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Irritable Bowel Syndrome Irritable Bowel Syndrome

Irritable Bowel Syndrome - PowerPoint Presentation

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Irritable Bowel Syndrome - PPT Presentation

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

ibs pain symptoms bowel pain ibs bowel symptoms irritable syndrome abdominal treatment patients improvement diarrhea intestinal increased gas predominant activity criteria gastroenterology

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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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