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Outline
IBS overview
International guideline IBS facts
IBS Overview
INTRODUCTION
Patients with functional gastrointestinal disorders are commonly seen in daily practice. 12% of patient encounters in primary care practice and 41% of those in gastrointestinal practice. The first reported account of IBS was published by Powell in 1818. Irritable bowel syndrome (IBS) is a common disorder that affects a large intestine (colon), causes cramping, abdominal pain, bloating, diarrhea and constipation
INTRODUCTION
Irritable Bowel Syndrome (IBS) doesn't cause permanent damage the colon Irritable bowel syndrome is a chronic relapsing and remitting condition Other names, Mucous colitis, Spastic colitis, Nervous colon, Irritable colon The criteria for diagnosis have evolved from the Manning criteria in 1978 to the Rome I criteria in 1988, Rome II criteria in 1998, Rome III criteria in 2006
Gastroenterology 2006;130:1480-91
Manning Criteria
Gut 2007;56:17701798
IBS Definition
World Gastroenterology Organisation Global Guideline
*In some languages, the words bloating and distension may be represented by the same term
World Gastroenterology Organization, 2009
EPIDEMIOLOGY
The prevalence of IBS ranges from 5-18 % In Europe and North America is estimated to be 1015%, in AsiaPacific region is increased (developing economies), Africa (Nigerian) based on the Rome II criteria found a 26.1% prevalence IBS is slightly more common in females IBS mainly occurs between the ages of 15 and 65. The first presentation of patients to a physician is usually in the 3050 year old age group
World map of IBS prevalence (20002004) based on the Rome II, III criteria, with figures for the Manning criteria in brackets where available.
IBS Classification
IBS with diarrhea (IBS-D):
Loose stools > 25% of the time and hard stools < 25% of the time Up to one-third of cases >> men
PATOFISIOLOGY
ALTERED BOWEL MOTILITY Abnormal timing & pattern of contractions w/ food or stress VISCERAL HYPERSENSITIVITY Abnormal excitability of neurons & pathways PSYCHOSOSIAL FACTORS May affect perceptions or central signal processing NEROTRANSMITTER IMBALANCE Increased serotonin levels? INFECTION / INFLAMATION Inflammatory cytokines may affect bowel sensitization
DIAGNOSTIC
Clinical history
It is important not only to consider the primary presenting symptoms, but also to identify precipitating factors and other associated gastrointestinal
Bloating ? Diarrhea
Dyspeptic symptoms
Constipation
Abdominal pain / discomfort
Psychological assessment
For these reasons, coexisting psychological conditions are common in referral centers and may include:
anxiety depression somatization hypochondriasis symptom-related fears
Severity Mild, can be ignored if the patient does not think about it Moderate, cannot be ignored but does not affect patient's lifestyle Severe/very severe, affects patient's lifestyle
Initial Assesment
Healthcare professionals should consider assessment for IBS if the person reports having had any of the following symptoms for at least 6 months:
A bdominal pain or discomfort B loating C hange in bowel habit.
NICE Guideline, 2008, IBS in Adults - Diagnosis and management of IBS in primary care
FBC, full blood count; FOBT, fecal occult blood test; ESR, erythrocyte sedimentation rate.
* Where relevanti.e., when there is a high prevalence of celiac disease, parasitosis, and inflammatory bowel disease or lymphocytic colitis, respectively.
Alarm Symptom
DIFFERENTIAL DIAGNOSIS
Celiac sprue/ gluten enteropathy Lactose intolerance IBD (Crohn's disease, ulcerative colitis) Colorectal carcinoma Lymphocytic and collagenous colitis Acute diarrhea due to protozoa or bacteria Small-intestinal bacterial overgrowth (SIBO) Diverticulitis Endometriosis Pelvic inflammatory disease Ovarian cancer Comorbidity with other diseases
IBS Management
Rediscovering treatment approach
Stability IBS: percentage of IBS patients after 1 and 7 years from the first interview
Representative diagram of the stability over time of IBS: percentage of the patients reporting IBS after 1 and 7 years from the first interview
Gastroenterol Res Pract.;2012:936-960
Management of IBS
Multi diciplinary approach No single treatment as beeing universally applicable to the management of IBS based on the predominant bothersome symptoms
Abdominal Pain :
Antispasmodics :
Mebeverine, Cimetropium, Trimebutine . Hyoscine, Otilonium . Pinaverium
4. Constipation :
Bulking agent Probiotic : Bifidobacterium lactic Laxative: Lactulose Lubiprostone
2.
Bloating / distension
Probiotik : Bifidobacterium lactis, Bifidobacterium infantis Antibiotic : Rifaximin
5.
3.
Diarrhea :
Loperamide, Alosetron
Gas
Fatigue
Diarrhea
Constipation 0 20 40 60 80 100
0.5
0.4
Correlation
0.3
0.2
0.1
Pain
Am J Gastroenterol 2006;101:124-132 Am J Gastroenterol 2000;95:999-1007
Gas
Q-TOT Bloating
Constipation
Diarrhea
Gut dysmotility
Brain-Gut axis
Visceral hypersensitivity
A combination of smooth muscle spasm, visceral hyperensitivity, and abnormalities of central pain processing may explain the abdominal pain that is an essential part of the symptom complex
Anti-spasmodic agents
Anticholinergics/antimuscarinics
secretomotornerve ending
Ca
++
SP
ACh
Ca Ca
+ +
+ +
N KA
Ca
+ +
Ca-channel M
NK1
Ca
+ +
Na Ca
++
Na Ca
++
NK2
Ca
+ +
Ca
cation-channel
Ca
+ +
Ca
++
++
Ca Ca
+ +
Ca
Ca
++
Ca
++
++
C a Ca
++
Pain improvement
11 RCT; Treatm. n=567; pla n=568
Mebeverine Cimetropium Trimebutine Otilonium Hyoscine Pinaverium TOTAL 0 1 2 3 4 5 6 7 OR: 2.13; P<0.00001
APT 2001;15:355-61
Control
Cimetropium
Piat Subtotal (95% CI)
Trimebutine
Flelding Moshal Subtotal (95% CI)
Otilonium
Baldi Barbier Battaglia Subtotal (95% CI) 7/15 16/36 76/160 99/211
106/182 106/182
Pain improvement
Hyoscine
Shafer Subtotal (95% CI)
Pinaverium
Delmont Subtotal (95% CI) 22/30 22/30 15/30 15/30
Total (95% CI) 300/567 233/568 Chi-squared 23.62 (d.f.=10) P=0.01 Z=4.09 P=0.00004
Favours placebo
0.1
0.2
10 Favours treatment
Inhibition muscle contraction at cellular level Increase in intracellular cAMP Stabilization of excitable membranes Weak anti-muscarinic activity
Independent of stimulus
**
***
Mebeverine
Mean symptoms score per month: mebeverine versus placebo
Tolerability MEBEVERINE
Generally very well tolerated % of patients without side effects NS between active arm and placebo arm Most side effects related to drugs with anticholinergic activity systemic effects (tachycardia, blurred vision, urinary retention)
Drug
Mebeverine Pinaverium bromide
Adverse Reactions
0.86, p=0.80 0.78, p=0.73 0.73, p=0.19 0.66, p=0.43 0.50, p=0.07 0.33, p=0.29
Hyoscine Trimebutine
Cimetroprium bromide Octilium bromide Peppermint oil Dicyclomide bromide Total Homogeneity p=0.19
0.0
Poynard, APT 1994;8:499
0.22, p=0.02
0.21, p<0.01
0.50, p<0.01
0.1
2 3 4 Odds ratio
Summary
IBS is a chronic, relapsing and often life-long disorder, characterised by the presence of abdominal pain or discomfort, which maybe associated with defaecation and/or accompanied by bowel habit change Treatment should be multidiciplinary, including education, doctor-patient relationship, dietary modification, pharmacotherapy ( antispasmodics, bulking agents, antidiarrhea, antidepressant, probiotics, and psychological treatment) Mebeverine as one of antispasmodic which effective in the pharmacological treatment of IBS with good tolerability safety profile