Inflammatory or Irritable? (the bowel, not the speaker)

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1 South GP CME Edgar Centre, Dunedin August 2014 Inflammatory or Irritable? (the bowel, not the speaker) Dr Jason Hill MBChB FRACP FRCP Edin Department of Gastroenterology, Southern DHB Dunedin School Of Medicine, University of Otago

2 Disclosures Advisory Board Baxter Healthcare NZ Honoraria - AbbVie - Abbott - Janssen Pharmaceuticals, Inc.

3 IBS or IBD? One man s constipation is another man s normality V Moore Gillan. Journal of the Royal Society of Medicine. 1984

4 Irritable bowel syndrome The most common GI diagnosis 1 The most common functional bowel disorder 2 One of the top 10 reasons for GP visits 3 Up to 20% of the population report symptoms 4 Affects predominantly females (~70% of sufferers) 5 of which 50% present <35 years old 1. Everhart and Renault. Gastroenterology. April 1991;100: Thompson et al. Gastroenterol Int. 1992;5: Physician Drug & Diagnosis Audit (PDDA), April 1999, Scott-Levin 4. Camilleri and Choi. Aliment Pharmacol Ther. 1997;11: Sandler. Gastroenterology. August 1990;99:

5 Irritable bowel syndrome Primary care Specialists ~25% Consulters ~75% Nonconsulters US prevalence rates: diabetes 3% asthma4% heart disease 8% hypertension 11% IBS 20% ~70% Female ~30% Male Drossman and Thompson. Ann Intern Med. June 1992;116(pt 1): Sandler. Gastroenterology. August 1990;99: Adams and Benson. Vital Health Stat 10. December 1991:83. DHHS publication no (PHS)

6 Inflammatory bowel disease Incidence (NZ) UC 7.5 per 100,000 CD 16 per 100,000

7 IBS or IBD? The importance of an accurate history cannot be underestimated

8 IBS or IBD? Intestinal Symptoms IBS IBD Alternating diarrhoea / constipation X Abdominal pain X X Bloating / distension X X Mucus X X Persistent diarrhoea X X Loss of appetite X Rectal bleeding X Nocturnal GI disturbance X Extra-intestinal Symptoms Worsening of symptoms during menses X X Anaemia X Eye / skin irritations X Fever X Weight loss X Related Conditions Urinary symptoms X X Fibromyalgia X X Anxiety / depression X X Arthritis X Liver complications X

9 IBS or IBD? 1. Do you suffer from abdominal cramps and pain and / or bloating? 2. Have you suffered pain before, while, or after passing a stool? 3. Do you ever move your bowels at night? 4. Have you experienced rectal bleeding? 5. Do you have persistent diarrhoea or constipation? 6. Do you have a fever? 7. Have you had loss of appetite and unintentional weight loss? 8. Are you feeling pain in your joints? 9. Are your eyes inflamed? 10. Do you have a parent, sibling or child with IBD?

10 IBS or IBD? To some diarrhoea is: BO > 1x per day, or faecal incontinence, or urgency Abnormal passage of 3 or more liquid stools per day with daily weight of 200g

the following: 1. Improvement of pain with defaecation 2.

11 Diagnosis IBS ROME III At least 3 months of symptoms, over the past 6 months, including recurrent abdominal pain, or discomfort associated with 2 or more of the following: 1. Improvement of pain with defaecation 2. Pain associated with change in frequency of stool 3. Pain associated with a change in form of stool

12 Diagnosis IBS Precipitated/exacerbated by stress / life event Worse with certain foods (gluten intolerant) Mood / anxiety issues Migraines Dyspareunia Poor sleep patterns

Specificity 100% PPV 100% FBC, electrolytes, LFTs, coeliac, CRP:

13 Diagnosis IBS In those below 55 years, and in the absence of alarm symptoms, Rome III criteria has: Sensitivity 65% Specificity 100% PPV 100% FBC, electrolytes, LFTs, coeliac, CRP: Sensitivity 83% Specificity 97% PPV 100% Vanner et al. Amer J Gast. 1999; 94:2912

14 Investigation Additional diagnostic screening generally only needed for atypical presentations such as: Unintentional weight loss Iron deficiency anaemia Nocturnal symptoms Family history of GI cancer or IBD Non-haemorrhoidal bleeding Abnormality on examination New onset of symptoms in patients 40+ years of age Paterson et al. Can Med Assoc J. July 1999;161:

15 Investigation IBS American Journal of Gastroenterology 2010 "people with irritable bowel syndrome (IBS) are not at increased risk for polyps, colon cancer or inflammatory bowel diseases, and, in most cases, don't require a colonoscopy." Wang S et al. Journal of International Medical Research 2013;

16 Investigation IBD

17 Management of IBS IBS Network Patient Requests: Recognition that IBS is an illness A clear explanation of what IBS is A statement that there is no miracle cure An indication that it is my body, my illness, and that it is up to me to take control An explanation that there will be good days and bad days An explanation of the different treatment options Consideration and offer of at least one complementary / alternative therapy Support and understanding

18 Management of IBS Patients concerns Explanation Treatment approaches

19 Management Patients concerns Explanation Some patients are concerned about a serious cause for symptoms Establish a positive diagnosis Treatment approaches Reassure that there is no serious organic disease Investigations may heighten anxiety Drossman. Aliment Pharmacol Ther. 1999;13(suppl 2):3-14 Klein. Gastroenterology. July 1988;95:

20 Management Patients concerns Explanation Treatment approaches Offer a plausible reason for symptoms Stress is a socially acceptable explanation for many symptoms Many IBS patients are not committed to seeking a somatic explanation for their symptoms and the majority readily accept the possibility of a psychological contribution to their gut problems BSG guidelines on IBS Gut 2007 Avoid saying: I don t know what s wrong... There s nothing wrong with you... It s all in your head...

21 Management Patients concerns Explanation Treatment approaches Placebo effect of up to 70% for all IBS treatments Treatment should depend on symptom sub-type Diarrhoea predominant (loose >25% time) Constipation predominant (hard stools >25% time) Pain predominant

IBS - constipation Increased soluble fibre and osmotic laxatives helpful (ispaghula husk) PEG solutions don t aggravate bloating Stimulant laxatives make symptoms worse Lactulose aggravates

22 IBS - constipation Increased soluble fibre and osmotic laxatives helpful (ispaghula husk) PEG solutions don t aggravate bloating Stimulant laxatives make symptoms worse Lactulose aggravates distension and flatulence Tegaserod (5-HT4 antagonist) shows clear benefit but withdrawn due to CV side-effects Linaclotide (peptide agonist of guanylate cyclase 2C) recently approved by FDA

IBS - diarrhoea Increasing dietary fibre is recommended in guidelines (BEWARE) Also avoid coffee, alcohol, spicy foods, pure fruit juices, artificial sweeteners

23 IBS - diarrhoea Increasing dietary fibre is recommended in guidelines (BEWARE) Also avoid coffee, alcohol, spicy foods, pure fruit juices, artificial sweeteners Regular loperamide with Colofac helps Increase stool firmness Decrease stool frequency Reduce urgency Alosetron (5-HT3 antagonist) withdrawn due to ischaemic colitis

24 IBS - pain Dietary measures Antispasmodics will help 66% - mebeverine Bloating may be helped by peppermint oil or peppermint tea Nausea may require domperidone Avoid narcotics

25 IBS - pain Very little evidence for SSRIs one study in Gut 2006 using citalopram in 23 patients Better evidence for tricyclics

IBS - FODMAPs Fermentable Oligosaccharides Disaccharides Monosaccharide And Polyols Include fructose, lactose, sorbitol and fructans; fructose found in fruits, honey and high fructose

26 IBS - FODMAPs Fermentable Oligosaccharides Disaccharides Monosaccharide And Polyols Include fructose, lactose, sorbitol and fructans; fructose found in fruits, honey and high fructose corn syrup fructans found in wheat and onions Food allergies are uncommon, no role for skin testing / allergen testing Shepherd SJ, et al Clinical Gastroenterology & Hepatology 2008;6:

27 IBS - FODMAPs No current guidelines discuss low FODMAP diets No systematic review evidence about the role of FODMAP diet in the management of IBS 2008 RCT. in patients with IBS and fructose malabsorption, dietary restriction of fructose and/or fructans is likely to be responsible for symptomatic improvement 2010 RCT. dietary FODMAPs induce prolonged hydrogen production that is greater in IBS, influence the amount of methane produced, and induce GI and systemic symptoms experienced by patients with IBS. Shepherd SJ et al. Clinical Gastroenterology & Hepatology 2008;6:

28 Non-traditional remedies Chinese herbal medicine Hypnotherapy / biofeedback / CBT Slippery Elm, Kiwi Crush, aloe vera Probiotics / FMT Antibiotics (rifaximin 550mg tid for 2 wks decreased IBS symptoms) Sugar pills placebo pills made of an inert substance that have been shown in clinical studies to produce significant improvement in IBS symptoms through mindbody self-healing processes Benoussan A. JAMA 1998 Pittler M. AJG 1998 Target I & II trials DDW 2010 Kaptchuk TJ. PLoS One 2010

29 Management of IBD 5-ASA Asacol Pentasa Sulphasalazine Prednisone 40mg per week reducing by 5mg/week

30 Summary IBS & IBD share a number of symptoms History is paramount IBS is common, IBD isn t Investigation always necessary in IBD, not IBS Treat symptoms in IBS, treat disease in IBD Crohn s not Chron s

31 Questions?

Irritable Bowel Syndrome. Mustafa Giaffer March 2017

Irritable Bowel Syndrome. Mustafa Giaffer March 2017 Irritable Bowel Syndrome Mustafa Giaffer March 2017 Introduction First described in 1771. 50% of patients present