_bowel syndrome肠易激综合征课件

Irritable Bowel Syndrome Dr Intekhab Alam Department of Medicine Postgraduate Medical Institute Lady Reading Hospital, Peshawar. Objectives nDescribe diagnostic criteria for IBS nUnderstand a cost-effective approach to diagnosing IBS nIdentify red flags that should alert you to further testing or consultation nDescribe a reasonable therapeutic approach based on the patients predominant symptom. What is Irritable Bowel Syndrome(IBS)? nA group of functional bowel disorders nChronic abdominal complaints without a structural or biochemical cause nConstitutes a major health problem with gastrointestinal (GI) symptoms nThe cause of IBS is unknown. nAffects up to 20 % adults in the industrialized world nThe condition is more frequent in women. nThe direct medical costs of IBS are $ US 8 billion in the US each year. Definition (modified Romes Criteria) n At least 12 weeks (not necessarily consecutive) in the preceding 12 months of abd. discomfort or pain that cannot be explained by structural or biochemical abnormalities and that has at least 2 of the following 3 features: 1.Pain is relieved with defecation. 2.Its onset is associated with a change in the frequency of bowel movements 3.Its onset is associated with a change in the form of the stool (loose, watery, or pellet-like). Subclassification of patients nSupportive symptoms of IBS Fewer than 3 bowel movements a week More than 3 bowel movements a day Hard or lumpy stools Loose or watery stools Urgency Feeling of incomplete bowel movement Passing mucus during a bowel movement Abdominal fullness, bloating or swelling nDiarrhea-predominant IBS (IBS-D) One or more of 2, 4 or 6 and none of 1, 3 or 5 nConstipation-predominant IBS (IBS-C) One or more of 1, 3 or 5 and none of 2, 4 or 6 Symptoms of IBS nAbdominal discomfort and pain nBloating, mucous in stools, diarrhea, constipation, or alternating diarrhea and constipation nDepression, anxiety or stress nIBS can be subdivided into Diarrhea-predominant (IBS-D) Constipation-predominant (IBS-C) Alternating diarrhea and constipation Pathophysiological Features n1. Altered Bowel Motility n2. Visceral Hypersensitivity n3. Psychosocial Factors n4. Neurotransmitter Imbalance n5. Infection and Inflammation Diagnosis nIf there are Red Flags, strongly consider investigations to exclude any underlying sinister pathology: Family h/o colonic cancer or IBD. Fever. Onset age 50. Nocturnal symptoms. Anemia. Diagnosis nRed Flags Cont: Persistent severe diarrhea or constipation. Hematochezia or melena. Weight Loss. Palpable rectal/abdominal mass. Investigations: Intensive and extensive investigations like flexible sigmoidoscopy, colonoscopy, EGD, barium enema, stool culture should not be recommended without red flags: However: nStools R/E, CBC with ESR, TSH, S Alb can be performed and should be normal. Differential Diagnosis nIBD- Chrons, UC nMedications- Laxatives, Constipating agents. nInfection- Parasitic, Bacterial, Viral, Opportunistic. nMalabsorption- Celiac, Ch:Pancreatitis, Lactose intolerance nEndocrine- Hypo/Hyperthyroidism, Diabetes, Addisons disease. nMalignancy. Therapeutic Approach nEstablish an empathetic physician- patient relationship: Reassurance, education, Support nIdentify associated factors and treat Anxiety Stress Social Phobias Depression/Dysthymia Panic Disorder Substance Abuse Previous sexual or physical abuse Therapeutic Approach Dietary Recommendations No specific advice has been shown to be efficacious in trials Expert opinion recommends limiting: nRaw onions, Cucumber, water melon. nCaffeine nFat. nExacerbating items known to the patient The emphasis should be shifted from “finding the cause” of the symptoms to finding “a way to cope with them” . Serotonin (5-hydroxytryptamine, 5HT) nA monoamine neurotransmitter nFound in cardiovascular tissue, the peripheral nervous system, blood cells, and the CNS n95 % resides in the GI tract nSerotonergic neurons secrete 5HT nThe function of serotonin is exerted upon its interaction with specific receptors. n7 distinct families of 5HTreceptors; 5HT1, 5HT2, 5HT3, 5HT4, 5HT5, 5HT6, and 5HT7 Therapeutic Approach nDiarrhea-Predominant Loperamide 2-4mg up to QID nCan be used prophylactically with anticipated stress Cholestyramine 4g 1-6x/day nSecond line, Level C evidence Clinidine (0.1 mg bid). Alosetron. Alosetron in IBS-D nThe first 5HT3 antagonist, approved only for female patients by FDA. nIschemic Colitis has been reported. Not yet available in Pakistan Therapeutic Approach nConstipation-Predominant Fiber 20-30g/day nStart slow and titrate up/may worsen bloating Osmotic Laxatives nMagnesium Citrate nLactulose nPolyethelyne Gylcol Tegaserod 6mg bid. nFDA approved in women for short term use (6 weeks) nDiarrhea most common side effect Tegaserod in IBS-C nThe first selective serotonin 5HT4 receptor partial agonist approved by FDA for the treatment of abdominal pain and constipation predominent IBS patients nNow available in Pakistan by different brand names. Therapeutic Approach nPain-Predominant Dicyclomine 10-20mg bid to qid nPRN usage only nAntispasmotic hyoscyamine. Mebeverine, Trimebutineetc etc. Amitryptyline 10-25mg qhs nTCA nSteinhart and colleagues showed in 1 RCT of 14 pts that amitriptyline showed global improvement in pts. with IBS nAnticholinergic Side Effects