Models of care in IBS

Outline

• Complex aetiology • Pain sensitizers• Clues to an organic

disease: serotonin• Other theories• Proven therapies• FODMAPs• NICE guidance

• Models of care– Expectations of

secondary care– Weaknesses of

secondary care– Cases

Genes

Early learningFamily influences

Susceptible individual

External stressors

IBS symptoms

Psychologicaldisturbance

Physiological disturbance

•Adverse life events•Chronic psychological stress•Gastrointestinal infection•Changes in diet

Aetiology:biopsychosocial model

Slide courtesy of Prof Robin Spiller

Rome III Criteria

• Recurrent abdominal pain or discomfort at least 3 days/month in the last

• 3 months associated with two or more of the following:– Improvement with defecation– Onset associated with a change in frequency of stool– Onset associated with a change in form (appearance) of

stool– * Criterion fulfilled for the last 3 months with symptom

onset– at least 6 months prior to diagnosis

Brain functional MRI showing regions activated during endogenous pain

modulation by heterotopic

stimulation (painful rectal distension with

foot cold pain) in healthy controls.

Wilder-Smith C H Gut 2011;60:1589-1599

Copyright © BMJ Publishing Group Ltd & British Society of Gastroenterology. All rights reserved.

Pain regulation I

Pain regulation II

“A majority of patients with IBS have diminished pain inhibition or even pain facilitation compared with healthy controls. “

“Brain imaging during specific activation of endogenous pain modulation demonstrates a fairly consistent functional hub of mainly frontal, limbic and brainstem modulatory regions in healthy humans.”

“ Patients with IBS have a different pattern of activation and a correlation between the imaging and sensory changes. “

Wilder-Smith C H Gut 2011;60:1589-1599

Factors potentially driving changes in endogenous pain

modulation in visceral pain syndromes.

Wilder-Smith C H Gut 2011;60:1589-1599

Copyright © BMJ Publishing Group Ltd & British Society of Gastroenterology. All rights reserved.

Pain regulation III

More than gut

The search for an ‘organic’ basis - Serotonin

Camilleri Gut 2002;51:i81-i86 doi:10.1136/gut.51.suppl_1.i81 Serotonergic modulation of visceral sensation: lower gut

Effect of alosetron 1 mg twice daily and placebo on adequate relief of pain (A) and stool consistency (B) in female patients with symptoms of diarrhoea.

Camilleri M Gut 2002;51:i81-i86

Copyright © BMJ Publishing Group Ltd & British Society of Gastroenterology. All rights reserved.

Effect of alosetron 1 mg twice daily and placebo on adequate relief of pain (A) and stool consistency (B) in female patients with symptoms of diarrhoea.

Camilleri M Gut 2002;51:i81-i86

Copyright © BMJ Publishing Group Ltd & British Society of Gastroenterology. All rights reserved.

Tegaserod

WITHDRAWN2007

AlosetronWITHDRAWN

2000 (reinstated 2002)

Numerous investigations possible

IBS-D Bile salt malabsorption – Sehcat scan; present in 10%

Small bowel overgrowth – Hydrogen breath test

Wedlake et al, APT 2009 (n=1223), 15 trials

Candida overgrowthProfessor ----- takes an individualised broad-based and holistic approach to each patient.... [However] when this is ineffectual, such as may be the case in patients with the Irritable Bowel Syndrome, then he does not hesitate to try unconventional treatments such as wheat-free diets (effective for bloating in IBS) and mould free diets (effective for the Intestinal Candida Syndrome), etc. In the most resistant cases he has established a sound collaboration with medically-trained homeopaths...

What definitely works: TCA

Effect of tricyclic antidepressants on “overall symptom improvement with therapy.” Trials

included used a validated pain scale to quantify improvement

TCA

Effect of tricyclic antidepressants on abdominal pain scores

Cognitive-Behavioural therapy

Meta-analysis of the efficacy of cognitive behaviour therapy:

(50% reduction of symptoms) gave an odds ratio of 12 (95% confidence interval 5.56 to 25.96) in favour of cognitive behaviour therapy, with a number needed to treat of 2.16.

CBTAuthors Size Description Results

Bennett andWilkinson

RCT; 12 CBT, 12 usual care Eight week package: stress managementtraining, cognitive therapy, and contingency management v medicaltreatment

Anxiety reduced in treatment group but not incontrol group; both achieved improvement in IBSsymptoms, restriction of activities, and fatigue

Lynch and Zamble RCT; 12 CBT, 12 waiting list Coping skills, assertiveness training, education, and progressive relaxation vwaiting list controls

Significantly greater improvement of IBSsymptoms and anxiety in treatment group

Guthrie et al RCT; n=102 Psychotherapy v “supportive listening,” 12 week study. After study, 33 patientsfrom control group acceptedPsychotherapy

Psychotherapy significantly superior in terms ofphysical and psychological symptoms. Results sustained at 12 month follow-up

Boyce et al RCT; n=105 Three arm trial: all groups received standard care, plus either CBT or relaxation training.Patients with“resistant IBS” not included

Significant improvements for all groups in IBS symptoms, physical/social functioning and general wellbeing, but no significant differencesbetween groups.

Greene andBlanchard

RCT; 10 CBT, 10 symptommonitoring

Individualised CBT for 10 sessions v dailygastrointestinal symptom monitoring over eight weeks

80% of treatment group showed clinicalimprovement compared with 10% of controls.

CBTAuthors Size Description Results

Bennett andWilkinson

RCT; 12 CBT, 12 usual care Eight week package: stress managementtraining, cognitive therapy, and contingency management v medicaltreatment

Anxiety reduced in treatment group but not incontrol group; both achieved improvement in IBSsymptoms, restriction of activities, and fatigue

Lynch and Zamble RCT; 12 CBT, 12 waiting list Coping skills, assertiveness training, education, and progressive relaxation vwaiting list controls

Significantly greater improvement of IBSsymptoms and anxiety in treatment group

Guthrie et al RCT; n=102 Psychotherapy v “supportive listening,” 12 week study. After study, 33 patientsfrom control group acceptedPsychotherapy

Psychotherapy significantly superior in terms ofphysical and psychological symptoms. Results sustained at 12 month follow-up

Boyce et al RCT; n=105 Three arm trial: all groups received standard care, plus either CBT or relaxation training.Patients with“resistant IBS” not included

Significant improvements for all groups in IBS symptoms, physical/social functioning and general wellbeing, but no significant differencesbetween groups.

Greene andBlanchard

RCT; 10 CBT, 10 symptommonitoring

Individualised CBT for 10 sessions v dailygastrointestinal symptom monitoring over eight weeks

80% of treatment group showed clinicalimprovement compared with 10% of controls.

FODMAPsFermentable, Oligo-, Di- and Mono-saccharides and Polyols,

Evidence suggests that reducing global intake of FODMAPs to manage functional gut symptoms provides symptom relief for about 75% of patients with FGDs.

Despite its apparent complexity, the FODMAPs approach can be effective when delivered by a dietitian skilled in its intricacies.

Patient compliance with this diet is very good, likely due to quality-of-life improvements

Gibson PR, Shepherd SJ. Evidence-based dietary management of functional gastrointestinal symptoms: The FODMAP approach. J Gastroenterol Hepatol. 2010;25(2):252-258Shepherd SJ, Parker FC, Muir JG, Gibson PR. Dietary triggers of abdominal symptoms in patients with irritable bowel syndrome: Randomized placebo-controlled evidence. Clin Gastroenterol Hepatol. 2008;6(7):765-771

FODMAPsFructans

Oligosaccharides made of fructose molecule chains that are completely malabsorbedCan contribute to bloating, gas, and pain. Wheat accounts for the majority of fructan intake.

Galactans Galactans are oligosaccharides containing chains of the sugar galactose. Dietary sources of galactans include lentils, chickpeas, kidney beans, black-eyed peas, broccoli, and soy-based products.

PolyolsSugar alcohols. Too large for simple diffusion from the small intestine, creating a laxative effect on the GI tract. They are found naturally in some fruits and vegetables and added as sweeteners to sugar-free gums, mints, cough drops, and medications.

NICE guidance - 1

First-line pharmacological treatment– Choose single or combination medication based on the

predominant symptom(s).– Consider offering antispasmodic agents - alongside

dietary and lifestyle advice.– Laxatives for constipation, but discourage use of lactulose.– Offer loperamide as the first choice of antimotility agent

for diarrhoea.– Advise people how to adjust doses of laxative or

antimotility agent according to response, shown by stool consistency. The aim is a soft, well-formed stool.

NICE guidance - 2

Second-line pharmacological treatment– Consider tricyclic antidepressants (TCAs) for their analgesic

effect if first-line treatments do not help.– Start at a low dose (5–10 mg equivalent of amitriptyline) taken

once at night and review regularly.– The dose may be increased (but should not usually exceed 30

mg).– Consider selective serotonin reuptake inhibitors (SSRIs) only if

TCAs are ineffective.– Take into account the possible side effects of TCAs and SSRIs.– If prescribing these drugs for the first time, follow up after 4

weeks and then every 6–12 months.

Expectations of primary care

• Make positive diagnosis and prescribe trial of first line therapy

• Clarify the psychological context• Identify difficult to treat cases• If confident of diagnosis, commence TCA

therapy

Expectations of secondary care

• Make a positive diagnosis and be honest• Do not over-investigate• Set out a management plan to facilitate

ongoing care in the community• Decide who to refer to psychologist• Identify who to refer to tertiary centre

Weaknesses of secondary care

• Not many gastroenterologists are interested in the disease

• There may be an empathy problem (easy for cancer and Crohn’s, not so for something we can’t see, feel or understand)

• If psychological support and continuity are important aspects, a ‘normal’ clinic is not the best place to access them

So, what do we really think our role is?

• Exclude ‘serious’ disease• Assess severity of the case• Deliver a ‘positive’ diagnosis and conceptual

model• Start the ball rolling and provide a basic route

map • ....and discharge

But not:

• Regular assessments of response• Titration of TCA• De facto psychological therapy in the clinic

Example cases

1 2 3

Case 1

• 20 year old • Previously seen at another

hospital 2009• Longstanding abdominal

pain and bloating• Episode gastroenteritis in

South America treated with antibiotics (U/S)

• Sx worse with wheat

Case 1

• AXR – fecal loading +++• MRI small bowel -

normal• Treated with Movicol

• End 2009 – re-referred• Long discussion about

IBS and laxatives• Dietician review

Case 1

• Review in clinic• Now more confident in managing constipation

and no need for further follow-up

Case 2

• Very worried man• 2007 – abnormal LFTs, foul

wind and abdominal pain. Liver biopsy –nil of concern

• 2008 – foul wind, something inside – he feels he needs an endoscopy – not organised

• 2008 – re-referred new consultant - colonoscopy NAD

Case 2• New consultant- requesting second opinion –

very angry, something is wrong and no-one will help. Wants an MRI abdo. Has been seen by many consultants in more than one hospital.

Case 2

• Main symptoms: abdominal bloating, worse when walking or lifting and feels that all his symptoms started after he tried herbal body enhancers approximately 4 years ago.

• Abnormal liver function tests but has had a normal liver biopsy and has found that Amitriptyline, a wheat-free diet, a dairy-free diet and a Dietitian review have been unhelpful.

• In addition to this 3 ultrasounds, colonoscopy and an OGD that he has had, although they have not revealed any significant abnormality, do still leave him concerned

Case 2

• Rebook appointment – ask for relative to be present. MRI organised as contract – no further investigations

• Explain – irritable bowel to both• Attitiude starts to change• Controlled in secondary care.. for now.

Case 3

• Mild asthma & bronchomalacia, overweight – bariatric surgery – may help with airway control

• Background – fibromyalgia, depression, cholecystectomy

• Post operative C Diff • Subsequent severe

diarrhoea

Case 3

• Had already tried – probiotics, loperamide, cholestyramine, some benefit from codeine.

• Colonoscopy NAD, surgeon says short bowel not possible

• Extreme distress – over course of time has SeCHAT (borderline but no benefit from treatment), CT, and MRI – all normal

Case 3

• LFTs obstructive – no suggestion of stones on MRCP, liver fatty on U/S

• Suggestion post infective irritable bowel – dietician, amitryptilline – do not control

• UCH suggest creon as stool fatty, with no benefit (fecal elastase normal)

Case 3

• Extreme distress and some pathology

• Referral to tertiary centre

• They say……..

• Creon + PPI• Treat for bacterial

OG• Treat with clonidine

in case of autonomic dysfunction

• Try octreotide

Summary

Can be very challengingRequire time that is often not availableTry not to over-medicalizePsychological support can help Dietary modificationHow to deal with false expectationsReturn onus of control to patient.