_bowel syndrome university of pittsburgh肠易激综合征匹兹堡大学课件

Irritable Bowel Syndrome Dr Bruce Davies www.bradfordvts.co.uk Sept 20011Bruce Davies Introduction First described in 1771. 50% of patients present 45 years at onset. Family history of bowel cancer. Failure of primary care management. Uncertainty of diagnosis. Abnormality on examination or investigation. Sept 200111Bruce Davies Urgent Referral Constant abdominal pain. Constant diarrhoea. Constant distension. Rectal bleeding. Weight loss or malaise. Sept 200112Bruce Davies Subtypes Diarrhoea predominant. Constipation predominant. Pain predominant. Sept 200113Bruce Davies Differential Diagnosis Inflammatory bowel disease. Cancer. Diverticulosis. Endometriosis. A positive diagnosis, based on Mannings criteria may provoke less anxiety than extensive tests. Sept 200114Bruce Davies Examination Results should be normal or non- specific. Abdomen and rectal examination. FBC, CRP. No consensus as to whether FOBs or sigmoidoscopy is needed. Sept 200115Bruce Davies Treatment Patients concerns. Explanation. Treatment approaches. Sept 200116Bruce Davies Patients Concerns. Usually very concerned about a serious cause for their symptoms. Take time to explore the patients agenda. Remember that investigations may heighten anxiety. Sept 200117Bruce Davies Explanation. Must offer a plausible reason for symptoms. Even if cause is unknown, patients require some explanation. Drawing a parallel with baby colic may help. Stress is currently a socially acceptable explanation for many symptoms in life. Sept 200118Bruce Davies Treatment Approaches. Placebo effect of up to 70% in all IBS treatments. Treatment should depend on symptom sub-type. Often considerable overlap between sub-groups. Sept 200119Bruce Davies Antidepressants Poor evidence for efficacy. Better evidence for tricyclics. Very little evidence for SSRIs. Sept 200120Bruce Davies Diarrhoea Predominant. Increasing dietary fibre is sensible advice. Fibre varies, 55% of patients will get worse with bran. “Medical fibre” adds to placebo effect. Loperamide may help. Sept 200121Bruce Davies Constipation Predominant. Increased fibre. Osmotic laxatives helpful. Ispaghula husk is one. Stimulant laxatives make symptoms worse. Lactulose may aggravate distension and flatulence. Sept 200122Bruce Davies Pain Predominant. Antispasmodics will help 66%. Mebeverine is probably first choice. Hyoscine 10mg qid can be added. Bloating may be helped by peppermint oil. Nausea may require metoclopramide. Sept 200123Bruce Davies Diet Dietary manipulation may help. Food intolerance is common food allergy is rare. Relaxation therapies may be useful adjunct. Sept 200124Bruce Davies Referral About 15% of patients seen by GPs with IBS are referred. Gastroenterology Mainly upper GI symptoms. General Surgical Lower GI symptoms. Sept 200125Bruce Davies Self-help IBS network, St Johns House, Hither Green Hospital, Hither Green Lane, London SE13 6RU Sept 200126Bruce Davies Audit? Numbers on repeat prescription for anti-spasmodics. Do they use their drugs as prescribed? What other medications do they use? Referral rates? What investigations are done? Protocol? Formulary? Sept 200127Bruce Davies Psychological Thoughts Should a