Presenter. Irritable Bowel Syndrome. Objectives. Introduction. Rome Criteria. Irritable Bowel Syndrome 2/28/2018

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1 Presenter Irritable Bowel Syndrome Current evidence for diagnosis & management Julie Daniels DNP, CNM Assistant Professor Course Coordinator of Primary Care of Women Faculty at Frontier Nursing University Since 2010 Tobacco Treatment Specialist No disclosures Objectives Analyze the clinical symptoms of irritable bowel syndrome. Rome IV criteria Compare and contrast irritable bowel syndrome, food intolerance and food allergies. Evidence for diagnosis Examine the current evidence on IBS management, including medications, probiotics and methods of incorporating the FODMAPS diet. Introduction Irritable Bowel Syndrome Epidemiology most common GI complaint [3.5 million visits / year] Females more than male Estimated 10-30% in Western cultures Racial & Socio-economic factors less clear Appears to be familial Annual direct & indirect costs 20 billion in US Irritable Bowel Syndrome Classified as Functional GI Disorder [now DGBI] A complex multi-factorial disorder Etiology no specific physiologic reason has been identified Suggested Causes Altered motility Microscopic inflammation Bacterial overgrowth Increased gut sensitivity Mental health problems Brain-gut signal problems, with suspected genetic linkage Rome Criteria Rome Criteria provides guidance What is ROME Criteria? Delphi method [consensus] Met in Rome, Italy in 1988 Rome IV pub 2016 Rome III pub 2006 More evidence for more recent editions FGIDs -> DGBIs: Disorders of gut brain interaction 1

Rome III to IV Changes Rome Criteria for IBS Timing Onset at least 6 months Recurrent abdominal pain At least 1 day / week Occurring in last 3 months Pain associated with at lease 2 of 3 Related to

2 Rome III to IV Changes Rome Criteria for IBS Timing Onset at least 6 months Recurrent abdominal pain At least 1 day / week Occurring in last 3 months Pain associated with at lease 2 of 3 Related to defecation Frequency Form Other associated factors Clear or white mucorrhea Dyspepsia / heartburn Nausea / vomiting Sexual dysfunction Urinary symptoms Comorbid fibromyalgia Systemic symptoms such as: Lethargy Tiredness Muscle aches Headaches Anxiety Low mood Symptoms may worsen with stress Symptoms worse during menses Three Types Constipation predominant Often resistant to fiber and laxatives Diarrhea predominant Mixed Differential Diagnoses Differential diagnosis list for IBS will be explored and cases presented to illustrate key features which can help rule in or rule out the diagnosis of IBS vs. other causes of GI symptoms. DIAGNOSING Food allergies Food intolerance Infections Other causes of GI symptoms Acute / serious Microbiome changes Helpful tools Food & symptom diary Apps 2

Micro Biome Testing Diagnostics ACG does not recommend laboratory testing or diagnostic imaging in patients younger than 50 years with typical IBS symptoms and without alarm features CBC, ESR, CRP if

3 Micro Biome Testing Diagnostics ACG does not recommend laboratory testing or diagnostic imaging in patients younger than 50 years with typical IBS symptoms and without alarm features CBC, ESR, CRP if inflammatory causes suspected Consider antibody testing only if Celiac suspected If alarm features [weight loss, GI / rectal bldg, anemia, mass, strong family hx colon CA, ovarian CA] refer Case example Best evidence will be explored regarding treatment options for IBS, including medications (including dosage, treatment duration and side effects), probiotics (including dosage, treatment duration and side effects), and dietary recommendations (including FODMAP diet). MANAGEMENT Management Goals Quality of life Reduction of symptoms Elimination / reduction pain First line Support Dietary modifications Fiber supplementation may improve the symptoms of constipation and diarrhea Polycarbophil compounds (eg, Citrucel, FiberCon) may produce less flatulence than psyllium compounds (eg, Metamucil) Judicious water intake is recommended in patients who predominantly experience constipation Caffeine avoidance may limit anxiety and symptom exacerbation Legume avoidance may decrease abdominal bloating Lactose, fructose, and/or FODMAPs (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) should be limited or avoided in patients with these contributing disorders 3

FODMAP Diet Restrict or eliminate foods w/ high potential to ferment in the gut Fermentation causes fluid shifts Increases bloating Increases gas Affects types of bacteria microbiome Other Diet

4 FODMAP Diet Restrict or eliminate foods w/ high potential to ferment in the gut Fermentation causes fluid shifts Increases bloating Increases gas Affects types of bacteria microbiome Other Diet Modifications Wheat-free Gluten-free Level B evidence: small RCTs Conflicting May improve sx pain, stool consistency, tiredness Prunes superior to psyllium fiber (Heidelbaugh, 2017) Medications Constipation Predominant Fiber Laxatives Prucalopride Linaclotide Lubiprostone Diarrhea Predominant Loperamide Rifaxmin Eluxadoline Anti-Depressants Amitriptyline [tricyclic agent] SSRIs Alternative Treatments Peppermint Oil Encapsulated, Extended release [new] Limits SE Evidence One recent study Participants dx w/ IBS mixed Acupuncture Biofeedback Exercise [one trial w/ signif. sx improvement (102p)] Herbal medicines Hypnosis Psychological treatments [CBT, IP, Relaxation / Stress Mgt] Evidence on Probiotics Probiotic use improves abdominal pain and global symptom scores in children and adults with irritable bowel syndrome. 3 studies Evidence level B: inconsistent or limited quality patient oriented evidence. 4

Probiotics Take Aways Source: Wilkins & Sequoia, 2017 Use Rome IV [Most recent] Criteria For those under 50 with good fit to criteria, no testing needed Listen, affirm & support Use shared decision

5 Probiotics Take Aways Source: Wilkins & Sequoia, 2017 Use Rome IV [Most recent] Criteria For those under 50 with good fit to criteria, no testing needed Listen, affirm & support Use shared decision making for management plan Best evidence supports dietary changes, probiotics & medications Questions References Gentry, J., Sherwood, L., Haynes, J. (2017). Gluten-free diet for irritable bowel syndrome. American Family Physician, 96(1), 52. Heidelbaugh, J. (2017). These 3 tools can help you streamline management of IBS. The Journal of Family Practice, 66(6), Marsh, A., Eslick, E.M., & Eslick, G.D. (2015). Does a diet low in FODMAPs reduce symptoms associated with functional gastrointestinal disorders? A comprehensive systematic review and meta analysis. European Journal of Nutrition, 55(2016), Pauls, R., & Max, J. (2017). Symptoms and Dietary Practices of IBS Patients Compared to Healthy Subjects: Results of a US National Survey. Journal of the Academy of Nutrition and Dietetics, 117(10), A130. Ruepert L, Quartero AO, de Wit NJ, van der Heijden GJ, Rubin G, Muris JWM. Bulking agents, antispasmodics and antidepressants for the treatment of irritable bowel syndrome. Cochrane Database of Systematic Reviews 2011, Issue 8. Art. No.: CD DOI: / CD pub3. Schmulson, M.J. & Drossman, D. (2017). What is new in Rome IV. Journal of Neurogastroenterol Motility, 23(2), Simren, M., Palsson, O., & Whitehead, W. (2017). Update on Rome IV Criteria for Colorectal Disorders: Implications for Clinical Practice. Current Gastroenterology Rep., 19(2017), 15. DOI /s Wilkins, T., Sequoia, J. (2017). Probiotics for gastrointestinal Conditions: A summary of the evidence. American Family Physician, 96(3), Vanuytsel, T., & Boeckxstaens, G. (2014). Treatment of abdominal pain in irritable bowel syndrome. Journal of Gastroenterology,,

Diagnosis and Management of Irritable Bowel Syndrome (IBS) For the Primary Care Provider

Diagnosis and Management of Irritable Bowel Syndrome (IBS) For the Primary Care Provider Elizabeth Coss, MD General Gastroenterologist Audie Murphy Veterans Hospital UT Health This presentation does not