By Tara Nowakhtar DidacticsOnlinecom Case Presentation 24 year old female presents with the following symptoms Crampy feeling abdominal pain varying intensity intermittent Stress and eating exacerbate pain ID: 690231
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Slide1
Irritable Bowel Syndrome
By Tara
Nowakhtar
DidacticsOnline.comSlide2
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 & constipation
Bloated/gassy feeling
Gastroesophageal
reflux (“heart burn”)
Dyspareunia, fatigueSlide3
Case:
Pt
has had these symptoms for several days a month in the last 6 months
PMHx
: depression, anxiety
SHx
: appendectomy
PE:
Abdomen tender to palpation in all 4 quadrants with significant guarding
Abdomen sounds tympanic on percussion
Global
fascial
tightness throughout abdomen
Paraspinal
changes at T9-T10Slide4
Epidemiology of IBS
IBS is an intrinsic colonic motility disorder with several plausible causes: loss of tolerance to GI flora, genetic factors, environmental triggers
MC functional bowel disorder
F>>M
Risk factors:
Hx
of childhood sexual abuse
Domestic abuse in women
Increased stress, depression, anxietySlide5
Pathophysiology of IBS
No pathognomonic pattern of gut
dysmotility
can be identified with IBS, unlike other functional gut disorders; 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 gasSlide6
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 nervesSlide7
Pathophys….
Postinfectious
IBS
– this has been suspected based upon a history of acute diarrheal illness preceding onset of IBS symptoms in some patientsSlide8
Signs & Symptoms
GI symptoms:
Chronic abdominal pain (
crampy
, variable intensity)
Emotional stress and eating
pain, defecation
pain
Altered bowel habits
Other GI symptoms:
GE reflux, dysphagia, early satiety, dyspepsia, nausea, non cardiac chest pain, abdominal bloating, increased gas (accompanied by flatulence or belching)
Non GI symptoms:
Impaired sexual function, dysmenorrhea, dyspareunia, increased urinary frequency/urgencySlide9
Altered Bowel Habits in IBS
Diarrhea
Frequent loose stools of small volume, with mucus
Generally in the morning or after meals
May be preceded by lower abdominal cramps and urgency
May have feeling of incomplete evacuation
Constipation
Days to months; may include bouts of diarrhea or normal bowel function
Stools often hard and pellet shaped
May sense incomplete evacuation even with empty rectumSlide10
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 defecationSlide11
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)Slide12
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)Slide13
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!Slide14
Keep in mind: IBS can look like other illnesses, and other illnesses can look like IBS!Slide15
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)Slide16
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 thingsSlide17
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
AntibioticsSlide18
Antispasmodics
Ex:
hyoscine
,
cimetropium
,
pinaverium
(short term relief, LT efficacy has yet to be demonstrated).
C
an
directly affect intestinal smooth muscle relaxation, or via anticholinergic/
antimuscarinic
properties
T
hey
reduce colonic motor activity and may improve postprandial abdominal pain, gas, bloating, and fecal urgency.Slide19
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 TCA’s and SSRI’s 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). TCA’s also slow down intestinal transit time via anticholinergic properties (helpful in diarrhea predominant IBS)Slide20
Antibiotics
Some patients show improvement in
sx’s
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 medicationSlide21
From the Osteopathic POV…
In a 2007 article in Journal of Gastroenterology &
Hepatology
titled “Treatment of Irritable bowel syndrome with osteopathy: Results of a Randomized controlled pilot study”, it was found that 13 of 19 patients in the group receiving osteopathic treatment had overall improvement of symptoms in 6 months, one was free of symptoms, and the remaining five showed slight improvement
In the standard care group, 3/17 subjects noted “definite” improvement, while 10 showed slight improvement. The remaining 3 had worsened
sx’s
Improvement was statistically significant in favor of the osteopathic treatment group with a p value <0.006Slide22
OMT can be used!
MFR of abdominal fascia
OA decompression
ANS treatments
Treatment of diaphragms (especially
thoraco
-abdominal!)
Treat the whole patient! Listen to the patient, make sure to get a good
hx
: remember, these patients have had it with doctors and are trying to understand their illness, do your best to help them!Slide23
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