Irritable Bowel Syndrome

Transcription

1 Irritable Bowel Syndrome Irritable Bowel Syndrome Jeffrey Jump, MD CHI Memorial Integrative Medicine Associates Chronic abdominal pain and altered bowel function in the absence of known organic cause for at least three months Prototype of Functional Bowel Disorders Prevalence Diagnosis Affects 10-15% of the population 2:1 3:1 female to male ratio 15% seek medical attention, but account for 25-30% of all GI referrals Second highest cause of work absentism Rome III Criteria Recurrent abdominal pain/discomfort for at least three months with at least two of the following Improvement with defecation Onset associated with change in frequency of stools Onset associated with change in form of stools Supportive Symptoms IBS Subtypes Abnormal Stool Frequency: 3/week or 3/day Abnormal stool form: hard/lumpy, loose/watery Defecation straining, urgency, or a feeling of incomplete bowel movement, passing mucous and bloating IBS-C: hard/lumpy 25%, loose/watery 25% of BM s IBS-D: loose/watery 25%, hard/lumpy 5% of BM s IBS-M: hard/lumpy 25%, loose/watery 25% of BM s Unspecified: insufficient consistency of stool consistency to meet above criteria 1

2 Diagnostic Approach Role of Alarm Symptoms Individual symptoms have limited accuracy for diagnosing IBS and, therefore, the disorder should be considered as a symptom complex. Alarm Symptoms Rectal Bleeding Nocturnal or progressive pain Weight Loss Lab abnormalities: anemia, increased inflammatory markers and/or electrolyte abnormalities Family history of IBD, CRC, Celiac disease 2009 ACG recommendations for diagnosis of IBS: in patients who fulfill symptom-based criteria of IBS, the absence of selected alarm features, including anemia, weight loss, and a family history of colorectal cancer, inflammatory bowel disease, or celiac sprue, should reassure the clinician that the diagnosis of IBS is correct. R.S. 26 y/o female Past Medical History CC: Chronic diarrhea, bloating and cramping. HPI: Onset in high school of intermittent loose bowels, up to 5-6 times a day, assoc. with bloating, abdominal discomfort and cramping relieved by BM s. Increased at times of stress BM s frequently soon after eating No other assoc. provoking factors or timing No alarm features PCOS with irregular and heavy periods controlled with BCP s MCTD IFG and elevated triglycerides meets criteria of metabolic syndrome GERD IDA in high school Medications: Plaquenil Mobic prn BCP s Pepcid prn Family History Social History Father: DM-2, Hypertension Mother: MG, Asthma, Morbid Obesity No history of CRC or other GI disease RN Recently divorced Moderate alcohol use, with some episodes of binge drinking No Tabaco use 2

3 Physical Exam Routine Lab 56 tall, 200 lbs. BMI: 32.3 Normal vital signs and normal exam CBC and CMP normal except mildly elevated blood sugar at 103 fasting TSH 1.34 ESR 12 Celiac Testing Celiac Disease Positive for serum IgA antibody to tissue transglutaminase Father and one sister also tested positive for Celiac Routine serologic screening for celiac sprue should be pursued in patients with IBS-D and IBS-M 2009 ACG recommendations for diagnosis of IBS Meta-analysis of 14 studies focusing on unselected adults who met diagnostic criteria for IBS, celiac disease was four times as likely as in controls without IBS 4% A prospective multicenter US study compared the prevalence of abnormal celiac antibodies and biopsy proven celiac disease in patients with nonconstipated (NC) IBS to that of healthy controls. Although more than 7 percent of NC-IBS patients had celiac disease associated antibodies suggesting gluten sensitivity, the prevalence of biopsy proven celiac disease was similar in NC-IBS and controls Disposition KW 36 y/o male RS had started a strict gluten free diet with resolution of her symptoms. She did not desire endoscopy confirmation of the diagnosis. Presenting complaint of diarrhea associated with significant bloating, especially after meals for the past 3+ years. Symptoms are daily with 3-4 loose watery BM s/day. No weight loss or rectal bleeding. No nocturnal symptoms. Mild cramping relieved by defecation. 3

4 Past Medical History Family History GERD with grade 1 esophagitis on endoscopy at age 28, small bowel biopsy negative for Celiac Medication Omeprazole 20mg daily Father: CAD with an MI at age 52 No history of CRC or other GI disease Social History Physical Exam Married with 3 children Lawyer with high stress levels Social alcohol use, no Tabaco use Frequent camping, hunting, fishing and hiking 74 inches tall, 200 lbs. BMI 25.7 Normal vital signs and exam Routine Lab Other Testing CBC and BMP and Magnesium normal B12: 350 pg/ml Stool O&P negative 4

5 Diagnosis SIBO IBS - D Possible Small Intestinal Bacterial Overgrowth SIBO Why? Suspicion of SIBO in chronic PPI use Theory of SIBO as underlying pathophysiologic mechanism for IBS - JAMA. 2004;292(7): Condition in which non-native bacteria and/or native bacteria are present in increased numbers in the proximal small bowel resulting in excessive fermentation, inflammation, or malabsorption. Present with nonspecific symptoms of bloating, flatulence, or abdominal discomfort and diarrhea Most patients with SIBO have no laboratory abnormalities SIBO - Diagnosis Breath Tests Jejunal aspirate cultures, considered the reference standard for the diagnosis of SIBO, have limitations in diagnosis and sensitivity and specificity. Invasive Culture is difficult and only approximately 40 percent of the total gut flora can be identified using conventional culture methods Oropharyngeal contamination is common Bacterial overgrowth can be patchy Studies to evaluate the performance of breath tests to diagnose SIBO have several limitations including heterogeneity in patient populations, small sample sizes, and the use of cutoffs to define a positive test that have not been validated. Not to mention that the gold standard to which to compare breath testing has difficulties that we just discussed Lactulose breath test has a sensitivity of 17 to 68 percent and specificity of 44 to 86 percent Poor reproducibility Breath Test Treatment Plan Negative Predictive Value: SP_x_(1-Prev) (1 Sen)x Prev + SP x (1-Prev) sensitivity of 17 to 68 percent and specificity of 44 to 86 percent Prevalence of SIBO Meta-analysis chronic PPI use found OR, 7.587; CI, of SIBO on aspirate 500 PPI users and 200 IBS patients: prevalence of 50% and 24.5% respectively Negative Predictive Value between 34.6% % FODMAP diet FODMAPs are short chain carbohydrates, may not be digested or absorbed well and are fermented upon by bacteria in the intestinal tract The FODMAPs: Fermentable Oligo-, Di-, Mononsaccharides and Polyols Fructose (fruits, honey, high fructose corn syrup (HFCS), etc) Lactose (dairy) Fructans (wheat, garlic, onion, inulin etc) Galactans (legumes such as beans, lentils, soybeans, etc) Polyols (sweeteners containing isomalt, mannitol, sorbitol, xylitol, stone fruits such as avocado, apricots, cherries, nectarines, peaches, plums, etc) 5

6 FODMAP Diet Treatment Plan Most IBS patients have visceral hypersensitivity and symptoms may be triggered by luminal distension. A high FODMAP diet has been shown to lead to luminal distension through colonic fermentation and increased delivery of fluid to the colon. In patients with SIBO reducing these carbohydrates may also lessen the development of D-lactic acidosis, the production of small bowel gas, bloating, and discomfort. Wean off omeprazole by taking qod for 1 month and then stopping, using OTC famotidine prn DGL 2 tabs before each meal Rifaximin 550mg TID for 10 days Disposition SD 41 y/o female Resolution of IBS symptoms within the first week of rifaximin treatment and going on the FODMAP diet Recurrence after about 2 months with reintroduction of carbohydrates to the diet. Repeated the treatment with rifaximin and continued the FODMAP for 2-3 months, after which he has had resolution of IBS symptoms Presenting Complaint: IBS Bloating and distention that is progressive over the day, starts with eating, discomfort that is described as clenching, tight and achy, periumbilical/generalized Constipation: able to have BM most days with taking Magnesium nightly, but never feels like BM is adequate. No diarrhea Ongoing most of adult life Increased symptoms noted with stress Past Work-up Past Treatments EGD 2005 unremarkable Celiac testing by serology and biopsy negative in 2005 H. Pylori serology negative in 2005 Unremarkable abdominal U/S in 2005 Omeprazole no benefit Dicyclomine no benefit Gluten and dairy free diet past several years minimal affect on GI symptoms, but states she has noted decreased aching in joints, so has maintained diet 6

7 Past Medical History Family History ADD B12 and Vitamin D deficiency No medication OTC s: Multivitamin Fish Oil Magnesium Citrate Vitamin D Adopted and unknown Social History Physical Exam Married with 3 children ages 3, 6, and 8 Less than one alcoholic drink a week Quit smoking in pack/year history 66 inches tall, 142 lbs., BMI 22.9 Vital signs and exam normal Routine Lab Diagnosis CBC: normal TSH: 1.21 Vitamin B12: 469 Folate: 26.3 Homocysteine: 6.5 Vitamin D 25-OH: 40 IBS - C 7

8 Treatment Plan FODMAP DIET FOMAP s diet Referral for biofeedback The Low FODMAP Diet Improves Gastrointestinal Symptoms in Patients With Irritable Bowel Syndrome R. H. de Roest; Int J Clin Pract. 2013;67(9): The observation that constipation also improved on a low FODMAP diet may seem counterintuitive given the proposed mechanism of action for most FODMAPs. However, this may reflect other aspects of dietary advice, which ensure sufficient fibre and other dietary constituents as part of a balanced diet. A key aspect to the dietary advice is ensuring not only that trigger foods are removed but also that the resultant diet is balanced. It is conceivable that this may have led to more fibre in the diet of those who previously had low fibre diets and were constipated. Stress and IBS Disposition One unifying hypothesis concerning the role of stress in IBS is based upon corticotropin releasing factor (CRF) Data suggest that over activity in the brain CRF and CRF-receptor signaling system contributes to anxiety disorders and depression. Intravenous administration of CRF increases abdominal pain and colonic motility in IBS patients to a higher degree than normal controls. Furthermore, this response can be blunted by the administration of a CRF receptor antagonist with no effect on the hypothalamus-pituitary-adrenal axis. uptodate. At the time of this writing she had gone through 6 weekly sessions of biofeedback training and been following a FODMAP diet with significant reduction in her symptoms. She reports that her BM s are now normal, bloating and discomfort are significantly reduced, but not completely eliminated. 8