UKLIN1693a, date of preparation: March 2013.

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Wilfrid Tucker
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2 This table shows the ICE model. Defining the patient s ideas, concerns, and expectations is an important part of the consultation that can lead to better outcomes. 2

Patients with IBS may have visceral hypersensitivity (enhanced perception of gut stimuli) and abnormal patterns of endogenous pain modulation: 1 Supraspinal: cognitive, emotional, and autonomic

3 Patients with IBS may have visceral hypersensitivity (enhanced perception of gut stimuli) and abnormal patterns of endogenous pain modulation: 1 Supraspinal: cognitive, emotional, and autonomic processes can alter pain modulation (green arrow) Spinal: a number of molecular mechanisms can affect whether peripheral inputs are enhanced (central sensitization) or inhibited (red arrow) Peripheral: injury or inflammation can lead to persistent peripheral input (peripheral sensitization red arrow) NB. Peripheral injury is not always present, but can exacerbate symptoms. This visual can be used when explaining the mechanisms of pain to IBS patients. It can also be used to explain how psychosocial factors can affect the gut. 1. Wilder-Smith CH. The balancing act: endogenous modulation of pain in functional gastrointestinal disorders. Gut 2011; 60:

Stressors can produce symptoms through physiological or psychological mechanisms: 1 Early life factors such as parents response to illness, exposure to infections, and genetic factors (for

immunity, and visceral hypersensitivity can affect one s susceptibility to gut dysfunction These psychosocial and physiological influences can reciprocally affect each other through the brain-gut

4 Stressors can produce symptoms through physiological or psychological mechanisms: 1 Early life factors such as parents response to illness, exposure to infections, and genetic factors (for example, serotonin reuptake transporter polymorphisms) affect one s susceptibility to life stress and the development of coping skills Physiological influences including abnormal motility, altered immunity, and visceral hypersensitivity can affect one s susceptibility to gut dysfunction These psychosocial and physiological influences can reciprocally affect each other through the brain-gut axis, and IBS is a product of the interaction between these two sets of factors 1. Drossman DA. The functional gastrointestinal disorders and the Rome III process. Gastroenterology 2006; 130:

Using an explanatory model that is relevant to the patient s ideas and

5 Explanatory models are concepts of a disease that explain aspects such as aetiology and pathophysiology. Using an explanatory model that is relevant to the patient s ideas and concerns about their symptoms may help them to accept a diagnosis. The visual can be used when explaining gut motility to patients. 5

In a healthy gut, the gut wall has no gaps and a thick layer of good bacteria (gut flora), and the bad proteins cannot get through However, a gut infection can cause holes in the gut walls and reduce

6 Approximately 17% of IBS patients in the UK have post-infectious IBS; IBS that develops after a specific bout of gastroenteritis. 1 This visual may help to explain the mechanisms of post-infectious IBS with diarrhoea (IBS-D) to patients. In a healthy gut, the gut wall has no gaps and a thick layer of good bacteria (gut flora), and the bad proteins cannot get through However, a gut infection can cause holes in the gut walls and reduce the number of bacteria, making the gut leaky and allowing bad proteins to get through the gut wall This leads to an immune response This response targets the gut, causing symptoms such as diarrhoea and abdominal pain 1. BSG guidelines: Spiller R, Aziz Q, Creed F, Emmanuel A, Houghton L, Hungin P, et al. Guidelines on the irritable bowel syndrome: mechanisms and practical management. Gut 2007; 56:

Psychological distress such as bereavement may open the gate for pain, whereas intense concentration such as

7 The figure on the slide can be used to explain the pain-relieving effect of antidepressants to patients together with the explanatory model below: Pain sensation from the gut to the brain is controlled by a pain gate Psychological distress such as bereavement may open the gate for pain, whereas intense concentration such as playing sports closes the gate Antidepressants work by closing the gate At low doses, antidepressants will not affect mood 7

Rome III: an ongoing journey for better diagnosis and treatment of functional gastrointestinal disorders

Mædica - a Journal of Clinical Medicine EDITORIALS Rome III: an ongoing journey for better diagnosis and treatment of functional gastrointestinal disorders Mircea DICULESCU, MD, Tudor ARBANAS, MD Gastroenterology