Irritable Bowel Syndrome. Mustafa Giaffer March 2017

Size: px

Start display at page:

Download "Irritable Bowel Syndrome. Mustafa Giaffer March 2017"

Juliet Sutton
6 years ago
Views:

1 Irritable Bowel Syndrome Mustafa Giaffer March 2017

2 Introduction First described in % of patients present <35 years old. Global prevalence of 11% UK prevalence of 14% GPs will diagnose one new case per week. GPs will see 4-5 patients a week with IBS. 2

3 What Is IBS? A syndrome. One man s constipation is another man s normality. Cause unknown. 20% seem to start after an episode of gastroenteritis. 3

4 Why IBS so imprtant Highly prevalent May profoundly impair QOL Costly to society

5 Issues related to IBS Diagnosis GP concerns Patient concerns and expectations Management

6 Diagnostic Criteria Rome Diagnostic criteria I,II and III Kruis Score Manning s Criteria. 6

7 Rome 11 Diagnostic Criteria. Supportive symptoms. Constipation predominant: one or more of: BO less than 3 times a week. Hard or lumpy stools. Straining during a bowel movement. Diarrhoea predominant: one or more of: More than 3 bowel movements per day. Loose [mushy] or watery stools. Urgency. 7

8 Rome 11 Diagnostic Criteria. General: Feeling of incomplete evacuation. Passing mucus per rectum. Abdominal fullness, bloating or swelling. 8

9 Rome 11I Diagnostic Criteria. Recurrent abdominal pain or discomfort at least 3 days / month in the past 3 months associated with two or more of the following: Improvement by defecation. Onset associated with change in stool frequency. Onset associated with change in form of the stool. 9

10 Manning s Criteria. Three or more features should have been present for at least 6 months: Pain relieved by defecation. Pain onset associated with more frequent stools. Looser stools with pain onset. Abdominal distension. Mucus in the stool. A feeling of incomplete evacuation after defecation. 10

11 Functional constipation Straining during at least 25 % of defecations Lumpy or hard stools in at least 25 % of defecations Sensation of incomplete evacuation for at least 25 % of defecations Sensation of anorectal obstruction / blockage for at least 25 % of defecations Manual maneuvers to facilitate at least 25 % of defecations (e.g., digital evacuation, support of the pelvic fl oor) Fewer than three defecations per week 11

12 Associations with IBS Psychological problems Depression Anxiety Upper GI symptoms Urinary bladder symptoms Chronic fatigue syndrome Headache Chronic pelvic pain syndrome

13 Be aware.. Nocturnal symptoms Weight loss Rectal bleeding Older than 45 FH of CRC or IBD Anaemia Raised inflammatory markers 13

14 Subtypes Diarrhoea-predominant (IBS-D) Constipation predominant (IBS-C) Mixed type (IBS-M) Unclassified (IBS-U) 14

15 Reasons for GP Referal Age > 45 years at onset. Family history of bowel cancer. Failure of primary care management. Uncertainty of diagnosis. Abnormality on examination or investigation. 15

16 Patient s concerns Uncertainty about diagnosis. Treatment. Phobias. Psychological factors. 16

17 Initial assessment Good history Abdomen and rectal examination. FBC, BCP, CRP. Coeliac screen and faecal calprotectin + pelvic US No consensus as to whether FOBs or sigmoidoscopy is needed. 17

18 When endoscopic investigations will be needed Presence of alarm features Change in the pattern of IBS symptoms Failure of standard treatment

19 Treatment Patients concerns. Patient s expectations Explanation. Treatment approaches. 19

20 Frustration Ignorance Avoid Showing lack of interest

21 Explanation. Must offer a plausible reason for symptoms. Address patient concerns Why investigations are needed/not needed Prognosis 21

22 Treatments 1. Diet and dietary manipulation 2. Fiber 3. Interventions that modify the microbiota: probiotics, prebiotics, antibiotics 4. Antispasmodics 5. Peppermint oil 6. Loperamide 7. Antidepressants 8. Psychological therapies, including hypnotherapy 9. Serotonergic agents 10. Prosecretory agents 11. Polyethylene glycol 22

23 Treatments 12. Biofeedback 13. Bile acid transporter inhibitors 14. Probiotics 15. Questran 23

24 IBS-D Cholestyramine Loperamide Ramosetron (males only)

25 IBS-C Simple laxatives Prucalopride (5HT RA) Lubiprostone (stimulate type 2 chloride channels) Linaclotide (guanylate cyclase C agonist)

26 IBS-M Same as IBS-C and IBS-D. GFD Fermentable olig-, di-, and monosaccharides and polyos,( FODMAP diet)

27 Alternative medicine Psychotherapy Hypnotherapy Acupuncture

28 Emerging drugs Rifaximine : (IBS without constipation) Eluxadoline : mixed opioid receptor agonist and antagonist Ibodutant : selective neurokin receptor antagonist. Ketotifen : mast cell stabliser Ebastine : histamine 1 Receptor antagonist

29 Self-help IBS network 29

30 What to read Modern management of irritable bowel syndrome: More than motility. Dig. Dis (34):

Irritable Bowel Syndrome (IBS)

Irritable Bowel Syndrome (IBS) Dr Rex J Polson 17 th January 2018 Overview Description of the condition Discussion of symptoms and investigations that may be required Discussion of management and treatment