Irritable Bowel Syndrome

Transcription

1 Irritable Bowel Syndrome A Simple Tool for Identification and Dietary Management Dr Adrian Gilliland, GP and Clinical Advisor Primary Care, Capital and Coast DHB. Dr Rees Cameron, Gastroenterologist, Capital and Coast DHB. Sarah Elliott, Dietitian, Foodsavvy, Taranaki St., Wellington. Jon Herries, Program Director, Integrated Care Collaborative, Capital and Coast DHB. 1 Overview What we Did? What is IBS? Diagnosis and Investigations Medical Management Dietary Management including FODMAPs Results and impacts so far 2 1

2 Clinical Pathways Collaborative Facilitated group of clinicians including Gastroenterologists, GPs, General Surgeons, Dietitians and managers Defined program of 5 meetings Identified IBS as significant opportunity for improving care for patients Developed 2 resources Simple Guide to Identifying and Investigating of IBS symptoms Dietary Management of Irritable Bowel Syndrome 3 Education 3 education sessions on IBS 123 individual Primary Care Clinicians attended Feedback 100% agreed and over 80% strongly agreed that the sessions presented new, relevant information and updated knowledge. Resources made available on: 4 2

3 What is IBS? Part of the spectrum of human bowel habit Disorder of normal gut function Can involve any part of the GI tract Oesophagus: NERD/non-cardiac chest pain Stomach: non-ulcer dyspepsia Small and large bowel: IBS Diarrhoea-predominant Constipation-predominant Mixed Alternating 5 Pathophysiology Central sensitisation (brainstem, cord) Disordered gut motility Visceral hypersensitivity 6 3

4 Common Typically population surveys give prevalence of 10-30% A much larger percentage probably experience IBS symptoms at some point in life but do not consult medical services 7 What causes IBS? Genes? Personality traits Acute gastroenteritis Diet? 8 4

5 What causes IBS Diet? Genetically, modern humans are identical to those living at least 30,000 years ago In the intervening period Domestication of wheat, maize and rice (from ~10,000 yrs ago) Domestication of cattle (~9,000 yrs) adult consumption of milk products Cultivation (~3,000 yrs) and widespread use (~400 yrs) of cane sugar Highly efficient milling of wheat for white flour (~250 yrs) Fortification of Western diets with wheat bran (~100 yrs) Fortification of Western diets with fructose (~40 yrs) Modern diets bear little resemblance to those of 30,000 years ago! 9 Diagnosis of IBS In most, a clinical diagnosis Made by history and physical exam Not a diagnosis of exclusion Rome III criteria: Recurrent pain or discomfort at least 3 days a month for 3 months with 2 or more of: Improvement with defaecation Onset associated with change in stool frequency Onset associated with change in stool form Manning criteria Pain relieved by defaecation More frequent or looser stools at onset of pain Visible abdominal distension Passage of mucus per rectum Sense of incomplete evacuation 10 5

6 These symptoms suggest IBS Fatigue typically worse when abdominal symptoms are worse Abdominal pain that radiates to lower back or down thighs Deep dyspareunia in the context of other suggestive bowel symptoms Bladder instability in the context of other suggestive bowel symptoms 11 These don t... Dysphagia Persistent rectal bleeding usually haemorrhoidal but generally needs some form of visual examination Progressive weight loss Persistent diarrhoea never has normal motion Constant pain, particularly away from midline Nocturnal pain Strong family history of colorectal cancer particularly if first degree relatives affected 12 6

7 Investigations I m just ordering these to make sure nothing else is going on Coeliac serology remember it is the anti-ttg titre that is the test, the IgA level only tells you the power of the test FBC if Fe deficient anaemia present then seek Gastroenterology opinion. Persistent thrombocytosis/leucocytosis might indicate underlying inflammation CRP TFTs and Ca/PO 4 if constipation predominant Liver enzymes if upper abdominal symptoms predominant Faecal calprotectin? Be very selective young patients with family history IBD, localised abdominal pain, extra-intestinal symptoms Don t order USS unless LFTs abnormal Don t order AXR 13 Management - fear What are the patient s concerns? what do you think is going on? Reassurance and explanation of symptoms are often all that is needed Very occasionally the only reassurance will be colonoscopy refer with expectation that it will be normal 14 7

8 Managing constipation Regular gentle exercise Habit training Make use of intrinsic reflexes by toileting after meals Toilet with box under feet to raise knees above hips, and lean forward Don t strain! Increase fruit and vegetable fibre (not wheat) Psyllium Laxatives don t use lactulose If bloating a problem, try the low FODMAP diet 15 Managing diarrhoea Psyllium Loperamide Low FODMAP or low cereal fibre diet 16 8

9 Cramping pain Peppermint oil capsules, or Buscopan 17 Managing severe pain symptoms (these patients generally need gastroenterologist input) Avoid opiates! Cause constipation, may cause narcotic bowel syndrome Avoid surgical or chronic pain service referral Achieve 2 motions daily through diet, laxatives Rule out endometriosis in women Nortriptyline mg o.d. Consider gabapentin Hypnotherapy probably the most effective therapy 18 9

10 Historical dietary recommendations Increased fibre Adequate fluid Regular physical activity Avoid triggers Highly spiced food Fatty food 'Windy' vegetables e.g. legumes, cabbage Large portions / eating too fast Caffeine / alcohol 19 Current dietary management Fibre manipulation (if deemed appropriate) Soluble vs. insoluble fibre High vs. low fibre intake Cereal fibres Identify potential triggers More exploration now Before any dietary changes check criteria 20 10

11 FODMAPs Poorly absorbed, short-chain carbohydrates Fermentable Oligo-saccharides Di-saccharides Mono-saccharides And Polyols 21 FODMAPs when are they indicated? IBS unresponsive to traditional advice IBD with IBS like symptoms particularly when disease controlled Coeliac disease without complete resolution of symptoms with strict gluten (and lactose) free diet Those avoiding gluten with partial improvement in symptoms 22 11

12 FODMAPs when are they not indicated? IBS associated with eating disorders?uncontrolled IBD Asymptomatic IBD Caution with low body weight unless symptoms contributing to this and investigations clear ('reduced' FODMAP) Other symptoms including headaches, rashes, asthma, eczema, allergies (incl. drug) Would consider a specialised low chemical diet first (RPAH allergy unit) 23 FODMAPs - how they work. FODMAPs are small so when malabsorbed, can have an osmotic effect = diarrhoea. Sugars reach large intestines, fermented by bacteria = gas. Gas in small and/or large intestines = wind, bloating, discomfort, nausea and abdo cramps. Gas can slow movement through bowel = constipation

13 Large intestine Small intestine FODMAPs water delivery Luminal distension gas production Diarrhoea, pain, bloating, distension, wind FODMAPs Fructans (e.g. wheat/rye, onion, garlic) Galactans GOS (e.g. windy vegetables, legumes) Polyols (e.g. 'ol' artificial sweeteners, stone fruit) Fructose (e.g. apple, pear, honey) Lactose (sugar in milk) 26 13

14 FODMAPs All humans have limited ability to digest: Fructans, GOS & polyols If FODMAPs are an issue, all will benefit from reduction Variable Fructose present in 30-40% of healthy individuals and those with IBS, breath test Lactose present in some, breath test 27 GP Involvement 1. Identify a need 2. Check with criteria 3. Consider using the GP resource Caution with overly restrictive types to stress reduction vs. avoidance 4. Referral to dietitian if appropriate 28 14

15 GP Resource Step 1: Are you following healthy eating guidelines? Food Eat a variety of foods from the 4 food groups each day * Include an adequate fibre intake Drink 6-8 cups of fluid each day (including water, tea, coffee, Milo, juice) Eat regular meals and snacks Other Exercise regularly (30 minutes most days) Address stress management * Use the Ministry of Health Eating for Healthy Adult New Zealanders resource 29 GP Resource Step 2 - Have you tried avoiding common triggers? Highly spiced foods Fatty foods Alcohol Caffeine (including tea, coffee and energy drinks) Windy vegetables i.e. onion, cabbage, brussel sprouts, peas, corn and legumes (e.g. lentils, chickpea, baked beans) 30 15

16 GP Resource Step 3: Then reducing your FODMAPs may help. Apple & pear (and their juice) Too much fruit/dried fruit/juice Honey Fructose Onion & garlic Artificial sweeteners ending in ol (sorbitol, mannitol, xylitol, isomalt) 31 Nutritional Management If patient improves fantastic! Encourage to discover tolerance. If partial or no improvements, refer to dietitian Complete low FODMAP diet needs guidance and education from a dietitian Information available on the internet is inconsistent, unreliable and often contradictory 32 16

17 300 Results at 18 months Total Number of Referrals 250 At 18 months P< % Jan-08 Jul-08 Jan-09 Jul-09 Jan-10 Jul-10 Jan-11 Jul-11 Jan-12 Average number of referrals has dropped from 172 per month to 143 per month. (17% reduction) Results at 18 months Number of FSAs 90 At 18 months P< % Jan-08 Jul-08 Jan-09 Jul-09 Jan-10 Jul-10 Jan-11 Jul-11 Jan Average number of FSAs has dropped from 71 per month to 61 per month. (14% reduction) 34 17

18 Projected Growth FSA Projections / / / /13 Projected* 2013/14 Projected 2014/15 Projected 2015/16 Projected Previous Growth Rate Projected with Project Actual We estimated that the effect would dissipate over 2 years, and growth (running at 6%) would return at the same rate. So far the actual change has been greater than we expected, The first 2 months of 2012/13 the growth in FSAs is following our original scenario. 35 Actual and Projected Savings Projected Accrued Savings $1600 K $1400 K $1200 K $1000 K $800 K $600 K $400 K $200 K $ K 2009/ / / / / / /16 FSAs Follow Ups Saved $495k in capacity - Based on actual performance since 09/10 Projected to be $1.5 million to 2015/16 (not adjusted for inflation)

19 Summary IBS is common and part of the spectrum of normal human bowel habit In most, IBS is a clinical diagnosis not a diagnosis of exclusion. If the symptoms on history are consistent and no symptoms or history suggesting other pathology and investigations are normal, then initial management should be dietary. Worth trialling those with unmanaged symptoms of IBS on a reduced FODMAP diet. Referral to dietitian for low FODMAP diet. From experience, many will manipulate their own diet or seek advice from alternative health practitioners, therefore structure and sound advice needed. Clear explanation from initial appointment of reduced load vs. total avoidance. Patients with IBS can be managed effectively in Primary Care settings with appropriate tools