IBS for final year MBBS

1. Dr Muzaffar Mehdi
SR Gastroenterology –Hepatology

2.  Irritable bowel syndrome is a functional GI disorder with
symptoms including abdominal pain associated with a
change in stool form or frequency
 Substantial impact on quality of life and social functioning
 Affects between 5% and 10% of the general population
 Treatment aims to improve abdominal pain and bowel habit
 Sub grouped -Predominant stool pattern
 IBS with diarrhoea
 IBS with constipation
 IBS with mixed stool pattern
 IBS unclassified

3.  Precise estimates of prevalence
is difficult to obtain
 No universally accepted
biomarker available
 Diagnosis relies on self-
reported symptom clusters
 Population-based
epidemiological studies
provide a prevalence between
5% to 10%
 with Rome III criteria 1·1% in
Iran to 45% in Pakistan in 2016

4.  Gender --women >men
 Age < 50 years (most common in women aged 20–40 y)
 Functional somatic syndromes
 Fibromyalgia
 Chronic fatigue
 Anxiety and Depression
 Sleep Disorders
 Psychosocial, biological, and environmental factors
 Enteric infection ,most well recognized risk factor for IBS, (10%
patients of IBS), risk >by 4 times in exposed individuals 12 months
after infection, better prognosis, can be seen upto 8 years post
infection
 Post - infection IBS:
 Bacterial
 Viral
 Protozoal infection
 Non-specific gastrointestinal infections

5.  Biopsychosocial model to explain symptoms of
abdominal pain and disordered bowel habit in
IBS conceptualized a genetic predisposition, in
which adverse events in early life,
psychological factors, or gastrointestinal
infections trigger alterations in the enteric
nervous system, which controls
gastrointestinal motor, sensory, mucosal
barrier, and secretory responses

6. Chromosome 9
Sucrase-isomaltase gene
SCN5A

8.  IBS is a chronic relapsing disorder
 Usually seen in younger age (average age is 45)
 Multifactorial and heterogeneous disorder
 Coexistent mood problems, and extra intestinal symptoms back pain,
gynaecological and bladder symptoms, headache, and fatigue
 Overlap with other functional gastrointestinal disorders
 Abdominal pain : (abdominal pain is essential to the definition of IBS)
 Chronic
 Recurrent/Intermittent
 Usually in the lower abdomen
 Associated with defecation
 Stool frequency or consistency Alterations
 Excessive straining, sense of incomplete rectal evacuation, or digitation of
the anus to facilitate defaecation support IBS –C diagnosis
 Bloating supports the diagnosis, particularly if it is diurnal. often
accompanied by visible abdominal distension.
 Sub grouped according to predominant stool pattern

10. IBS Recurrent abdominal pain, on average for at least 1 day per week in
the past 3 months, associated with two or more of the following:
related to defaecation, a change in frequency of stool, a change in stool
form; criteria must be fulfilled for the past 3 months, with symptom
onset at least 6 months before diagnosis
IBS with
constipation
≥25% of bowel movements of Bristol Stool Form types 1 or 2, and
<25%Bristol Stool Form types 6 or 7
IBS with
diarrhoea
≥25% of bowel movements of Bristol Stool Form types 6 or 7, and
<25%of Bristol Stool Form types 1 or 2
IBS mixed ≥25% of bowel movements of Bristol Stool Form types 1 or 2, and
≥25% of bowel movements of Bristol Stool Form types 6 or 7
IBS
unclassified
Patients who meet criteria for IBS, but do not fall into one of the other
three subgroup

11.  Diagnosis is clinical
 Positive diagnosis by use of symptom-based diagnostic criteria Rome
IV(2016)
 No universally accepted biomarker
 Investigation to exclude an organic cause are expensive & non reassuring
 Performance of the Rome criteria can be enhanced
 Absence of nocturnal stools
 Presence of anxiety Depression
 Extra intestinal symptoms
 Normal full blood count C-reactive protein
 Alarm symptoms
 Age >50
 IDA
 Bleeding PR
 Nocturnal Diarrhoea
 Symptom of bowel obstruction
 F/H of CRC
 F/H of IBD
 F/H of coeliac disease

13. Faecal calprotectin, which is a cytosol protein released by neutrophils, can differentiate
between IBS and IBD

14.  Coeliac disease:
 TTG, Duodenal biopsies
 IBD:
 ESR,CRP,FCP
 Microscopic colitis:
 age >50, women ,short history
 Autoimmune disease:
 Nocturnal diarrhoea
 Carbohydrate intolerance:
 Lactose/fructose/sucrose intolerance, Elimination of dairy from diet, Enzyme
immunoassay, breath tests
 NSAIDS & ,PPI use:
 Usually report nocturnal diarrhoea
 Bile acid diarrhoea:
 Ileal dysfunction , Chronic pancreatitis, Celiac disease,ideopathic (SeHCAT scanning,
48 h faecal bile acid excretion, bile acid sequestrant trial ),fasting serum C4.

15.  SIBO:
 H/O gastric or intestinal surgery or known structural abnormalities
diverticulosis -breath tests, aspirates & empirical ABX
 Food allergy:
 Angioedema—symptoms of swelling and SOB
 Carcinoid Diarrhoea:
 Hyper secretion of serotonin from neuroendocrine cells 5--hydroxyindoleacetic
acid (found in the urine) and chromogranin A- found in the serum
 Chronic Pancreatitis:
 CT,MRCP ,HBA1C,Stool Elastase
 Ovarian Cancers :
 Constipation - CT scan ,MRI
 Pelvic floor outlet obstruction disorders :
 IBS-C (Dyssynergia, Symptoms of incomplete evacuation, straining, prolonged
toileting, DRE,Manometery,defecography,balloon explusion test
 Endometreosis:
 Chronic pelvic Pain ,MRI , laparoscopy

16.  Fluctuating symptoms, in terms of bowel habit
 New onset IBS was approximately 1·5–2·5% per year
 Prevalence remains stable (new symptoms appear/ symptoms
disappear or fluctuate)
 IBS causes morbidity, but not mortality
 Affects quality of life, work productivity, social integration, and
psychosocial factors, such as general and gut-related anxiety,
depression, and somatization
 Diarrhoea limits travel or leaving the house because of concerns
about toilet access
 Constipation- avoid sexual intercourse and reported difficulty
concentrating
 Reduced quality of life, increased rates of psychological
symptoms, and reduced coping

17.  No medical therapy is proven to alter natural history
 Empathetic approach is key
 Discuss the limitations of available therapies to manage
expectations
 Explain the disorder, its pathophysiology, and natural
history
 Symptoms improvement is in only 25–30%
 Treatment is directed towards the predominant symptom
 The final decision of the choice of treatment should be the
patient’s

18.  Exercise :
 Instructed by a physiotherapist--symptoms improved significantly
 Dietary fiber
 Increase intake help, soluble (e.g., barley, beans, oat bran, psyllium (Ispaghula Husk)
rather than insoluble (e.g., wheat bran, whole grains, some vegetables) fiber improves
global symptoms of IBS
 FODMAP:
 Restriction -improvement in IBS symptoms, long term use may -deleterious alterations in
the microbiome
 Gluten-free diet :
 Little evidence to support benefit , wheat contains fructan a FODMAP, a gluten-free diet
incorporates elements of a low FODMAP diet
 Probiotics:
 which combination, species, or strain is effective data is limited
 Eat small regular meals, avoid known trigger foods, and reduce alcohol
and caffeine

20.  Laxatives (osmotic and stimulant laxatives)
 Antidiarrhoeals (loperamide)
 Antispasmodics (otilonium, cimetropium,
pinaverium, & hyoscine)
 Peppermint oil also appeared superior to placebo
 Glutamine powder 5 g three times daily for 8 weeks
 Daily bowel movement
 Frequency and stool form and
 Normalization of intestinal permeability versus placebo

21.  Antidepressant
 Tricyclic Antidepressants- neuromodulatory properties and slow gastrointestinal
transit, best for patients with predominant pain, diarrhoea, or both
 Selective serotonin reuptake inhibitors
 Neuromodulators
 Adverse events are common
 Pregabalin
 improvements in global symptoms, pain, diarrhoea, and bloating
 5-HT4 agonists
 accelerate gastrointestinal transit
 Prucalopride, was superior to placebo in chronic constipation
 Intestinal secretagogues
 lubiprostone, linaclotide, plecanatide, and tenapanor act on ion channels in
enterocytes, leading to water efflux, thereby accelerating gastrointestinal transit
 Linaclotide ranked first for improvements in global symptoms, abdominal
pain, and stool frequency

22.  Alosetron and Ramosetron:
 5-HT3 antagonists selective serotonin (5-HT3) receptor antagonist-
 Dose -0.5 to 1.0 mg twice daily for at least 6 months
 5-HT3 antagonists also alter rectal compliance
 5-HT3 antagonists ranked first for improvement in global symptoms,
abdominal pain, and stool consistency
 Eluxadoline :
 Peripherally acting mixed μ-opioid and κ-opioid receptor agonist and δ-
opioid receptor antagonist
 Dose is 75–100 mg bid for up to 6 months
 Rifaximin :
 Minimally absorbed antibiotic ,Rifaximin has been tested on the basis that
alterations in the gastrointestinal microbiota and small intestinal bacterial
overgrowth might, in part, be responsible for symptoms.
 Dose : 550-mg tablet three times daily for 2 weeks, may receive up to two
additional rifaximin courses for symptom recurrence

24.  Advantages
 Central effects on mood
 Peripheral effects
 Pain perception
 Visceral hypersensitivity
 Gastrointestinal motility
 Cognitive behavioral therapy
 Gut-directed hypnotherapy
 Relaxation therapy
 Multicomponent psychological therapy
 Dynamic psychotherapy

25.  Involves the transfer of donor fecal matter by
enema, endoscopy, or an oral pill
 Did not significantly decrease global symptoms
of IBS compared with placebo
 ACG guideline for IBS management
recommends against the use of FMT for
treatment of IBS