IBS
Dr. Matt W. Johnson
BSc MBBS MRCP MD
1
L&D
2
Graham Holland’s
‘the optimism and the frustration of living in a metropolis’
3
IBS is a Diagnosis of Exclusion
......or is it ?
If in doubt go see your local
Shamen……..occasionally they
come to see you
4
5
British Society of
Gastroenterology
Guidelines
2000
6
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) 7
IBS
• Rome Criteria 3
• 3m of Abdominal Pain / Discomfort
• Associated with 2 of 3
– Altered frequency
– Altered consistency
– Improves with defaecation
8
IBS - Associated symptoms
•
•
•
•
•
•
Tiredness / lethargy
Poor sleep
Backpain
Fybromyalgia
Urinary urgency and frequency
Dysguesia - Unpleasant taste in mouth
9
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%)
10
Gastro Psychiatrist
11
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
12
Give me a Gastro patient that
doesn’t fit these criteria !
• Pancreatic Ca, Crohn’s stricture, Colonic Ca
• Rome Criteria 3 - Surely we can all relate
personally to these
3m of Abdominal Pain / Discomfort
Associated with 2 of 3
– Altered frequency
– Altered consistency
– Improves with defaecation
– But what about “bloaty” woman, I hear you cry 13
?????
Warning - Before you diagnose
someone with IBS - be aware
• Ford AC. ArchIntMed 2009
– 4.1% of all IBS = Coeliac disease
• Garcia-Rodriguez LA. ScanJGastro. 2000: 35;
306
– IBS patients have a 6x risk of Ca in 1st year
– IBS patients after 5y have >20x risk of CrD
• Hamilton W. BMJ. 2009: 339
– 2.5% Ovarian Ca present with bloating
14
IBS Facts
• Google = 6.5 million entries for IBS
• Heaton. GUT. 1992
– Only 58% of normal pop conformed to
producing normal stool on Bristol Stool Chart
• Piessevaux. DDW. 2009
– 80% of Belgiums have lower GI symptoms
– 10% reach IBS criteria
15
New IBS referral
What does it mean to me?
• Could be anything
gastroenterological, that hasn’t yet
been given a label
16
IBS - Is there better terminology
to explain what we mean?
• Non-organic disorder or
• Functional bowel symptoms (FBS)
– My preference
17
The Secret of Treating IBS /
Functional Bowel Syndrome
“Don’t treat the symptoms
- Treat the root cause”
18
Functional Bowel Syndrome
What are the main symptoms
• 1) Chronic Diarrhoea (rare)
• 2) Classic Constipation
• 3) Constipation Cycle Functional Bowel
Syndrome (C-IBS)
– Diverticulosis, Coeliac
– Right sided faecal loading
• 4) Pain
– Faecal loading (Left Vs Right or Pan-colonic)
– Bloating / Aerophagia
• 5) Bloating
19
1) Chronic Diarrhoea
20
Probably not the healthiest
curry house in town
21
D-IBS > 3x/d
• Fernandez-Banares F. AmJGastro. 2007: 102; 2520
– 62 Colonoscopy -ive patients
– 82% had an underlying diagnosis
•
•
•
•
•
Coeliac + sb Crohn’s
Lactose + Fructose intolerance
Small bowel bacterial overgrowth
Bile acid malabsorption
Pancreatic insufficiency
– 18% had functional IBS (?psych / PI-IBS)
22
Post-Infectious IBS
• Meta-analysis = 5-10% develop PI-IBS
– Halvarson AmJG. 2006; 101: 1994
• Campylobacter - 27%
– Parry S. AmJGastro 2003:98;1970
• Salmonella - 18%
– Mearin F. Gastro. 2005: 129; 98
• E.coli - (63% with ETEC/EATC) 18% of
these suffered IBS after 6m
– Okhuysen PC AmJGastro. 2004:99;1774
23
Chronic Diarrhoea
• All patients need to be actively
investigated
• All patients should be referred to a
gastroenterologist
• NB- IBS symptoms can still be experienced in
patients with organic disease
• 60% of UC patients
• 39% of CrD patients
• Keohane J. AmJGastro. 2010: 105; 1788
24
2) Left sided Constipation
• 1) LIF 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
25
Some slides have be borrowed
with kind regards to;Dr. Anton Emmanuel of
and also to the
SHIRE Team and the Advanced
Constipation Training Course
UK/BU/RES/11/0051n
26
Date of preparation: September 2011
3) Constipation cycle functional bowel
syndrome
- Proximal / 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)
32
Right sided faecal loading
33
4) Abdominal Pain
43
Abdominal Pain
• a) Faecal Loading
– Left sided
– Right sided
– Pan-colonic
• b) Diverticulosis
• c) Bloating
– Aerophagia
44
Bloating
45
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
46
Aerophagia
47
One remedy
48
Low FODMAP Diet
• FODMAPs =
• Fermentable Oligo-, Di-, and Mono-saccharides,
And Polyols.
• Typical symptoms would include
– abdominal bloating
– excessive gas
– chronic diarrhea or constipation
• Strict FODMAP avoidance
49
Low FODMAP Diet
OligoDiMonoPolyols
saccharides
saccharides saccharides
Fructans
Galactans
Lactose
Fructose
Sorbitol
white bread
cabbage
milk
honey
sugar free gum
pasta
brussel sprouts
butter
dried fruits
low cal foods
pastries
soy beans
cheese
apples
stone fruits
cookies
chickpeas
yoghurt
pears
peaches
onions
lentils
sweets
cherries
apricots
artichokes
chocolate
peaches
plums
asparagus
beer
agave syrup Xylitol
leeks
pre-prep soups watermelon
berries
garlic
pre-prep sauce corn syrup
chewing gum
chicory roots
50
51
Diverticulosis
54
Complications
• Bleeding (15%)
• 40% of all LGIBleeds
• Assoc colitis
• Stricture Obstruction
• Diverticulitis
inflammation “itis”
– Fistula
– Sepsis
– Perforation
55
DD Re-Bleeding Rates
Year
1
2
3
4
1
Percentage
9%
10%
19%
25%
Longstreth Am J Gastro 1997
56
Use of surrogate markers of inflammation and
Rome criteria to distinguish organic from nonorganic 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
Sensitivity
Specificity
FC OR=27.8 p<0.0001
FC
89%
79%
IP
63%
87%
Rome I
85%
71%
58
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
59
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
Same price as doing a ESR + CRP
60
Graham Holland’s Vision of Luton
61
Further Information
• www.drmattwjohnson.com
•
•
•
•
Oesophageal Laboratory
Small bowel capsule enteroscopy
Faecal calprotectin
IBD-SSHAMP
• Spire - 07889 219806
• L&D - 01582 497242
Learning objective 1
• Tests expected pre-referral
•
•
•
•
•
FBC + ESR (1%)
TFT (6%)
Coeliac (2-15%)
Ca + Albumin
Stool MCS + COP
• Consider
•
•
•
AXR
Pelvic US
Faecal Calprotectin
63
Learning objective2
• European Constipation Treatment Algorithm
64