Melbourne GI & Endoscopy

Transcription

1 1 Melbourne GI & Endoscopy Multi-disciplinary care for your patients Gastroenterology Hepatobiliary & upper gastrointestinal surgery Colorectal surgery Oncology Perioperative care One contact & one address for all your GI care P F E admin@mgie.com.au W Grey St, East Melbourne

2 Irritable Bowel Syndrome Work-up, a positive diagnosis & treatment options Dr. Anthony Rode MBBS (Hons), FRACP, PhD MELBOURNE GI & ENDOSCOPY EPWORTH FREEMASONS EPWORTH RICHMOND

3 IBS overview Comprises a group of functional bowel disorders in which abdominal discomfort or pain is associated with defecation or a change in bowel habit, and with features of disordered defecation. Thompson et al, 1999

4 Case discussion 42 y.o M, works in finance high stress job Crampy abdominal pain and bloating for 12 months Occasional diarrhea, no blood. Never constipated Another G.P has told him he has IBS but she wants a second opinion. Comes to see you.

5 Case discussion - continued Other history Lost 2-3kg weight over 6 months (BMI 23), but been going to the gym No PR blood Regular meds: mobic for headaches. G.P: Blood tests FBE normal LFTs normal CRP normal. 5

6 Case discussion: other blood tests? Coeliac serology - negative Vitamin D: 30 Iron studies: Ferritin 58

7 Case discussion Ferritin = storage form of iron best measure of iron def. Family history father CRC at 53 yo Possibilities? Serology negative coeliac disease Inflammatory bowel disease Need to screen for CRC REFER: Gastroscopy and colonoscopy

8 Gastroenterologist r/v Referred for open access endoscopy: Gastroscopy/colonoscopy No sign of coeliac disease on duodenal biopsies Normal terminal ileum biopsy and random colon biopsies No polyps Post scopes review: Relieved doesn t have CRC/polyps (father has a bag ) Friend had done breath testing for similar symptoms

9 Lactose & fructose intolerance Saw our dietician

10 Ongoing review Compliant with dietary interventions Bloating improved, less abdominal pain Needs follow up colonoscopy in 5 years

11 IBS or not? Red flags Weight loss Iron deficiency PR bleeding Pain wakes at night Nocturnal diarrhoea New onset symptoms Family history of IBD/coeliac

12 Rome III Irritable Bowel Syndrome Diagnostic Criteria Recurrent abdominal pain or discomfort** at least 3 days per month in the last 3 months associated with 2 or more of the following Improvement with defecation Onset associated with a change in frequency of stool Onset associated with a change in form (appearance) of stool Criteria fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis. **Discomfort means an uncomfortable sensation not described as pain Gastroenterology 2006;130:

13 Subtyping of IBS Important to subtype because they are associated with different treatment options and pathophysiologic mechanisms IBS constipation predominant IBS diarrhoea predominant IBS mixed IBS unsubtyped

14 Pathophysiology

15 QUALITY OF LIFE

16 A positive diagnosis of IBS

17 Red flags History & examination Unintentional weight loss PR bleeding Fever Severe diarrhoea/constipation Onset in older patient (>50 years) Family history of cancer or IBD Investigations Low Hb High WBC, CRP, ESR Nutritional deficiencies iron, B12, folate Positive coeliac serology Abnormal colonoscopy

18 Need to rule out underlying pathology 90% of patients with classical IBS symptoms have the diagnosis BUT 10% DON T Coeliac IBD Microscopic colitis Pancreatic dysfunction

19 The Manitoba Inflammatory Bowel Disease Cohort Study: Prolonged Symptoms Before Diagnosis How Much Is Irritable Bowel Syndrome? 400 pts with IBD Mean time between symptom onset and diagnosis 11 years - 49% had likely IBS or possible IBS before diagnosis - 1/5 pts had an inadequate work-up for IBD - If IBS relative risk of IBD = 16 times higher than general population* - IBS delays IBD diagnosis - BE CAREFUL Burgman et al. CGH 2006, *Rodriguez

20 Medical work up optional Imaging Upper abdominal US CT abdomen or MRI Breath testing Fructose & lactose intolerances most common Others Gastric emptying studies/transit studies ph studies Manometry

21 TREATMENT

22 TREATMENT Education Dietary manipulation Medications Cognitive therapy Hypotherapy

23 Treatment

24 Diet history Breakfast Latte and a muffin Often skipped Lunch Wrap with chicken, cheese, mayo, lettuce OR takeaway noodles Afternoon Occasionally Chips, latte Dinner Grilled meat, mashed potato, cauliflower, beans Soup Out at least 2-3 nights per week Pasta, risotto or noodles or Thai curries Drinks Coffee and water, vodka and soda when out

25 Initial Education Outline Low FODMAP FODMAPs and the mechanism of action Lactose, fructose, fructan/gos, polyol restriction total FODMAP Meal Pattern restriction Discuss quick breakfast options spelt toast, yoghurt and fruit (suitable), quick oats Eating Out Discuss suitable options grilled meat and vegetables (suitable), rice noodles/rice dishes, state no onion/garlic, ask waiter for onion/garlic free options Fibre Adding breakfast daily will help Increase fruit (suitable), nuts, vegetables (suitable) Iron Opt for red meat options when possible + choose foods high in vitamin C with meals broccoli etc Fortified products cereals, soy milks

26 Review 4 weeks later Outcome: Symptoms improved Compliant most days, off diet some days reacts but understands why and is happy with this What now?

27 What now? Only need to follow the diet as strictly as symptoms require Level of restriction varies with: Individuals level of tolerance Different FODMAP subtypes Why tolerance test? FODMAPs are found in fibre-rich foods and have a prebiotic effect therefore long term strict compliance with diet is not ideal Long term goal is to achieve balance restricting some high FODMAP foods to level that provides symptomatic response, but allows moderate/occasional intake of FODMAP-rich foods

28 Testing Tolerance Consume small amounts of the test food to determine if you can get away with small doses of the FODMAP in question An individual may malabsorb the FODMAP, e.g in this case fructose, but can tolerate small amounts of honey e.g. as an ingredient in a fruit free muesli bar Encourages the individual to build up intake to level of tolerance

29 SUMMARY IBS work-up 1. Think of alternative diagnoses 2. Ask about Red flags 3. Remember nobody gets it right all the time Average time from symptom to a diagnosis of IBD = 11 years Have a low threshold for suggesting gastroenterology review: It is better for us to see a patient with IBS and confirm this, than to miss a diagnosis of a more serious condition