Gastroenterology for GP’s
Dr Charmian Banks
Gastroenterology Consultant RSCH
Oct 2013
Outline of Talk
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Diarrhoea
When to refer
Faecal calprotectin
Diarrhoea predominant IBS
FODMAP’s
Constipation predominant IBS
Treatment options available
Case studies
Diarrhoea
• WHO Definition: Having three or more liquid
stools per day (type 5-7 on Bristol Stool chart).
• Or having more stools than is necessary for
that person.
Types of diarrhoea
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Secretory
Osmotic
Exudative
Motility related
Inflammatory
Secretory Diarrhoea
• An increase in active secretion or inhibition of
absorption.
• E.g. Cholera toxin, which stimulates secretion
of anions such as Cl- and to maintain a charge
balance in the lumen, sodium and water are
carried along with it.
• Diarrhoea continue even when there is no oral
intake.
Osmotic diarrhoea
• Occurs when too much water drawn into the
bowels.
• E.g. Lactose/fructose intolerance,
maldigestion (where nutrients are left in the
lumen to pull in water, CD/pancreatic disease.
• Osmotic laxatives
Exudative Diarrhoea
• With blood and pus in the stool
• E.g. Inflammatory bowel disease, sever
infections such as E.Coli
Motility-related
• Hypermotility or rapid transit through the
bowels
• E.g. Post vagotomy, diabetic neuropathy, short
bowel, hyperthyroidism
Inflammatory Diarrhoea
• Damage to the mucosal lining leading to
passive loss of protein rich fluids.
• Causes include bacterial or viral infections,
parasitic infections, IBD, microscopic colitis,
TB, colon cancer and enteritis.
Causes of Diarrhoea
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Infectious
Malabsorption
Inflammatory/microscopic
Malignancy
Irritable bowel syndrome
Ischaemic
Small bowel bacterial overgrowth
Bile-salt malabsorption
Short bowel syndrome
Hormone-secreting tumours
Medication-related
Laxative abuse
Investigations
• Good history e.g. travel, acute/chronic onset,
family history, social
• Examination including PR for all with
tenesmus or blood PR
• Bloods including
FBC/U&E’s/LFT’s/CRP/TSH/Calcium/TTG
• Stool sample for MC&S (consider C diff, OCP,
micro/cryptosporidium depending on history)
• Faecal Calprotectin?
Alarm features
Alarm features from NICE and BSG guidelines.1,2
Faecal Calprotectin
• Calprotectin is a major protein found in the
cytosol of inflammatory cells.
• It is stable in stool samples for up to seven days
• Since 2000 it has been evaluated in numerous
diagnostic studies.
• Meta-analysis in BMJ 2010 evaluated whether
adding faecal calprotectin testing to the
investigation of patients with suspected
inflammatory bowel disease reduced the number
of unnecessary endoscopies.
• Studies showed that adding calprotectin to the
screening pathway can lead to delays in diagnosis
• There has been debate in the values used as the
cut-off points
• The level of calprotectin does not always
correlate with degree of inflammation
• A third of patients with suspected inflammatory
bowel disease will have a negative colonoscopy
increasing to half if there is no pr bleeding.
• However, an increase in faecal calprotectin
levels identifies patients who are most likely
to have inflammatory bowel disease and then
justifies an urgent colonoscopy.
• Use of faecal calprotectin as a screening test
reduces the number of endoscopies with
negative results in both adults and children
with suspected inflammatory bowel disease.
Irritable Bowel Syndrome
• Rome III diagnostic criteria for irritable bowel
syndrome:
– At least 3 months, with onset at least 6 months
previously of recurrent abdominal pain or discomfort
associated with 2 or more of the following
 Improvement with defecation
 Onset associated with a change in frequency of
stool
 Onset associated with a change in form of stool
NICE criteria for IBS
• Abdo pain relieved by defecation or associated
with altered stool frequency/form, plus 2 or
more of
– Altered stool passage
– Abdominal bloating/distention
– Symptoms made worse by eating
– Passage of mucus
Sub-typing of IBS
• Based on stool consistency alone
– IBS with constipation (IBS-C)
– IBS with diarrhoea (IBS-D)
– IBS mixed type (IBS-M)
– IBS unsubtyped (IBS-U)
Diagnosing IBS
• Abdominal pain or discomfort
• Bloating
• Change in bowel habit
When to refer- red flags in the history
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Unintentional/ unexplained weight loss
Rectal bleeding
Fhx CRC/ovarian cancer
Looser/more frequent stools persisting for
more than 6 weeks in a person aged over 60
When to refer- red flags clinically
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Anaemia
Abdominal masses
Rectal masses
Raised inflammatory markers
Proposed mechanisms of IBS
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Genetics
Parental influence
Disturbance of GI motility
Increased colonic motility
Visceral hypersensitivity
Altered pain processing
Stress response
Post-infective
Management
• Dietary and lifestyle advice
– Identify and make the most of their available leisure
time and to create relaxation time
– Encourage an increase in their activity levels
– Diet: regular meals, avoid missing meals, 8 cups of
fluid per day, restrict tea and coffee, reduce alcohol
and fizzy drinks, limit high-fibre foods, limit fresh fruit
to 3 portions a day, avoid processed or recooked
foods, avoid sorbitol, encourage people with bloating
to eat oats and linseeds (NICE 2008).
– Low FODMAP diet
Pharmacological therapy
• Antispasmodics
• Laxatives- avoid lactulose
• Loperamide (liquid preparation allows finer
adjustment to prevent constipation)
• Colpermin
• Tricyclic anti-depressants as second-line
treatment, start at 10mg ON and increase to max
30mg ON. (S/E constipation)
• SSRI’s – S/E diarrhoea
Psychological interventions
• CBT
• Hypnotherapy
• Psychological therapy (psychodynamic
interpersonal therapy)
• No evidence to support acupuncture or
reflexology in IBS
– Consider in patients who do not respond to
pharmacological treatments after 12 months i.e.
those with refractory IBS.
FODMAPs
• Rapidly fermentable short-chain carbohydrates
• Fermentable Oligo-, Di-, Mono- saccharides And
Polyols.
• 3 common functional properties
– Poorly absorbed in the small intestine
– Small and osmotically active
– Rapidly fermented by bacteria
• 2 key components to the FODMAP concept
– Dietary approach restricts FODMAP’s globally not
individually
– FODMAP’s do not cause the underlying functional disease
but represents an opportunity for reducing symptoms
Shepherd and Gibson 2006
• Retrospective study of 64 IBS patients on low
FODMAP diet
• 77% adhered
• ¾ had marked improvement of all IBS
abdominal symptoms
Fructose malabsorption and symptoms of irritable bowel syndrome: guidelines for effective dietary management. J
Am Diet Assoc 106:1631-1639
Staudacher 2010
• UK service evaluation assessed response to
the low FODMAP diet compared to those
given the NICE guideline advice
• Dieticians completed questionnaires for each
IBS review patient seen
• Symptom and satisfaction questions
• Total n=82 (n=39 standard; low FODMAP
n=43)
Results- Symptom change
Symptom
Standard
Low FODMAP
P value
Bloating
17/39
32/39
0.002
Abdo pain
20/33
29/34
0.02
Diarrhoea
18/29
30/36
0.052
Flatulence
14/28
33/38
0.001
Constipation
10/22
14/21
0.2
Nausea
4/14
10/15
0.04
Poor energy
11/30
10/15
0.04
Composite score
19/39
37/43
<0.001
Global satisfaction
20/37
32/42
0.04
Shepherd et al 2008
• 25 IBS patients
• Already had symptomatic improvement on
low FODMAP diet
• Challenges with fructose and fructans induced
symptoms
• Therefore improvement not placebo or due to
change in other dietary components e.g.
gluten.
Dietary triggers of abdominal symptoms in patients with irritable bowel syndrome: randomised placebo-controlled
evidence. Clin Gastroenterol and Hepatol 6:765-771
De Roest et al 2013
• Prospective study
• 90 patients with a mean follow up of 15.7 months who
had performed breath testing for fructose and lactose
malabsorption and had received dietary advice for low
FODMAP diet
• Abdo pain, flatulence, bloating and diarrhoea
significantly improved (p<0.001 for all)
• Fructose malabsorption significantly associated with
symptom improvement.
• 75.6% adherent to the diet which was associated with
symptom improvement.
• 72% satisfied with their symptoms
The low FODMAP diet improves gastrointestinal symptoms in patients with irritable bowel syndrome: a prospective
study. Int J Clin Pract 2013 Sep;67(9):895-903
Constipation-predominant IBS
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Lifestyle advice
Linseeds
Anti-spasmodics
Laxatives
TCA’s or SSRI’s
Psychological interventions
Linaclutide
• Only treatment licensed specifically for IBS-C
• Licensed for the symptomatic treatment of
moderate to severe IBS-C
• Novel targeted therapy, dual mode of action
taken once a day
• Targets abdominal pain, bloating and
constipation and acts locally in the GI tract
• 2 randomised double blind placebo controlled trials in 1602
patients
• 26 week treatment or 12 week treatment
• Both trials showed significant and early reduction of abdo
pain p<0.0001
• Significant and sustained decrease in bloating p<0.0001
• Significant improved stool frequency, consistency and
straining p,0.0001
• Well tolerated as minimally absorbed, diarrhoea main side
effect, no differences in serious adverse events between
linaclutide and placebo
• A bit more expensive than prucalopride?
Cases
Case study: Kate
Kate W* is 36 and works as a personal
assistant in a busy office.
Over the past 12 months, she has consulted
five other GPs in your practice for
symptoms of anxiety, headache,
abdominal pain, and constipation.
*All patient names are fictional
Case study: Kate
You have heard your colleagues in the staff
room discussing how Kate keeps
returning with non-specific symptoms
and never seems satisfied with the
various treatments given.
She has booked a consultation with you
later today.
GI routemap
UKLIN1693, date of preparation: March 2013.
Case study: Kate
When you see Kate, she explains that she has
abdominal discomfort and frequent bloating.
She does not pass stools very frequently and usually
finds that she has to strain.
She describes her stools as ‘hard,’ and finds that her
symptoms are relieved by having a ‘good’ bowel
movement.
Case study: Kate
When asked how long she has been having
symptoms, Kate explains that she has had
them intermittently for 10 years, but has
never received a satisfactory diagnosis or
management plan.
What is your gut feeling about her diagnosis?
An important part of GI diagnosis is
eliminating organic disease
Need to eliminate the possibility of organic
disease:1
• Check for alarm features2,3
Case study: Kate
• Questioning reveals that Kate does not have any
alarm features. From her notes, you can see that the
results of previous investigations have been
unremarkable, and therefore her history does not
indicate cause for concern.
Case study: Kate
• You can be fairly confident of a functional diagnosis
for Kate.
Agreeing an IBS diagnosis
Agreeing an IBS diagnosis: ideas
• You’ve had these symptoms for a while now, what’s
been going through your mind?
• What thoughts have you already had about this?
• What is your perception of what’s happening?
Agreeing an IBS diagnosis: ideas
• You’ve had these symptoms for a while now, what’s
been going through your mind?
• What thoughts have you already had about this?
• What is your perception of what’s happening?
Agreeing an IBS diagnosis: concerns
• Is there anything that you are particularly worried
this might be?
• I’m wondering what your partner thinks…
• Some patients find that…
• Have you changed any aspects of your life because
of your symptoms?
Case study: Kate
With prompting, you discover that Kate
is still concerned that her symptoms
are due to something more serious
than IBS.
How can you explain that you are sure her symptoms are
caused by IBS?
The bowel is a muscular tube
– The bowel is a muscular tube
that squeezes content from one
end to the other
– In IBS-D, muscular contractions
may be stronger and more
frequent than normal. In IBS-C,
contractions may be reduced
Gut response to triggers may
be altered in IBS
• Contractions can be triggered
by waking and eating
• In IBS-D, the response to these
normal triggers may be
stronger than normal. In IBS-C,
the response may be reduced
IBS pain does not indicate disease
• The pain associated with
IBS is like cramp; it hurts,
but does not indicate
disease
The stress response may
be chronic in IBS
• We all get butterflies
and diarrhoea in
response to stress
• In IBS, the gut is more
sensitive to stress,
and this response can
become chronic
The brain hears the gut
too loudly in IBS
• The brain is able to
hear messages from
the gut such as
hunger or the urge
to go to the toilet
• In IBS the brain
hears these
messages too loudly
Heightened gut awareness
• The gut works all day,
every day, but most
people do not feel it
• People with IBS often
have an excessive
awareness of normal
digestive processes
IBS requires long-term management
IBS patients tend to have a long-term consultation
pattern.1
• Initial consultation
Provide positive diagnosis
• Subsequent consultations
Formulate management plan
IBS diagnosis: key points
Patients who present with IBS are often female, in
their 30s/40s, have stress comorbidity, and a pattern
of repeated consultations.
The main symptoms of IBS are abdominal pain,
bloating, and change in bowel habit. Symptoms tend
to be relapsing and remitting and relieved by
defaecation.
IBS diagnosis: key points
Abnormal patterns of endogenous pain modulation
have been seen in IBS patients.
Irritable bowel syndrome can be associated with
constipation. The three subtypes of IBS are IBS with
constipation, IBS with diarrhoea, and mixed IBS.
IBS diagnosis: key points
IBS can be positively diagnosed using symptoms,
alarm features, and minimal investigations.
Defining patients’ ideas and concerns and using
explanatory models can help patients to accept a
diagnosis of IBS.
• Thank-you for listening
• Any Questions?