IBS, IBD

Name two medications indicated for the tx of IBS

Hyosyamine and dicyclomine are antimuscarinic antispasmodics indicated for irritable bowel syndrome

2+ Rome Criteria *Pain or discomfort relieved by defecation *Pain associated w/ increased or decreased stool frequency *Pain associated w/ harder or looser stools

IBS

Altered bowel habits: Diarrhea, constipation and/or alternating diarrhea and constipation

IBS

Bloating and N/V are common Pain often relieved by defecation BM's are irregular and vary from constipation to diarrhea

IBS

MRI/PET studies show increased central pain processing with colorectal distention in

IBS

Most bowel movements preceded by lower abdominal cramping pain, urgency and sensation of incomplete evacuation or tenesmus (cramping rectal pain even if rectum empty)

IBS

Stools often hard and described as pellet-shaped

IBS may experience tenesmus even when rectum is empty

Abnormal Motility Visceral Hypersensitivity Psychosocial interactions

IBS (pathophysiology)

abnormal motility caused by chemical imbalance (5HT & acetylcholine) in intestine that leads to spasm and abdominal pain

IBS (pathophysiology)

psychosocial interactions & altered CNS processing

IBS (pathophysiology)

Brain-Gut connection

IBS (pathophysiology) more lifetime and daily stressors reported

A 23 y/o female presents with diarrhea and abd pain for the past 4 months. She has been more stressed lately preparing for final exams and has noticed her abd pain and cramping getting worse. Her stomach "binds up" whenever she eats fast food and even after she eats apples. What is the dx?

IBS -Irritable Bowel Syndrome

Subtypes of IBS

IBS-C IBS-D Unsubtyped IBS

Patient reports that abnormal bowel movements are usually diarrhea

IBS-D

A 40 y/o woman comes to your office with a several-year hx of lower abdominal pain associated with constipation (one hard bowel movement every 3 days) and frequent mucous discharge. She states that her abdominal pain is better after a bowel movement. She has never passed blood per rectum. She describes no fever, chills, weight loss or gain, jaundice, or any other symptoms. There is no relationship between the abdominal pain and specific food intake. on physical examination, the abdomen is scaphoid, and no hepatosplenomegaly or masses are palpated. There is a mild generalized abdominal tenderness, but it does not localize.

Irritable Bowel Syndrome

chronic functional idiopathic d/o (abnormal peristaltic contractions) with NO organic cause, pain often relieved with defecation

Irritable Bowel Syndrome (organic causes are things like Celiac Sprue or IBD)

A 40 y/o woman comes to your office with a several-year hx of lower abdominal pain associated with constipation (one hard bowel movement every 3 days) and frequent mucous discharge. She states that her abdominal pain is better after a bowel movement. She has never passed blood per rectum. She describes no fever, chills, weight loss or gain, jaundice, or any other symptoms. There is no relationship between the abdominal pain and specific food intake. On physical examination, the abdomen is scaphoid, and no hepatosplenomegaly or masses are palpated. There is a mild generalized abdominal tenderness, but it does not localize.

Irritable Bowel Syndrome (IBS)

What characterizes irritable bowel syndrome?

Irritable bowel syndrome is a gastrointestinal disorder characterized by recurrent abdominal pain, bloating, and regular changes in bowel habits typically between constipation or diarrhea.

Who is most commonly affected by IBS?

Irritable bowel syndrome most commonly affects middle-aged women

Initial IBS Therapy

Lifestyle changes *Smoking cessation *Low fat/unprocessed food diet *Avoid beverages w/ sorbitol or fructose (eg, apples, raisins), avoid crucierfous veggies (broccoli, kale) low-FODMAPs diet (F-fermentable, O-Oligosarharrides) *Sleep *Exercise (3-5 days/wk at least 30 min/day)

What foods have lactose?

Milk Custard Ice cream Yogurt

Patient reports that abnormal bowel movements are usually both constipation and diarrhea (more than 1/4 of all the abnormal bowel movements were constipation and more than 1/4 were diarrhea

Mixed IBS

side effects for Lubiprostone IBS tx

Nausea, abd pain, dry mouth, gas

Do IBS loose stools occur at night?

No, generally occurs during waking hours (morning or after meals is most common)

side effects of Antidiarrheals (loperamide) for IBS tx

dizziness, drowsiness, dry mouth, constipation

Tx for IBS-C

osmotic laxatives (PEG) Cl channel activator (lubiprostone) Guanylate cyclase agonist (linaclotide)

requires presence of abd pain or discomfort for at least 3 days/mo in the last 3 mo along with > or = 2 of the following: *improvement w/ defecation *onset (of each episode of discomfort) associated w/ a change in frequency of defecation *change in consistency of stool

Rome Criteria IBS

How is IBS diagnosed?

Rome criteria as long as patients have no red flag findings, such as rectal bleeding, weight loss, and fever, or other findings that might suggest another etiology. Patients w/ red flag findings require further imaging and/or colonoscopy; routine lab studies (CBC, chemistries) are normal in IBS

What is affected by brain-gut dysregulation in IBS?

Serotonin and acetylcholine

side effects of Antispasmodic agents (Dicyclomine)

Severe constipation, bloating, abd pain, dizziness, dry mouth, blurred vision, nervousness

IBS adjunctive therapy pharm rx

Step-wise Approach 1st soluble fiber (Psyllium) >Polyethylene glycol (PEG) Lubiprostone for constipation Diarrhea - stop anticholinergics/spasm (eg, Dicyclomine) -antidiarrheals (eg, Loperamide) Constipation -prokinetics -bulk-forming laxatives (Psyllium) -saline or osmotic laxatives (PEG) -Lubiprostone - activates intestinal chloride transporter and increases intestine fluid & motility Pain -TCAs(Amitryptilline) -5HT receptor agonists for intractable pain

Rome criteria for IBS

The Rome criteria are standardized symptom-based criteria for diagnosing IBS. It requires the presence of abdominal pain or discomfort for at least 3 days/mo in the last 3 mo along with > or 2 of the following: -improvement with defection -onset (of each episode of discomfort) associated with a change in frequency of defecation -change in consistency of stool

What does IBS PE look like?

Usually normal, may have abd tenderness to palpation

patients have lower pain tolerance to intestinal distention

Visceral hypersensitivity (IBS pathophysiology)

Foods that contain Fructans, Galacto-oligosaccharides

What Barley Rye Onion Leek White part of spring oonion Garlic Shallots Artichockes Beetroot Fennel Peas Chicory Pistachio Cashews Legumes Lentils Chickpeas

side effects of Psyllium for IBS tx

abd pain, constipatioon, impaction

IBS Red Flags

age onset >50 yrs fever rectal bleeding/melena nocturnal diarrhea unexplained wt loss FHx IBD or colorectal cancer

When a pt presents with IBS symptoms what should you pay attention to in the pt hx?

*Signs of organic dz *Exposure to meds that cause similar s/s ---anticholinergics, iron, barium, opiates, CCBs (constipation), antiarrhythmics, antihypertensives, diuretics, anti-anxiety meds, bile acids, laxatives (diarrhea) *FHx (IBD, colorectal cancer, celiac dz)

patient reports that abnormal bowel movements are usually constipation, which type of IBS is this? A) IBS w/ predominant constipation B) IBS w/ diarrhea C) Mixed IBS D) Unclassified IBS

A) IBS w/ predominant constipation

Which of the following symptoms indicates a need for laboratory testing or diagnostic imaging in patients with IBS younger than 50 years? A) Iron deficiency anemia B) Abdominal pain C) Amenorrhea D) Hypokalemia

A) Iron deficiency anemia The 2009 American College of Gastroenterologists (ACG) evidence-based position statement on the management of IBS does not recommend laboratory testing or diagnostic imaging in patients younger than 50 years with typical IBS symptoms and without "alarm features." Alarm features include the following symptoms and history: *Weight loss iron deficiency anemia *FHx of certain organic GI illnesses (eg, IBD, celiac sprue, colorectal cancer) *Although rectal bleeding and nocturnal symptoms have also been considered alarm features, they are not specific for organic dz

A 25 y/o lady presents at the clinic with complaint of 8 month hx of intermittent crampy lower abdominal pain, with passage of loose stools 4 times a day. Pain is usually worse during her menstrual period, and is relieved by defecation. She also feels bloated. On inquiring, she says she has been undergoing work-related stress for months. No ALARM symptoms. Nothing significant was found on physical examination. What is her most likely dx? A) Irritable bowel syndrome B) Lactase deficiency C) Ulcerative colitis D) Crohn disease

A) Irritable bowel syndrome Irritable bowel syndrome is a functional bowel disorder. It's commoner in young women. Presents as recurrent abdominal pain associated with change in bowel habit. May be precipitated by certain food or stress.

Tx for IBS abdominal pain

Antispasmodics TCAs (low dose) SSRIs

Foods with Sorbitol, mannitol, maltitol, and xylitol

Apples Pears Apricots Cherries Nectarines Peaches Plums Watermelon Mushrooms Cauliflower Artificially sweetened chewing gum and confectionery

"Free fructose" (fructose in excess of glucose)

Apples Pears Mangoes Cherries Watermelon Asparagus Sugar snap peas Honey High-fructose corn syrup

Which of the following is incorrect about Irritable Bowel Syndrome (IBS)? A) It is a dx of exclusion B) It is an organic disorder C) Young women are affected 2-3 times more often than men D) May occur following an episode of gastroenteritis

B) It is an organic disorder IBS is a functional disorder, not an organic disorder. All other statements are correct.

abd pain associated w/ diarrhea, nausea, bloating

Bowel Infection

Which of the following is a symptom consistent with a diagnosis of IBS? A) Painless diarrhea B) Fever C) Postprandial urgency D) Steatorrhea

C) Postprandial urgency Postprandial urgency is common, as is alteration between constipation and diarrhea. Symptoms not consistent with IBS should alert the clinician to the possibility of an organic pathology. Inconsistent symptoms include the following: Onset in middle or older age Acute symptoms (IBS is defined by chronicity) Progressive symptoms, Nocturnal symptoms, anorexia, or weight loss, fever, rectal bleeding, painless diarrhea, steatorrhea gluten intolerance

Which of the following is associated with irritable bowel syndrome (IBS)? A) Alvarado score B) Ranson criteria C) Rome criteria D) Revised Jones criteria

C) Rome criteria The Rome III criteria is used in diagnosing IBS.

Labs for pts suspected of having IBS

CBC CRP &/or fecal calprotectin (pt w/ IBS-D) Abd radiograph (pt w/ IBS-C) Serologic testing for celiac dz Colorectal cancer screening (based on age)

abd pain, wt loss, may have osteoporosis

Celiac Disease

abd pain may present w/ fatigue, wt loss, presence of oral ulcers, perianal skin tags, palpable mass may be present in ileocecal area

Chron's Disease

abd pain w/ constipation or small stools and some have blood in stool, older person typically

Colon Cancer

Tx for Irritable Bowel Syndrome?

Counseling Stress management Diet Increase physical activity IBS-C ---> Laxatives IBS-D --->Antidiarrheals Abx Antispasmodics (pain) TCA low dose (pain) SSRIs (pain)

Which of the following is NOT recognized s a symptom that supports the dx of IBS according tot he Rome criteria? A) Altered stool frequency B) Mucorrhea C) Abdominal bloating or subjective distention D) Frequent nausea

D) Frequent nausea A consensus panel created and then updated the Rome criteria to provide a standardized dx for research and clinical practice. The Rome III criteria for the dx of IBS require that patients have had recurrent abdominal pain or discomfort at least 3 days per month during the previous 3 months that is associated with two or more of the following: *Relieved by defecation *Onset associated w/ change in stool frequency *Onset associated w/ change in stool form or appearance: altered stool frequency/form/passage (straining and/or urgency) *Mucorrhea abdominal bloating or subjective distention

Which of the following is essential in investigating the above mentioned patient? A) Colonoscopy B) Barium enema C) Abdominal radiograph D) None of the above

D) None of the above The American College of Gastroenterologists does not recommend laboratory testing or diagnostic imaging in patients younger than 50 years with typical symptoms of IBS and without ALARM symptoms.

alternating bouts of constipation and diarrhea, crampy abdominal pain made worse by eating certain foods and sometimes better by defecation. Hard-pellet feces. What is the dx? A) Lactose intolerance B) Celiac disease C) Early Irritable Bowel Disease -IBD D) Laxative abuse E) Irritable Bowl Syndrome - IBS

E) IBS

group most affected by IBS

F>M, age of onset 30-50 yrs

feeling like you still have to evacuate bowels yet you can't or there is nothing there

tenesmus

red flags for IBS

wt loss, bleeding

What percentage of stools are diarrhea in IBS-D?

~75%

what percentage of stools are constipated in IBS-C?

~75%

What is prevalence of IBS in North America?

10-15% prevalence is 25% less in those over age 50, mainly affects younger people

IBS-D tx

1st line - antidiarrheals (Loperamide) 2nd line - bile acid sequestrians (cholestyramine, colestipol) Others: antispasmodics --Dicyclomine + Hyoscyamine w/ anticholinergic properties for abd pain due to bloating ---TCAs for slow intestinal transit time

Which of the following infections has been associated with an increased prevalence of IBS? A) Giardia lamblia B) Escherichia coli C) Shigella D) Salmonella

A) Giardia lamblia Infection with G lamblia has been shown to lead to an increased prevalence of IBS as well as chronic fatigue syndrome. In a historic cohort study of patients with G lamblia infection as detected by stool cysts, the prevalence of IBS was 46.1% as long as 3 years after exposure, compared with 14% in controls.

IBS-D

Antidiarrheals Antibiotics *Loperamide *Bile Acid Sequestrants (cholestyramine) *5-HT antagonists (alosetron) *rifaximin (antibiotic)

IBS-D tx

Antispasmodics Dicyclomine Hyoscyamine Loperamide

Is IBS more common in males or females?

F>M

Rome Criteria

IBS

Tx includes increased fiber, avoid milk products and high-fat diet

IBS

abd pain associated w/ change in stool freq/form, pain relieved w/ defecation. PE of abdomen is normal

IBS

cramping abdominal sensation with variable intensity and periodic exacerbations

IBS

crampy, lower abdominal pain relieved by defecation, irregular disturbances in defecation (constipation & diarrhea), abdominal bloating

IBS

due to abnormal motor function of the GI tract and increased gut visceral sensitivity

IBS

exaggerated response to cholecystokinin and altered response to meal ingestion

IBS

pain ranges from mild to severe; location and character of pain varies; sometimes pain relieved by defecation but sometimes exacerbated, emotional stress & meals may exacerbate, abd bloating and increased gas often accompany pain

IBS

What dietary modification may relieve symptoms of irritable bowel syndrome in patients with constipation as the primary symptom?

Increased dietary fiber may relieve symptoms of IBS in patients w. constipation as the primary symptom, as symptoms normally improve w/ defecation.

abdominal pain associated with altered defecation and bowel habits

Irritable Bowel Syndrome (hallmark finding)

IBS Risk Factors

Psychosocial stressors Anxiety Stress Depression

Rome IV Diagnostic Criteria for IBS

Recurrent Abdominal pain on ave at least 1 day/wk in last 3 months associated w/ at least 2 of the following 3: 1) related to defecation 2) onset associated w/ change in stool frequency 3) onset associated w/ change in stool form (appearance)

may present w/ bloody diarrhea, hx lower abd pain (erythema nodosum) and no mass on digital rectal exam

UC - Ulcerative Colitis

Patients who meet diagnostic criteria for IBS but cannot be accurately categorized into one of the other three subtypes

Unclassified IBS

What causes IBS?

Unknown

side effects of TCAs for IBS tx

blurred vision, dry mouth, constipation, rash, hives

IBS prognosis

can cause substantial physical discomfort and emotional stress, most are able to control symptoms and live normal life w/o serious health problems. Less than 5% are diagnosed with another GI condition.

side effects of Bile-acid sequestrians (cholestyramine) for IBS tx

constipation, abd pain, N/V, loss appetite

side effects of Polyethylene Glycol (PEG) such as Miralax for IBS tx

nausea, abd pain, gas

IBS-C tx

prokinetics bulk-forming laxatives Lubiprostone

Tx of IBS

symptomatic -dietary management and drugs including anticholinergics (hyoscyamine 0.125 mg po 30-60 min before meals may be used for their antispasmodic effects) and agents active at serotonin receptors -increase fiber -decrease dietaryf at -drug therapy directed toward dominant symptoms

When do pts typically present with IBS?

teens, early 20s