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IBS Dr. Matt Johnson

BSc MBBS MRCP MD

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Specialty Areas of Interest

• EofE Train the Trainers in Constipation Management

• Inflammatory Bowel Disease – including tertiary referral clinics at St. Mark’s and St. Thomas’s hospitals.

• Surgical Gastroenterology - National Referral Unit for ileoanal pouches, faecal incontinence, complex anorectal fistula disease at St. Mark’s

• Small bowel pathology + Coeliac disease tertiary referral clinics for complicated and non-responsive cases.

• Hepatology (General hepatopancreatobiliary medicine, Hepatitis clinics, Liver ITU, pre/post liver transplant medicine)

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St. Thomas’s Hospital

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St. Mark’s

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Research Fellowship

• St. Marks’ and St. Thomas’ Hospital• The Bacterial Pathogenesis of Pouchitis

and Development of Novel Probiotic Therapies

• Prof PJ. Ciclitira, Prof RJ. Nicholls and Prof A. Forbes

• MD

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18 PublicationsManagement of colonic diverticulosis.

Coeliac disease in the elderly. Nat Clin Pract Gastroenterol Hepatol. 2008 Dec; 5(12): 697-706

Bacterial community diversity in cultures derived from healthy and inflamed ileal pouches after restorative proctocolectomy. IBD. 2009 Nov

The bacteriology of pouchitis: A molecular phylogenetic analysis. GUT. 2009. Dec

The prevalence of osteoporosis and osteopenia in ileal pouch patients post-restorative proctocolectomy. IBD. 2009. Sept

Prolonged toxic megacolon secondary to Salmonella. [Submitted to Diseases of the Colon and Rectum]

Coeliac disease in the older patient: Are we ageist in our practice. [Awaiting publication in Gastroenterolgy CME Journal]

The medical management of patients with an ileal pouch anal anastomosis after restorative proctocolectomy. EJoGH.

Faecal M2-pyruvate kinase; a novel, non-invasive marker of ileal pouch inflammation. EJoGH

Faecal calprotectin: A non-invasive diagnostic tool and marker of severity in pouchitis. Eur J Gastroentero Hepatol. 2008 March; 20(3): 174-179

Hyperbaric oxygen as a treatment for malabsorption in a radiation damaged short bowel. June 2006; 18(6):685-688

Risk of dysplasia and adenocarcinoma following restorative procto-colectomy for ulcerative colitis. Colorectal Disease. CDI-00256-2005.R1. 03/05/06

Use of fecal lactoferrin to diagnose irritable pouch syndrome: A word of caution. Gastroenterology. 2004. 127(5):1647-8

Presentation, diagnosis and management of inflammatory bowel disease in older people. CME Geriatric Medicine, 2005; 7(3): 149-153

The pathogenesis of coeliac disease. Molecular Aspects of Medicine, Dec 2005: 26 (6); 421-458

11th International Symposium on Coeliac Disease: A report. Gastroenterology Today. Summer 2004; 14 (2): 46-7

Clinical toxicity of HMW glutenin subunits of wheat to patients with celiac disease.

Proceedings of the 19th Meeting of the Working Group on the prolamin analysis and toxicity, 2004; III Symposium: 147-9

Malaria: The dilemmas of malarial diagnostics. J R Army Med Corps 2002; 148: 122-126

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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

• 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• 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 - 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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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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IBS Treatment• Pain

– Anticholinergics– Antispasmodics– Tricyclic antidepressants

• Urgency + Diarrhoea– Loperamide – Codeine

• Constipation– Increased fibre– Ispaghula

• Others = Placebo

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Gastro Psychiatrist

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

• Rome Criteria 3 - Surely we can all relate !

3m of Abdominal Pain / Discomfort

Associated with 2 of 3– Altered frequency– Altered consistency– Improves with defaecation

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IBS - What does it mean to me?

• Non-organic disorder• Functional bowel symptoms (FBS)• Talk to your patients about their life and their

bowel habits

“Don’t treat the symptomsTreat the cause”

• Anyone with chronic diarrhoea need full Ix

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FBS - What are the main symptoms

• Chronic Diarrhoea (rare)• Pain

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

• Bloating• Constipation• Constipation Cycle functional bowel

symptoms– Diverticulosis, Coeliac– Right sided faecal loading

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Chronic Diarrhoea

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Chronic Diarrhoea

• Lactose Intolerance• Infection eg Giardia• Bile acid malabsorption• Coeliac disease• Small bowel bacterial overgrowth (SBBO)• Inflammatory bowel disease (UC / Crohn’s)

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

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Left sided Constipation

• 1) RIF 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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Right sided faecal loading

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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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Osmotic agents: polyethylene glycol

251. Attar et al. Gut. 1999.44.226-302. Andorsky & Goldner. Am J Gastroenterol. 1990;85(3):261-53. Corazziari et al. Dig Dis Sci. 1996;41(8):1636-424. Di Palma et al. Am J Gastroenterol. 2007;102(9):1964-71

P<0.0001P<0.005

Higher stool frequency with PEG vs lactulose after 1 month1

Less straining with PEG vs lactulose after 1 month1

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Idiopathic Slow Transit Constipation

Day 5 after taking markers

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Abdominal Pain

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Abdominal Pain

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

• Diverticulosis

• 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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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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One remedy

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• Matt Johnson + David Dewar• Professor Paul Ciclitira• St Thomas’s Hospital, London

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AD and age at diagnosis:

Group Prevalence AD

A1 – age<2yrs 5.1%

A2 – age 2-10yrs 17%

A3 – age>10yrs 23.6%

• Prevalence of autoimmune disease is related to duration of gluten exposure

Ventura A (1999) Gastroenterology 117:297-303

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Osteoporosis

• 47% women < 50% men on GFD have osteopenia / osteoporosisa

• Improvement 1 year post treatmentb

aMcFarlane (1995) Gut 36:710-14bValdimarsson (1996) Gut 38:322-7

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Diverticulosis

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Physiology and Anatomy

•Terminal arterial branches

•Penetrate circular muscle

•Often lie adjacent to taenia

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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

Faecal Calprotectin

• Business Case as a QUIPP Project• 1 year = 2600 colonoscopies • Cost = 2600 x £394 = £1,020,240• Normals = 40%

• Cost of FC in those 40% = £13,000• Cost of colonoscopy in those 40% = £409,760

– +/- the additional complications• Ease pressure on our colon lists + BCS lists• Increase OGD capacity, when Community Endo Unit

closes

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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