advertisement

approach to the patient with irritable bowel syndr

0 %
100 %
advertisement
Information about approach to the patient with irritable bowel syndr
Education

Published on September 21, 2008

Author: ashrafalabasiry

Source: authorstream.com

advertisement

Slide 1: Dr.Ashraf Sobhy Al-Abasiry MBBCh.MSc Internist,Primary Care Department Saad Specialist hospital Email : ashrafalabasiry@yahoo.com Approach To Patients With Irritable Bowel Syndrome Introduction : Introduction Irritable Bowel Syndrome is the most common functional gastrointestinal disorder ( FGID) FGID are characterized by chronic or recurrent gastrointestinal symptoms that is not explained by structural or biochemical abnormalities. Functional GI Disorders (FGIDs) : Functional GI Disorders (FGIDs) In the Rome III classification, the Functional GI Disorders (FGIDs) are classified into six major domains for adults: Esophageal (category A) Gastrodudenal (category B) Bowel (category C) Functional Abdominal Pain Syndrome (category D) Biliary (category E) Anorectal (category F) Rome III Slide 5: Irritable bowel syndrome (C1) Functional Bloating (C2) Functional Constipation (C3) Functional Diarrhea (C4) Unspecified FBD (C5) Functional Bowel Disorders (C) Rome III 1786 Drossman DA. Gastroenterology 2006;130:1377-90. Slide 6: Definition: Irritable bowel syndrome (IBS) is a chronic, relapsing and often life-long disorder with key features of. Abdominal Pain /Discomfort which may be Associated with: ►Defaecation . ► Change in bowel habit. ► Feeling of incomplete evacuation. ► Passing mucus per rectum. ► Abdominal fullness, bloating or swelling. Irritable bowel syndrome: NICE guideline August 07 Slide 7: *Common associated symptoms in patients with IBS include: Heartburn. Dyspepsia. Excessive belching and nausea. *Extraintestinal symptom also occure such as: Fatigue.headachs , including (migraine) Urinary symptom. Dysmenorrhoea,dyspareunia. Joint and muscle pains. MODERN MEDICINE - Vol. 21, NOVEMBER 2004 Slide 8: Prevalence in the general population is estimated to be around 10 – 15 %. Less than one-third of them seek medical attention. Half of the people who have IBS develop symptoms before age 35, and 40% develop symptoms between the ages of 35 and 50. In women, IBS is 2 to 3 times more common than in men. MODERN MEDICINE - Vol. 21, NOVEMBER 2004 Prevalence. Prevalence of IBS Across the World : New Zealand IBS: 17% UK IBS: 22% Australia IBS: 12% USA IBS: 9–20% Scandinavia IBS: 13% Prevalence of IBS Across the World Pathogenesis : Pathogenesis A number of pathophysiologic mechanisms have been identified In IBS Patients. Researchers are pursuing five areas in which there may be a difference between the bodies of people who suffer from IBS and those who don’t. MODERN MEDICINE - Vol. 21, NOVEMBER 2004 A-Abnormal Motility : A-Abnormal Motility A variety of abnormal myoelectrical and motor abnormalities have been identified in the colon and small intestine. There is some evidence that the speed of this movement is altered in both the colon and the small intestines of individuals with IBS. MODERN MEDICINE - Vol. 21, NOVEMBER 2004 B-Heightened Visceral Perception : B-Heightened Visceral Perception The increased sensitivity of the gut to normal physiological events or minor noxious stimuli is well described in IBS. Studies have shown that many patients with IBS experience pain in the rectum at a different threshold level than people who do not have the disorder. It is thought that this difference in pain perception is the result of a process in which the nerves of the gut become oversensitized to stimulation. MODERN MEDICINE - Vol. 21, NOVEMBER 2004 C-Brain GUT Connection : C-Brain GUT Connection The digestive system has a sort of brain of its own, the enteric nervous system. There is evidence that dysfunction in the interactions between the gut and the brain may underly the motility disturbance and visceral hypersensitivity that result in IBS symptoms. Slide 14: D-Inflammation Recent studies have revealed low grade chronic inflammation with an increase in inflammatory cells in the ileal and colonic mucosa in some patients with IBS. E-Gut Bacteria Research focus on gut bacteria has begun to offer some evidence that there is a difference between the bacterial makeup of some IBS patients and those who do not suffer from the disorder. MODERN MEDICINE - Vol. 21, NOVEMBER 2004 Slide 15: is Irritable Bowel Syndrome A Diagnosis of Exclusion? Dr.Ashraf Al-Abasiry Irritable Bowel Syndrome Diagnostic Criteria: : Irritable Bowel Syndrome Diagnostic Criteria: In 1978 Manning et al., Found, from questionnaire data, that IBS sufferers reported four common symptoms. The Manning Criteria was established to distinguish organic causes for symptoms from those of IBS. Manning’s Criteria are: : Manning’s Criteria are: Onset of pain linked to more frequent bowel movements. Looser stools associated with onset of pain. Pain relieved by passage of stool. Noticeable abdominal bloating. Sensation of incomplete evacuation more than 25% of the time. Diarrhea with mucous more than 25% of the time. Irritable Bowel Syndrome Diagnostic Criteria: : Irritable Bowel Syndrome Diagnostic Criteria: In 1992 the Rome I Criteria was established by a multinational committee of specialists, which further refined the Manning Criteria. In 1998 the At the 13th International Congress of Gastroenterology in Rome, Italy a group of physicians defined criteria to more accurately diagnose IBS. They produced the Rome II Criteria. Slide 19: ROME II criteria (1998) Improvement with defecation Recurrent abdominal pain or discomfort at least 3/12 of previous yr associated with 2 or more : Onset associated with a change in frequency of stool Onset associated with a change in form (appearance) of stool and and MODERN MEDICINE - Vol. 21, NOVEMBER 2004 ROME II criteria (1998) : ROME II criteria (1998) Symptoms that cumulatively lend support to the diagnosis: Abnormal stool frequency (>3/ day/ <3/ week) Abnormal stool consistency. Abnormal passage of stool. (incomplete feeling evacuation/ urgency). Passage of mucus. Bloating/ sensation of abdominal distension. MODERN MEDICINE - Vol. 21, NOVEMBER 2004 Bristol stool form scale : Bristol stool form scale Heaton KW, Fast Facts of IBS 1999;27. Slide 22: Rome III Criteria (2006) Improvement with defecation Recurrent abdominal pain or discomfort at least 3 days/month In the last 3 months associated with 2 or more : Onset associated with a change in frequency of stool Onset associated with a change in form (appearance) of stool and and Longstreth G., Gastroenterology 2006 Criteria fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis. Sub-typing IBS by predominant stool pattern : Sub-typing IBS by predominant stool pattern Subtype (absent use of antidiarrheals or laxatives) IBS-C (IBS with constipation). IBS-D (IBS with diarrhea). IBS-M (mixed IBS). IBS-U (unsubtyped IBS): insufficient abnormality of stool consistency to meet criteria for IBS-C, D, or M. Stool form: Bristol scale Longstreth GF, et al. Gastroenterology 2006;130:1480-91. Slide 24: The Rome III criteria encourage clinicians to make a positive diagnosis of IBS on the basis of validated symptom criteria, and emphasize that IBS is not a diagnosis of exclusion. This recommendation based on extensive evidence that diagnostic tests generally have a very low yield in patients who fulfil the Rome criteria but who otherwise lack alarm signs or symptoms.(1) (1)Longstreth GF et al. (2006) Functional bowel disorders. Gastroenterology 130: 1480–1491 RED FLAGS:Features suggesting a diagnosis other than IBS : RED FLAGS:Features suggesting a diagnosis other than IBS Age of onset >50 yrs. Nocturnal symptoms. Rectal Bleeding. Unexplained/ unintentional weight loss. Recurrent vomiting. Fever. Anaemia. Steatorrhoea. Severe/ progressive symptoms. FHx colon cancer, IBD, Coeliac disease. MODERN MEDICINE - Vol. 21, NOVEMBER 2004 Approach to the Patient : Approach to the Patient Dr.Ashraf Al-Abasiry History Taking : History Taking Primary care clinicians should consider assessment for IBS if the patient reports having had any of the following symptoms for at least 6 months. change in bowel habit abdominal pain/discomfort bloating. Irritable bowel syndrome: NICE guideline August 07 History Taking : History Taking During the initial consultation, important question to ask include: Is stress provoking symptom? were symptom precipitated by an infective gastrointestinal illness? what is the predominant symptom diarrhea, constipation, or abdominal pain? MODERN MEDICINE - Vol. 21, NOVEMBER 2004 History Taking : History Taking what is your fiber intake, milk products, caffeine &other fluids? what about medication ( antacids, antibiotic, or other drugs)? FHx colon cancer, IBD, Coeliac disease. MODERN MEDICINE - Vol. 21, NOVEMBER 2004 Physical Examination : Physical Examination Physical examination is usually normal in patient who have IBS ,although mild abdominal tenderness or loaded sigmoid colon may be noticed. MODERN MEDICINE - Vol. 21, NOVEMBER 2004 Differential Diagnosis : Differential Diagnosis Colorectal Cancer& Colonic polyps. Coeliac disease. Inflammatory bowel sisease,especially Crohn’s disease. Complicated diverticular disease. Intermittent bowel obstruction. Giardiasis. Lactose intolerance. Pelvic pathology. MODERN MEDICINE - Vol. 21, NOVEMBER 2004 Investigations : In people who meet the IBS diagnostic criteria, it is recommended that the following tests should be undertaken to exclude other diagnostic possibilities. Full blood count (FBC). Erythrocyte sedimentation rate (ESR). C-reactive protein (CRP). Antibody testing for coeliac disease (endomysial antibodies (EMA)) or tissue transglutaminase (TTG). Irritable bowel syndrome: NICE guideline August 07 Investigations Investigationscont, : Investigationscont, The following tests should not be done to confirm diagnosis in people who meet the IBS diagnostic criteria. Ultrasound. Rigid/flexible sigmoidoscopy. Colonoscopy; barium enema. Thyroid function test. Faecal ova and parasite test. Faecal occult blood. Hydrogen breath test (for lactose intolerance and bacterial overgrowth). Irritable bowel syndrome: NICE guideline August 07 Clinical management of IBS : ©1999 TED GOFF FROM CARTOONBANK.COM ALL RIGHTS RESERVED “I hope you’re not going to be like the twenty incompetent doctors who couldn’t find anything wrong with me.” 1175 Clinical management of IBS Clinical management of IBS : Clinical management of IBS Dietary and lifestyle advice. Pharmacological therapy. Behavioural therapies Complementary and alternative medicine (CAM) therapies. Follow up. Irritable bowel syndrome: NICE guideline August 07 Dietary and lifestyle advice : Dietary and lifestyle advice People with IBS should be given information that explains the importance of self-help in effectively managing their IBS. This (self-help booklet) should include information on general lifestyle, physical activity, diet and symptom-targeted medication. Primary care clinicians should give lifestyle advice, encouraging people with IBS to make the most of their available leisure time and ensuring that they create relaxation time. Irritable bowel syndrome: NICE guideline August 07 Dietary and lifestyle advice : Dietary and lifestyle advice Primary care clinicians should assess diet and nutrition for all people with IBS and provide the following general advice. ►Have regular meals and take time to eat. ►Avoid missing meals, or leaving long gaps between meals. ►Drink at least 8 cups of fluid per day, especially water or herbal teas. ►Restrict tea and coffee to not more than 3 cups per day. Irritable bowel syndrome: NICE guideline August 07 Dietary and lifestyle advice : Dietary and lifestyle advice Try eating a lower-fat diet, selecting baked or grilled meats, low fat and light foods. Try a lactose free diet. Lactose is found in certain dairy products. Avoid some foods commonly reported to also cause gas and bloating include: beans, onions, celery, carrots, raisins, bananas, apricots. Dietary and lifestyle advice : Dietary and lifestyle advice Reduce intake of ‘resistant starch’, which is often found in processed or re-cooked foods, as it may increase symptoms. People with diarrhoea should avoid sorbitol, which is found in sugar-free sweets (including chewing gum) and drinks, and some diabetic and slimming products. Irritable bowel syndrome: NICE guideline August 07 Dietary and lifestyle advice : Dietary and lifestyle advice Primary care clinicians should review the fibre intake of a person with IBS, adjusting it according to effect while monitoring symptoms. People with IBS should be actively discouraged from taking insoluble fibre (bran). If an increase in dietary fibre is advised, this should be soluble fibre or foods high in soluble fibre such as legumes (lentils, chickpeas and beans), oat bran and some fruits and vegetables, such as apples, oranges and carrots. Referral to dietitian is helpful. Irritable bowel syndrome: NICE guideline August 07 Clinical management of IBS : Clinical management of IBS Dietary and lifestyle advice. Pharmacological therapy. Behavioural therapies. Complementary and alternative medicine (CAM) therapies. Follow up. Irritable bowel syndrome: NICE guideline August 07 Pharmacological therapy : Pharmacological therapy Antispasmodic:Primary care clinicians should consider prescribing antispasmodic agents, to be taken as required, alongside dietary and lifestyle advice. Laxatives:should be considered for the treatment of constipation in people with IBS,but they should be actively discouraged from taking lactulose. Pharmacological therapy : Pharmacological therapy Loperamide: should be considered as first-line treatment for diarrhoea in people with IBS. Primary care clinicians should advise people with IBS how to adjust laxative or antimotility agent doses according to the clinical response. Pharmacological therapy :  Pharmacological therapy Psychotrobic drugs Primary care clinicians should consider the benefit of prescribing tricyclics as second-line treatment for people with IBS. Treatment should be initiated at a low starting dose (5–10 mg equivalent of amytriptyline), once at night, which should be reviewed regularly. The dose can subsequently be increased, but does not usually need to exceed 30 mg. Primary care clinicians should consider prescribing selective serotonin reuptake inhibitors (SSRIs) only when tricyclics have been shown to be ineffective. Irritable bowel syndrome: NICE guideline August 07 Pharmacological therapy : Pharmacological therapy Antibiotic It is thought that bloating and flatulence, especially troublesome in patients with irritable bowel syndrome (IBS), may be caused by bacterial overgrowth in the small intestine. The theory is that this overgrowth can be detected by measuring hydrogen released during bacterial carbohydrate fermentation with a lactulose hydrogen breath test (LHBT). Pharmacological therapy : Pharmacological therapy A 10-day course of rifaximin reduced bloating and flatulence in patients with and without IBS. October 17, 2006, issue of Annals of Internal Medicine. Slide 49: Pharmacological therapy Probiotic Probiotics are dietary supplements containing potentially beneficial bacteria or yeasts. According to the currently adopted definition by FAO/ WHO, probiotics are: ‘Live microorganisms which when administered in adequate amounts confer a health benefit on the host’. Probiotic : Probiotic Strains of the genera lactobacillus and Bifidobacterium, are the most widely used probiotic bacteria. Short term therapy with probiotics such as Lactobacillus Plantarum LP01(1) and Bifidobacteria infantis(2), significantly improves symptoms and quality of life in patients with irritable bowel syndrome (IBS) and other bowel disorders. (1)Eur J Gastroenterol Hepatol 13 (10): 1143–7. PMID (2)Am J Gastroenterol.. Retrieved on 2007-12-02 Slide 52: Clinical management of IBS 1- Dietary and lifestyle advice. 2- Pharmacological therapy. 3- Behavioural therapies. 4- Complementary and alternative medicine (CAM) therapies. 5- Follow up. Irritable bowel syndrome: NICE guideline August 07 Slide 53: Behavioural therapies: Primary care clinicians should consider referring people with IBS who do not respond to first- line therapies after 12 months and who develop a continuing symptom profile (described as refractory IBS) for behavioural therapies: Cognitive behavioural therapy ( CBT). Hypnotherapy. Dynamic Psychotherapy. Irritable bowel syndrome: NICE guideline August 07 Predictors of a positive response to psychological treatment generally are: : Predictors of a positive response to psychological treatment generally are: (1) awareness that stress exacerbates their bowel symptoms, (2) mild anxiety or depression. (3) The predominant bowel symptom is abdominal pain or diarrhea and not constipation, (4) the abdominal pain waxes and wanes in response to eating, defecation, or stress rather than being constant pain. (5) The symptoms are of relatively short duration. Slide 55: Clinical management of IBS 1- Dietary and lifestyle advice. 2- Pharmacological therapy. 3- psychological Therapies. 4-Complementary and alternative medicine (CAM) therapies. 5- Follow up. Irritable bowel syndrome: NICE guideline August 07 Slide 56: Complementary and alternative medicine (CAM) therapies. Primary care clinicians should not encourage the use of acupuncture in the treatment of IBS. Primary care clinicians should not encourage the use of reflexology in the treatment of IBS. Irritable bowel syndrome: NICE guideline August 07 Slide 57: Clinical management of IBS 1- Dietary and lifestyle advice. 2- Pharmacological therapy. 3- psychological Therapies. 4- Complementary and alternative medicine (CAM) therapies. 5- Follow up. Irritable bowel syndrome: NICE guideline August 07 Slide 58: Follow up. Follow-up should be mutually agreed between primary care clinicians and people with IBS based on symptom response to interventions. This should form part of the annual patient review. Irritable bowel syndrome: NICE guideline August 07 Slide 59: Therapeutic relationship / Continuity of care Education / Reassurance IBS - Treatment Symptomatic medical treatment Stress reduction Exercise, etc. CBT Hypnosis psychotherapy Stress management Low dose TCA or SSRI Combined AD + psych Mental health referral Psychiatric referral Severity * Monitor side effects Severe Moderate Mild All Summary Slide 60: Summary IBS Is not a diagnosis of exclusion. Keep investigations to a minimum and be clear to patient that expect the results to be normal. Explain from outset different approaches and if one fails doesn’t mean necessarily wrong diagnosis. Don’t be reluctant to try antidepressants- shown to be effective in people who are not depressed. Slide 61: Thanks..

Add a comment

Related presentations

Related pages

Diagnostic Approach to the Patient with Irritable Bowel ...

Diagnostic Approach to the Patient with Irritable Bowel Syndrome Max W. Schmulson, MD, Lin Chang, MD Irritable bowel syndrome (IBS) is a common chronic
Read more

Approach to the Patient with Severe, Refractory Irritable ...

Approach to the Patient with Severe, Refractory Irritable ... with irritable bowel syndrome ... dealing with a patient with IBS and a history ...
Read more

Diagnostic approach to the patient with irritable bowel ...

Diagnostic approach to the patient with irritable bowel syndrome. ... is a common chronic functional bowel disorder characterized by abdominal pain or ...
Read more

Therapeutic Approach to the Patient with Irritable Bowel ...

Therapeutic Approach to the Patient with Irritable Bowel Syndrome Michael Camilleri, MD This article reviews briefly the evidence to support current ...
Read more

Diagnostic approach to the patient with irritable bowel ...

Abstract. Irritable bowel syndrome (IBS) is a common chronic functional bowel disorder characterized by abdominal pain or discomfort and alterations in ...
Read more

Therapeutic approach to the patient with irritable bowel ...

Abstract. This article reviews briefly the evidence to support current therapies in irritable bowel syndrome (IBS) and the novel therapeutic approaches on ...
Read more

Diagnosing the Patient with Abdominal Pain and Altered ...

A practical approach for diagnosing irritable bowel syndrome ... Diagnosing the Patient with ... Patient subgroups in irritable bowel syndrome that ...
Read more

Approach to the IBS Patient With Persistent Abdominal ...

... present with significant persistent abdominal distension, ... Approach to the IBS Patient With ... patients with irritable bowel syndrome ...
Read more

Treatment of Irritable Bowel Syndrome - American Family ...

Herbal therapies such as peppermint oil also may be effective in the treatment of irritable bowel syndrome. ... Approach to the Patient. Jump to section +
Read more