals and when stressed
• Has had a number of anti-biotic and antiparasitic regimes
• No weight loss
• Extensive and repeated investigations
– Blood work, gastroscopy, colonoscopy, small bowel
x-rays, abdominal imaging
» All negative
Management
• Listen and appreciate
– Understand aggravating factors and modify
• Symptomatic
– Anti-diarrhoeals
– Laxatives
– Anti-spasmodics
• Tricyclic anti-depressants (low dose); SSRI’s
• Behavioral and psychological therapies
Summary
• Motility disorders
– Not common
– May cause considerable disability
– Based on disorders of intestinal nerve or
muscle or their central connections
• “Functional” disorders
– Common
– May cause considerable impairment in
quality of life
– Pathophysiology not fully understood