1 / 56

IRRITABLE BOWEL SYNDROME

IRRITABLE BOWEL SYNDROME. Joseph Zimmerman MD Gastroenterology Hadassah-Hebrew University Medical Center Jerusalem, Israel. The Irritable Bowel Syndrome (IBS).

fai
Télécharger la présentation

IRRITABLE BOWEL SYNDROME

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. IRRITABLE BOWEL SYNDROME Joseph Zimmerman MD Gastroenterology Hadassah-Hebrew University Medical Center Jerusalem, Israel

  2. The Irritable Bowel Syndrome (IBS) “IBS is defined by abdominal discomfort associated with altered bowel habits not explained by structural or known biochemical abnormality” ACG Position Statement 2002

  3. IBS: The Rome III Criteria for Diagnosis Recurrent abdominal pain or discomfort at least 3 days/month in the last 3 months associated with 2 or more of the following: • Improvement with defecation; • Onset is associated with a change in the frequency of stool; • Onset is associated with a change in form (appearance) of stool.

  4. OTHER BOWEL SYMPTOMS IN IBS • Abnormal stool passage (straining etc.); • Passage of mucus; • Bloating or feeling of abdominal distention.

  5. IBS: Clinical Subtypes • IBS is sub-classified into three types based on the primary bowel symptom: • constipation: IBS-C • diarrhea: IBS-D • alternation between constipation and diarrhea: IBS-A • Patients may shift between the various types.

  6. EPIDEMIOLOGY OF IBS

  7. The Irritable Bowel Syndrome • Symptoms compatible with IBS are present in 7-15% of the general population. • Females predominate 2:1. • Most of the people who meet diagnostic criteria for IBS have never consulted a doctor for bowel symptoms (IBS nonpatients).

  8. IBS: A Multidimensional Disorder • BIOLOGICAL • PSYCHOLOGICAL • BEHAVIORAL

  9. IBS is a Syndrome of Visceral Hyperalgesia • Low visceral pain threshold; • Normal compliance of the bowel wall; • Normal threshold for SOMATIC pain (in most but not all studies); • May we widespread;

  10. CONTROLS IBS Mayer EA, Gebhart GF, Gastroenterology 1994;107:271

  11. Is It in the Brain? • Some studies have shown that IBS patients differ from control subjects in the pattern of brain activation as a response to balloon distention in the distal colon. • The reported findings are inconsistent.

  12. ABNORMAL GAS PROPULSION IN IBS • Abdominal girth normally swells during the day, peaking in the late evening. • This phenomenon is exaggerated in IBS. • Studies using infusion of gas into the small intestine have shown that IBS patients retain more gas than controls, indicating abnormal gas propulsion.

  13. BLOATING AND DISTENTION IN IBS • During gas infusion, IBS patients, in contrast to healthy controls, involuntarily suppress their abdominal wall muscle contraction, reflecting an abnormal intestinal somatic reflex response.

  14. IBS: Additional Clinical Features • Non-Digestive Symptoms; Association with fibromyalgia. • Association with other functional GI disorders; • Relationship to enteric infections;

  15. SOMATIC PAIN SCORE IBS = IBD > Normal; F=7.7; p=0.001.

  16. URINARY SYMPTOMS SCORE IBS > IBD = normal; F=8.7; p<0.001.

  17. SLEEP DISTURBANCES SCORE IBS = IBD > Normal; F=5.5; p<0.001

  18. IBS: Additional Clinical Features • Non-Digestive Symptoms; • Association with other functional GI disorders; • Relationship to enteric infections;

  19. GI disorders of function commonly co-exist Upper GI tract Non-cardiac chest pain Heartburn Lower GI tract Gastroesophageal reflux disease (GERD) Functional abdominalpain Functional dyspepsia (FD) IBS Functionalconstipation/diarrhea

  20. IBS: Additional Clinical Features • Non-Digestive Symptoms; • Association with other functional GI disorders; • Relationship to enteric infections;

  21. Post Infectious IBS New onset of IBS symptoms following an episode of infectious enteritis

  22. Postinfectious IBS (PI-IBS):CLINICAL FEATURES • Usually diarrhea predominant; • The duration of PI-IBS spans months and years following the episode of acute infectious enteritis.

  23. Postinfectious IBS (PI-IBS):EPIDEMIOLOGY • Has been described following dysentery (bacillary or amebic), campylobacter infections and salmonellosis. • PI-IBS developed in 7-31% of cases.

  24. Postinfectious IBS (PI-IBS):PATHOGENESIS HOST FACTORS PATHOGEN FACTORS • Biological • Psychological

  25. Postinfectious IBS (PI-IBS):PATHOGEN FACTORS • The risk varies with the pathogen. • The risk associated with infections with shigella or campylobacter jejuni is 10-fold higher than that associated with salmonella.

  26. Postinfectious IBS (PI-IBS):Risk Factors for its Development (1) FACTORODDS RATIO • Female gender 3.4 • Duration of diarrhea • 0-7 days 1.0 • 8-14 days 2.9 • 15-21 days 6.5 • >22 days 11.4

  27. Postinfectious IBS (PI-IBS):HOST FACTORS • Psychometric testing of patients admitted for acute gastroenteritis revealed that those who scored higher on anxiety, depression, somatization and neurotic traits during the acute illness were more likely to develop a PI-IBS. Gwee et al, Lancet 1996;347:150-53

  28. Postinfectious IBS (PI-IBS):MUCOSAL ABNORMALITIES1 • Campylobacter infection may cause mucosal changes that persist for months. • These include enterochromaffin cell hyperplasia and an increase in mucosal T-lymphocyte counts. • Both changes tend to be more severe in patients with PI-IBS. 1. Dunlop et al. Gastroenterology 2003;125:1651-59

  29. Prevalence of IBS in community-based populations IBS features are highly prevalent in the population. Yet, most people with this “trait” do not consult a doctor for bowel symptoms.

  30. WHAT MAKES A PERSON WITH THE IBS ”TRAIT” BECOME AN IBS PATIENT?

  31. PSYCHOLOGICAL FACTORS; • STRESSFUL LIFE EVENTS; • BEHAVIORAL FACTORS;

  32. The Irritable Bowel Syndrome: Psychological Profile of Patients • No pattern of psychological symptoms is unique to patients with IBS. • IBS patients tend to score high in somatization, obsessive-compulsive, depression, anxiety and hostility scales. • In some studies, the proportion of patients meeting a criterion for a psychiatric diagnosis is 54-100%.

  33. The Irritable Bowel Syndrome: Stressful Life Events (1) • Acute induction of pain or emotional arousal increases the motility of the distal colon under experimental conditions. • This response is exaggerated in IBS patients1. • Exacerbation of symptoms is frequently associated with psychological stress. 1. Welgan et al., Gastroenterology 94: 1150, 1988

  34. The Irritable Bowel Syndrome: Sressful Life Events (2) • Studies of the prevalence of stressful life events in IBS patients have yielded inconsistent results. • Loss of a parent in childhood is an important factor1. • A history of physical or sexual abuse, particularly at a young age, is significant. 1. Lowman et el. , J Clin Gastroenterol 9:324, 1987

  35. The Irritable Bowel Syndrome:ILLNESS BEHAVIOR IBS PATIENTS: • Make 2-3 times as many visits to doctors for non-GI complaints than controls1. • Are more likely to have surgery. 1. Drossman et el. , Dig Dis Sci 38:1569 , 1993

  36. IBS and Surgery Of 89,009 HMO members, patients diagnosed with IBS (5.2%) were significantly more likely to undergo the above operations: • CHOLECYSTECTOMY: A 3-fold higher rate; • APPENDECTOMY: A 2-fold higher rate; • HYSTERECTOMY: A 2-fold higher rate; • BACK SURGERY: A 50%-fold higher rate. Longstreth GF et al. Gastroenterology 2004:126;1665

  37. IBS: ECONOMIC ASPECTS • IBS is associated with costs because of: • Days lost from work; • Excess physician visits; • Excess diagnostic testing; • Excess use of medications; • In the USA, the estimated annual cost of IBS is 8 billion dollars.

  38. IBS AND QUALITY OF LIFE

  39. IBS: Differential Diagnosis • CHO maldigestion (i.e. lactase deficiency) • Inflammatory Bowel Diseases • Celiac disease • Laxative abuse syndrome • Panic disorder • Parasitic infections • Carcinoma of colon • Other conditions

  40. IBS: What is against this diagnosis? • Onset after the age of 50; • Significant weight loss; • Prominent nocturnal symptoms; • Rectal bleeding, anemia;

  41. IBS: Clinical Workup • Lab: CBC, ESR, CRP, TSH levels; • Serological tests for celiac disease; • Fecal occult blood; • Stool microscopy (in IBS-D) ; • Sigmoidoscopy;

  42. The Management of Irritable Bowel Syndrome (IBS)

  43. IBS Management - General • Reassurance and explanation of the nature of the problem: IBS is a recognized clinical entity; symptoms can fluctuate; diet or stress may precipitate symptoms. • Dietary counseling (fiber supplementation with psyllium); • Symptomatic treatment: antispasmodics (papaverine, mebeverine), anti diarrhea agents etc.

  44. Management of Refractory Patients • Antidepressants • Psychological Treatments: • Hypnotherapy • Cognitive Behavioral Therapy (CBT)

  45. HYPNOTHERAPY FOR IBS

More Related