_bowel syndrome didacticsonline肠易激综合征 课件

Irritable Bowel Syndrome By Tara Nowakhtar DidacticsO Case Presentation 24 year old female presents with the following symptoms Crampy feeling (abdominal pain), varying intensity, intermittent Stress and eating exacerbate pain Bowel movement relieves pain Alternating diarrhea however, it is suggested that a motility disturbance is the underlying issue in IBS patients Increased sensitivity in the viscera is commonly found in IBS patients Distention - Awareness and pain caused by balloon distention in intestine are experienced at lower volume than with controls Bloating studies have shown that although there are similar amounts of gas in IBS vs. control patients, there is impaired transit of that intestinal gas Pathophys. Intestinal Inflammation mucosal immune activation has been shown in IBS, characterized by alterations in immune cells and markers ; mostly in diarrhea predominant Lymphocytes increased numbers reported in colon and SI in he myenteric plexus Mast cells in terminal ileum, jejunum, colon; some studies have showed a correlation between abdominal pain and the presence of activated mast cells around colonic nerves Pathophys. Postinfectious IBS this has been suspected based upon a history of acute diarrheal illness preceding onset of IBS symptoms in some patients Signs may include bouts of diarrhea or normal bowel function Stools often hard and pellet shaped May sense incomplete evacuation even with empty rectum Diagnostic Criteria There are no biologic disease markers for IBS, so diagnosis has been standardized with symptom based criteria Manning Criteria 1978, not used as much anymore Rome Criteria 1992, revised 2005, defined as recurrent abdominal pain/discomfort associated with altered defecation Rome Criteria Recurrent abdominal pain/discomfort at least 3 days per month in the last 3 months associated with 2 or more of the following: Improvement with defecation Onset associated with change in frequency of stool Onset associated with change in form of stool (appearance) Subtypes IBS with constipation (hard/lumpy stools predominant) IBS with diarrhea (loose/watery stools predominant) Mixed IBS (neither predominates) Unsubtyped IBS (insufficient stool abnormality to meet the above subtypes) Noncompatible symptoms Pain associated with: anorexia, malnutrition, weight loss these are rare with IBS unless there is severe psychologic illness Progressive pain Pain that prevents sleep or wakes patient from sleep Rectal bleeding Lab abnormalities: anemia, inflammatory markers, electrolyte disturbances These are “alarm” symptoms and require additional testing! Keep in mind: IBS can look like other illnesses, and other illnesses can look like IBS! Treatment of IBS Dietary modification: pt may have food allergies, should exclude gas- producing foods, coffee, fatty foods, carbohydrates (sx may be related to impaired absorption of carbohydrates: FODMAPs enter distal small bowel and colon when they are fermented, leading to sx and increased intestinal permeability, although there have been few studies to demonstrate this); Increase fiber intake (say most studies, although keep in mind that might be an issue for diarrhea-predominant IBS) Treatment (continued) Patient-physician relationship is important! Physical activity: in a randomized trial, this was examined - Physical activity comprised of 20-6- min of moderate to vigorous activity 3-5x/w showed improvement in severity of IBS compared with control group Psychosocial therapies: behavioral treatments for those who associate sx with stressors the goal being to reduce anxiety, among other things Pharmacologic treatment of IBS *these are to be used as an ADJUNCT to tx* Antispasmodics Antidepressants Antidiarrheal agents Benzodiazepines 5-HT 3 receptor antagonists 5-HT 4 receptor agonists Lubiprostone Guanylate cyclase agonists Mast cell stabilizers Antibiotics Antispasmodics Ex: hyoscine, cimetropium, pinaverium (short term relief, LT efficacy has yet to be demonstrated). Can directly affect intestinal smooth muscle relaxation, or via anticholinergic/antimuscarinic properties They reduce colonic motor activity and may improve postprandial abdominal pain, gas, bloating, and fecal urgency. Antidepressants Independent of their mood improving effects, antidepressants have analgesic properties, and therefore may be beneficial in patients with neuropathic pain The assumed MOA with TCAs and SSRIs are facilitation of endogenous endorphin release, blockade of NE reuptake (leading to enhancement of descending inhibitory pain pathways), and blockade of the pain neuromodulator (5-HT). TCAs also slow down intestinal transit time via anticholinergic properties (helpful in diarrhea predominant IBS) Antibiotics Some patients show improvement in sxs of bloating, abdominal pain or altered bowel habits after use of antibiotics Rifaximin, a nonabsorbable antibiotic, globally improved IBS symptoms in reports of two randomized trials MOA is unclear, may be due to suppression of gas producing bacteria in the colon CONS: Usually, pt has to pay out of pocket due to the outrageous cost of this medication From the Osteopathic POV In a 2007 article in Journal of Gastroenterology 130:1480 2.Swarbrick ET, Hegarty JE, Bat L, et al. Site of pain from the irritable bowel. Lancet 1980; 2:443 3.Whorwell PJ, McCallum M, Creed FH, Roberts CT. Non-colonic features of irritable bowel syndrome. Gut 1986; 27:37 4.Hershfield NB. Nongastrointestinal symptoms of irritable bowel syndrome: an office-based clinical survey. Can J Gastroenterol 2005; 19:231 5.Owens DM, Nelson DK, Talley NJ. The irritable bowel syndrome: long-term prognosis and the physician-patient interaction. Ann Intern Med 1995; 122:107 6.Gibson PR, Shepherd SJ. Personal view: food for thought-western lifestyle and susceptibility to Crohns disease. The FODMAP hypothesis. Aliment Pharmacol Ther 2005; 21:1399 7.Johannesson E, Simrn M, Strid H, et al. Physical activity improves symptoms in irritable bowel syndrome: a randomized controlled trial. Am J Gastroenterol 2011; 106:915 8.Choi YK, Johlin FC Jr, Summers RW, et al. Fructose intolerance: an under-recognized problem. Am J Gastroenterol 2003; 98:1348 9.Poynard T, Regimbeau C, Benhamou Y. Meta-analysis of smooth muscle relaxants in the treatment of irritable bowel syndrome. Aliment Pharmacol Ther 2001; 15:355 10.Eisendrath SJ, Kodama KT. Fluoxetine management of chronic abdominal pain. Psychosomatics 1992; 33:227 11.Hameroff SR, Weiss JL, Lerman JC, et al. Doxepins effects on chronic pain and depression: a controlled study. J Clin Psychiatry 1984; 45:47 12.Pilowsky I, Barrow CG. A controlled study of psychotherapy and amitriptyline used individually and in combination in the treatment of chronic intractable, psychogenic pain. Pain 1990; 40:3 13.Gorard DA, Libby GW, Farthing MJ. Effect of a tricyclic antidepressant on small intestinal motility in health and diarrhea- predominant irritable bowel syndrome. Dig Dis Sci 1995; 40:86 14.Bueno L, Fioramonti J, Delvaux M, Frexinos J. Me