IBSBaku university

05-03-2014

OVB

Irritable Bowel Syndrome

• Invalidating > 60 % sick leave ( not at

work > 1,5 day/month) Dutch data

• QoL the same as in COPD or CRC !!

• Most common diagnosis in gastro-

enterology (25-50 % of diagnosis)

• Diagnose per exclusionem

IBS

• IBS is not a disease, but the sum of a

few symptoms. Difficult to explain and

no particular investigation possible.

• People with IBS can also have chronic

fatigue syndrome, fibromyalgia and

other difficult define entities.

IBS

•

IBS

• Rome III criteria.

http://romecriteria.org/assets/pdf/19_

RomeIII_apA_885-898.

pdf

IBS• Cause :??

• Post infection with

Clostridium,Salmonella, Yersinia; 6x

chance to get IBS

• SIBO ? Small intestinal bacterial

overgrowth

IBS• In NL 90 % of patients will be ”

treated “ by GP

• Only further investigation when ”

alarm signals “ or when GP thinks: ”

something wrong ?? ”

• Patient is insecure

IBS

• History

• Physical examination !! (Herniations of abd

wall ,Costa XII syndrome ,Xyphoidalgia/-

dinia,

radiating pain from vertebral column,

pathological-mass , diffuse pain? or local

pain? etc )

IBS DIFF DIAGNOSISin gastro-enterology

• CRC :Colonoscopy

• IBD: calprotectine; endoscopy

• Coeliack disease :IgA anti-ttg

• Lactose malabsorption : LTT and H2 breath test

• Microscopic/collagene colitis : biopsy

• Parasitic infection: Dientamoeba fragilis;Giardia

• Bact overgrowth: lactose breath test

Dientamoeba fragilis

Dientamoeba fragilis

• Pathogene in children, not in adults

protozoa

Feco-oral route

Abdominal pain and watrery diarrhea.

Investigation: TFT (=triple feces test) warm ! 3 days

Metronidazol 3 x 500 mg/d ; 7-10 days (adult)

Child: 15 mg/kg/day in 3 doses; 7-10 days

IBS DD

• Bile malabsorbtion : 72 hour bile in

stool/test treatment with Questran

(Cholestyramine )

• Hyperthyreoid disease : TSH

• and do not forget gyn- or urologic

disorders

IBS managment

• No strong evidence for diet or

medication

• Evidence for hypnotherapy and

cognitive behavioral therapy

• Dientamoeba fragilis: therapy

especially in children

IBS

• Reassurance, explaining that it is not

a disease etc.

• Give your patient a lot of attention

• Be careful with fibers (bloating)

IBS• Divided in predominant diarrhea

(IBS-D) and

• predominant

constipation (IBS-C)

• and IBS-M =

mixed

IBS

• Diet measures?: trial and error

• Soluble fibers like psyllium = Metamucil ?

• Lactose free ?

• Fructose free (Cola,Fanta etc)?

• No beans, broccoli, cauliflower ,

cabbage?? =Insoluble fibres

IBS

• Medication ? Not very easy

• IBS-C : laxans like lactulose , MgO , macrogol

(PEG) or psyllium( with a lot of water)

• Tegaserod : Zelnorm selective 5HT agonist:

Only for women with IBS-C. 2x 6mg/day

FDA removed it from market in 2007/08 .

(heart attack)

IBS

• Cramps : peppermint oil ( Gives

heartburn because opening of LES,

and anal- and perianal burning) 3x 2

EC tablets before meals

IBS

• IBS-D

• Therapy : loperamide= Imodium

• Or codeine 3 x 20 mg to start with.

• Questran: Start with half of sachet

IBS

IBS• Antibiotics ??? Rifaximin 3x 550

mg/day /14 days

• When positive breath test (LTT) 60-

80% improves. BUT… after 6 month

44 % of patients have the same

complaints.

IBS

• Antidepressants : TCA

• Amitriptyline (Tryptizol): low dosis !! Not dose used

in depression! > 5-10-25 mg

• imipramine (Tofranil) 25 mg > 10 mg; max 50 mg

• SSRI: duloxetine(Cymbalta) ; effective, expensive

and obstipation

Fluoxetine ( Prozac ) when also depression

IBS

• Probiotics ??

• Google quick search : 3 reports 2 of

them funded by industry

• Third study : meta analysis with

weak positive efffect. Not very

convincing but not negative

IBS

• Probiotics ??

IBS conclusion ?

Most patients need reassuring and

support

Try to avoid medication. Try change in

food habbits. Exclude coeliac disease.

Good physical examination.

Behaveour therapy if

available ;Hypnosis if available ??

Treat diarrhea or constipation

IBS conclusion ?

• Antidepressants in low dose

• Probiotics not really helpful .

• A good long walk at the beach is

probably better

New medication in IBS-C

• Linaclotide 290 microgr/day

• Peptide of 14 aminoacids.

• FDA approved 2012/13

• Constella Linzess

• 2 studies : 32,5% vs 13,2 %

(p<0.0001) NNT 5,1

New medication in IBS-C

• Lubiprostone: 2 dd 8 mcg

• Not much data available.

• Maybe in future candidate as

therapeutic agent

IBS

• Thank you for your attention