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IBS Dr. Matt W. Johnson BSc MBBS MRCP MD

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L&D

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Graham Holland’s ‘the optimism and the frustration of living in a

metropolis’

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IBS is a Diagnosis of Exclusion

......or is it ?

If in doubt go see your local Shamen……..occasionally they

come to see you

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British Society of Gastroenterology

Guidelines 2000

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IBS• 9-12% of adult population• 40-60% of all Gastro OPA referrals• 1M : 2.5F

• Aetiology– Psychological (Increased incidence of Psych Hx)– Stress (ppt in 50%)– Post infective(ppt in 10-20%)– Consulting behaviour / Abnormal illness behaviour– Gut motility (no consistent evidence)– Visceral hypersensitivity– Diet (lactose + wheat intolerance)

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IBS

• Rome Criteria 3

• 3m of Abdominal Pain / Discomfort• Associated with 2 of 3

– Altered frequency– Altered consistency– Improves with defaecation

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IBS - Associated symptoms

• Tiredness / lethargy• Poor sleep• Backpain• Fybromyalgia• Urinary urgency and frequency• Dysguesia - Unpleasant taste in mouth

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IBS - Investigation

• FBC + ESR (1%)• TFT (6%)• Coeliac (2-15%)• Ca + Albumin• Stool MCS + COP• Faecal elastase• US (incidental gallstones and fibroids 8%)• Lactose intolerance testing (21-25%)• Flexible sig / BaEnema / Colonoscopy• SeHCAT scan - Bile acid malabsorption (8%)

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Gastro Psychiatrist

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IBS Management• Positive diagnosis• Listen• Lifestyle advice• Placebo (50%)• Dietary advice

– (exclude lactulose, wheat, caffeine, CHO)

• Psychological therapies– Diagnosis + Psych referral– Relaxation, Biofeedback, Hypnotherapy, Cognitive behavioural,

Psychotherapy

• Pharmacological Rx– PTO

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Give me a Gastro patient that doesn’t fit these criteria !

• Pancreatic Ca, Crohn’s stricture, Colonic Ca• Rome Criteria 3 - Surely we can all relate

personally to these

3m of Abdominal Pain / DiscomfortAssociated with 2 of 3

– Altered frequency– Altered consistency– Improves with defaecation

– But what about “bloaty” woman, I hear you cry ?????

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Warning - Before you diagnose someone with IBS - be aware

• Ford AC. ArchIntMed 2009– 4.1% of all IBS = Coeliac disease

• Garcia-Rodriguez LA. ScanJGastro. 2000: 35; 306– IBS patients have a 6x risk of Ca in 1st year– IBS patients after 5y have >20x risk of CrD

• Hamilton W. BMJ. 2009: 339– 2.5% Ovarian Ca present with bloating

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IBS Facts• Google = 6.5 million entries for IBS

• Heaton. GUT. 1992– Only 58% of normal pop conformed to

producing normal stool on Bristol Stool Chart

• Piessevaux. DDW. 2009– 80% of Belgiums have lower GI symptoms– 10% reach IBS criteria

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New IBS referralWhat does it mean to me?

• Could be anything gastroenterological, that hasn’t yet

been given a label

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IBS - Is there better terminology to explain what we mean?

• Non-organic disorder or

• Functional bowel symptoms (FBS)– My preference

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The Secret of Treating IBS / Functional Bowel Syndrome

“Don’t treat the symptoms- Treat the root cause”

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Functional Bowel Syndrome What are the main symptoms

• 1) Chronic Diarrhoea (rare)• 2) Classic Constipation• 3) Constipation Cycle Functional Bowel

Syndrome (C-IBS)– Diverticulosis, Coeliac– Right sided faecal loading

• 4) Pain– Faecal loading (Left Vs Right or Pan-colonic)– Bloating / Aerophagia

• 5) Bloating

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1) Chronic Diarrhoea

2121

Probably not the healthiest curry house in town

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D-IBS > 3x/d• Fernandez-Banares F. AmJGastro. 2007: 102; 2520

– 62 Colonoscopy -ive patients– 82% had an underlying diagnosis

• Coeliac + sb Crohn’s• Lactose + Fructose intolerance• Small bowel bacterial overgrowth• Bile acid malabsorption• Pancreatic insufficiency

– 18% had functional IBS (?psych / PI-IBS)

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Post-Infectious IBS

• Meta-analysis = 5-10% develop PI-IBS– Halvarson AmJG. 2006; 101: 1994

• Campylobacter - 27%– Parry S. AmJGastro 2003:98;1970

• Salmonella - 18%– Mearin F. Gastro. 2005: 129; 98

• E.coli - (63% with ETEC/EATC) 18% of these suffered IBS after 6m– Okhuysen PC AmJGastro. 2004:99;1774

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Chronic Diarrhoea

• All patients need to be actively investigated • All patients should be referred to a

gastroenterologist

• NB- IBS symptoms can still be experienced in patients with organic disease

• 60% of UC patients• 39% of CrD patients

• Keohane J. AmJGastro. 2010: 105; 1788

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2) Left sided Constipation

• 1) LIF pain (exclude DD)• 2) Reduced frequency• 3) Harder consistency with Straining +/-

Haemorrhoids or Fissure

• Mx• 1) Increase fluid intake >2L/day• 2) High fibre diet (not if DD present)• 3) Laxatives• 4) Stimulants

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Some slides have be borrowed with kind regards to;-

Dr. Anton Emmanuel of

UK/BU/RES/11/0051n Date of preparation: September 2011

and also to the

SHIRE Team and the Advanced Constipation Training Course

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3) Constipation cycle functional bowel syndrome

- Proximal / Right sided faecal loading

• 1) Altered bowel habits = Hard pellets + episodic loose• 2) Bloating / Flatulence / Borborygmi• 3) Sense on incomplete emptying• 4) Straining +/- Haemorrhoids

• Mx• 1) Increase fluid intake >2L/day• 2) Low residue (high soluble fibre) diet• 3) Osmotic agents (Movicol) +/- Laxatives• 4) Stimulants +/- 5HT4 agonists (Prucalopride)

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Right sided faecal loading

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4) Abdominal Pain

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Abdominal Pain

• a) Faecal Loading– Left sided– Right sided– Pan-colonic

• b) Diverticulosis

• c) Bloating– Aerophagia

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Bloating

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3 Main Causes

• 1) Air swallowed = Aerophagia• 2) Gas production = SBBO• 3) Air trapped = Faecal Loading

• Mx• 1) Awareness / Exercise / Positional

deflation /Anti-anxiety agents• 2) H2 Lactulose breath test + Abs• 3) Rx to soften and shift the bowel

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Aerophagia

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One remedy

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Low FODMAP Diet

• FODMAPs =• Fermentable Oligo-, Di-, and Mono-saccharides,

And Polyols.

• Typical symptoms would include – abdominal bloating– excessive gas– chronic diarrhea or constipation

• Strict FODMAP avoidance

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Low FODMAP Diet

Oligo-saccharides

Di-saccharides

Mono-saccharides

Polyols

Fructans Galactans Lactose Fructose Sorbitol white bread cabbage milk honey sugar free gum

pasta brussel sprouts butter dried fruits low cal foods pastries soy beans cheese apples stone fruits cookies chickpeas yoghurt pears peaches onions lentil s sweets cherries apricots

artichokes chocolate peaches plums asparagus beer agave syrup Xylitol

leeks pre-prep soups watermelon berries garli c pre-prep sauce corn syrup chewing gum

chicory roots

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Diverticulosis

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Complications

• Bleeding (15%)• 40% of all LGIBleeds

• Assoc colitis• Stricture Obstruction• Diverticulitis

inflammation “itis”– Fistula – Sepsis– Perforation

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DD Re-Bleeding Rates

Year Percentage1 9%2 10%3 19%4 25%

1 Longstreth Am J Gastro 1997

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Use of surrogate markers of inflammation and Rome criteria to distinguish organic from non-

organic intestinal diseaseTibble J. Gastro. 2002; (123): 450-460

• 602 new referrals with bowel symptoms

• All patients had FC, intestinal permeability studies and either Ba enema or colonoscopy

• 263 had organic disease, 339 diagnosed with IBS

• FC OR=27.8 p<0.0001Sensitivity Specificity

FC 89% 79%

IP 63% 87%

Rome I 85% 71%

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BMJ Meta-analysisRheenen P.F. BMJ. 2010;341:c3369

• 13 studies = 670 adults + 371 children

• Sensitivity = 0.93 (0.85-0.97) in adults

• Specificity = 0.96 (0.79-0.99) similar in kids

• Screening potential IBD patients would reduce 67% of colonoscopy

• 6% false negative = delayed diagnosis

• 9% may have a non-IBD pathology

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Can FCalp reduce unnecessary colonoscopy in IBS

Whitehead SJ. GUT. 2010; (59): A36

• 2419 patients

• 1750 -ives

• 669 +ives (FC > 50mcg/g) = 58% pathology

• Cheaper + more effective at differentiating between IBS and IBD

• Same price as doing a ESR + CRP

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Graham Holland’s Vision of Luton

Further Information

• www.drmattwjohnson.com

• Oesophageal Laboratory• Small bowel capsule enteroscopy• Faecal calprotectin• IBD-SSHAMP

• Spire - 07889 219806• L&D - 01582 497242

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Learning objective 1

• Tests expected pre-referral

• FBC + ESR (1%)

• TFT (6%)

• Coeliac (2-15%)

• Ca + Albumin

• Stool MCS + COP

• Consider

• AXR

• Pelvic US

• Faecal Calprotectin

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Learning objective2

• European Constipation Treatment Algorithm