Management of Irritable Bowel Syndrome (IBS) in Family Medicine

Meera Kaur, PhD, RD, CDE Assistant Professor, Family Medicine

University of Manitoba, Canada

http://home.cc.umanitoba.ca/~kaur/

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IBS is defined as “abdominal pain or discomfort that occurs in association with altered bowel habits over a periods of at least three months.” 1

•Probably the most challenging of all functional GI disorders

•7-10% people worldwide have IBS

• Prevalence in N. America is 3-20% with an average range of 10-15%

•Peaks in the 3rd and 4th decades of life and declines in 6th and 7th decades

•Patients with IBS consumes 50%more health care resources than those without it.

1 Brandt et al., Am. J.Gastro, 2009;104:SI-S-35

What is IBS?

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Pathophysiology

• IBS is characterized by changes in motility in response to environmental or enteric stimuli

• Visceral hypersensitivity is well documented in IBS patients

• Serotonin, which has both motility and sensory modulating properties, could represent a common factor linking the symptoms of IBS

• Mucosal inflammatory process

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Symptoms

• Loose stool

• Constipation

• Alternating Diarrhea and Constipation

• Urges to move bowel again immediately following a bowel movement

• Mucus in stool

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Subtypes

• Diarrhoea predominant (IBS-D)

• Constipation predominant (IBS-C)

• Pain predominant (IBS-P)

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Diagnosis….

• Approach: Before doing any test…

– Gain the confidence of the patient at the first consultation, let them talk and just listen

– Remain aware that some IBS patients have a hidden agenda

– Do not say to the patient what some FPs say, namely, “I don’t know what is wrong with you.”

– Do not say what some Specialists say, namely: “There is nothing wrong with you” or “it is in your head.”

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Diagnosis….

• Approach: Before doing any test

– Get all the test reports from the other MDs files and

– Show & discuss those test results with the patient

– In those below 55 yrs. and in the absence of “alarm symptoms”, if “routine” blood tests + ESR/CRP are normal, diagnosis of IBS has:

- 83% sensitivity- 97% specificity- 100% PPV

Therefore, please consider doing these testsTolliver et al (1994) Amer J Gast 89:176

1. Manning

2. Kruls

3. Rome

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Diagnostic Criteria

J Jailwala An Int Med 2000;133:136-147

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• Dietary – e.g. lactose intolerance, ↑ caffeine etc.• Infections – Giardia, Bacterial Overgrowth Syndrome• Inflammatory Bowel Disease – UC, CD, • Microscopic Colitis• Malabsorption syndrome – Celiac Disease • Pancreatic Insufficiency• Psychological – Depression Anxiety, Somatization• Other - Neuroses

Differential Diagnoses

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• Onset after 55 years• Persistent anorexia & weight loss > 10 lbs• Persistent “fever” in the evening• Pain – changing pattern or increasing after food

and persisting for a few hours• Awakened by pain &/or diarrhea at night• Rectal bleeding, not just on wiping• Stools “like malabsorption syndrome”• P/E: palpable mass in the abdomen

“Red Flags’” - Alarm Symptoms/Signs

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• IBS remains a clinical diagnosis

• In those below 55 years and in the absence of alarm symptoms, Rome II Criteria (Clinical) has:

- Sensitivity → 65%

- Specificity → 100%- PPV → 100%

Vanner et al (1999) Amer J Gast 94:2912

Diagnosis Summary

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Traditional therapies focused on individual symptoms of IBS with constipation

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AbdominalAbdominalpain /pain /

discomfortdiscomfortBloating /Bloating /distentiondistention

Constipation Constipation or Diarrheaor Diarrhea

Abdominal pain / discomfort Antispasmodics Tricyclics Analgesics

Bloating and distention Dietary modifications Antispasmodics Antiflatulants Digestive enzymes Antibiotics

Irregular Bowel Habit

Fiber Laxatives Imodium

None of these medications effectively treat the multiple symptoms of IBS. May exacerbate individual symptoms e.g., fiber and bloating; antispasmodics and constipation

IBS: Symptomatic Therapy

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Abdominalpain/

discomfort

Abdominalpain/

discomfortBloatingBloating

CONSTIPATIONFibresOsmotic agents5-HT4 agonists Prokinetics

Altered bowelfunction

Altered bowelfunction

Smooth muscle relaxants5-HT agonists/antagonistsTCAs, SSRIs

Smooth muscle relaxants5-HT agonists/antagonists

Antiflatulents

DIARRHEALoperamide

Cholestyramine5-HT3 antagonists

1. Herbal– Peppermint oil capsule

– Turmeric Extract

– Artichoke leaf Extract

2. Mind-Body Therapies– Hypnotherapy

– Cognitive-behavioral Therapy (CBT)

3. Relaxation Technique

4. Acupuncture and Moxibustion

5. Diet, lifestyle

6. Probiotics

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Alternative/Complementary Approach

Yoon et al, Altern Med Rev, 2011; 16(2): 134-151

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Evidence-Based Position Statement on Management of IBS

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•Summary (Grades of Evidence)– IBS defined by abdominal discomfort plus altered

bowel habits (C)– IBS significantly decrease quality of life (QOL) of

most patients seeking care (C)– Treatment indicated when patient & physician

believe QOL is diminished (C)– IBS therapies should improve global symptoms

including discomfort, bloating, and altered bowel habits (C)

Am J Gastro 2002; 97:S1-S5

Management - Summary

•Lifestyle (poor data)•Diet (poor data)•Pain management (meta-analysis)•Antidiarrheals (db, pc trials)•Osmotic laxatives (poor data)•Psychotherapy (no good data)•Antidepressants (meta-analysis)•Probiotics (poor data)•Others - Alternative Medical Therapies (poor data)

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Concluding Statements

IBS is a benign condition without benign effects. We should keep an open mind while managing IBS.

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References

• Books

• Journal articles published during 1990-2012

• International, National and Provincial governments’ relevant websites

• Regulatory organizations’ websites and reports

• Other relevant organizations’ publications/reports

• Evidence-based Guidelines

References are available on request

Questions?

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