IRRITABLE BOWEL

SYNDROME
Presented By:
Dr.H.S.Imran-ul-Haque
Asst.Prof
DIMC
• IBS is a disorder of the GI tract that interferes with the normal
functions of the colon.
• IBS is described as a functional disorder, which means that it involves
symptoms that cannot be attributed to a specific injury, infection, or
other physical problem.
• IBS is one of the most common disorders seen in primary care and
the most common reason for referral to gastroenterologists.
• In GI-related problems 15% to 20% suffer from IBS.
• IBS affects women about twice as often as men.
• IBS can occur at any age but is most common between 20 and 50
years.
• There is a strong association between emotional distress and IBS.
• Psychosocial trauma (eg, a history of abuse, recent death of a close
relative or friend, or divorce) is more likely to be found in patients
presenting with IBS than in the general population.
• An increased prevalence of psychiatric disorders such as anxiety,
depression and personality disorders occurs among adults with IBS.
• Some people show first evidence of IBS after contracting
gastroenteritis (sometimes referred to as postinfectious IBS).
• Menstrual periods may trigger symptoms in some women.
PATHOPHYSIOLOGY
• Enteric nerves control intestinal smooth muscle action and are
connected to the brain by the autonomic nervous system.
• IBS is thought to result from dysregulation of this “brain–gut axis.”
• The enteric nervous system and the central nervous system (CNS) are
interconnected and interdependent.
• A number of neurochemicals mediate their function, including
serotonin (5-hydroxytryptamine or 5-HT), acetylcholine, substance P,
and nitric oxide, among others.
• Serotonin is particularly important because the GI tract contains the
largest amounts in the body.
• Two 5-HT receptor subtypes, 5-HT3 and 5-HT4 , are involved in gut
motility, visceral sensitivity, and gut secretion.
• The 5-HT3 receptors slow colonic transit and increase fluid
absorption,
• 5-HT4 receptor stimulation accelerates colonic transit.
• Studies suggest that the colon of IBS sufferers is abnormally sensitive
to normal stimuli.
• Enhanced visceral sensitivity manifests as pain, especially related to
gut distention
• Some IBS patients demonstrate sensitivity to common foods such as
wheat, beef, pork, soy, and eggs.
CLINICAL PRESENTATION AND DIAGNOSIS
• The diagnosis of IBS is made by symptom-based criteria and the
exclusion of organic disease.
• Patients should be questioned about the frequency, consistency,
color, and size of stools.
• Because of the functional nature of IBS, a patient may present with
symptoms of upper GI problems such as gastroesophageal reflux
disease or with excessive flatulence.
• Patients should also be questioned about diet to establish any
symptom relationship to meals or specifically after consumption of
certain foods
• The Rome III diagnostic criteria define IBS as occurring when
symptoms of recurrent abdominal pain or discomfort exist for at least
3 days/month in the last 3 months associated with two or more of the
following:
• (a) improvement with defecation,
• (b) onset associated with a change in the frequency of stool, and/ or
(c) onset associated with a change in the form (appearance) of stool.
• These criteria should be fulfilled for the previous 3 months with
symptom onset at least 6 months prior to diagnosis.
TREATMENT
• The principal goal of IBS treatment is to reduce or control symptoms.
• A standard treatment regimen is not possible because of the
heterogeneous nature of the IBS patient population.
• Patients suffering from IBS can benefit from clinician support and
reassurance.
 Treatment

Non-
Pharmacological
Pharmacological
Nonpharmacologic Therapy
Diet and Other General Modifications:
• Dietary modification is a standard therapeutic modality.
• Food hypersensitivities and adverse effects have been associated with IBS,
especially IBS-D.
• Elimination diets are the most commonly used strategy, usually focusing on
milk and dairy products, fructose and sorbitol, wheat, and beef.
• Flatulence may be controlled by reducing gas-causing foods (beans, celery,
onions, prunes, bananas, carrots, and raisins).
• Response to elimination diets varies widely, but they may be useful in
individual patients.
• Care should be taken to avoid nutritional deficits while attempting to
eliminate offending foods.
• The low FODMAP (fermentable oligosaccharides, disaccharides,
monosaccharides and polyols) diet is said to control IBS symptoms in
some patients.
• FODMAPS are carbohydrates that are poorly absorbed and quickly
fermented (by bacterial action).
• The gas byproduct of the bacterial action is thought to contribute to
IBS symptoms.
• Probiotics may also be an option for some patients with IBS.
• Bifidobacterium infantis is one product used for its effect in
constipation, diarrhea, gaseousness, bloating, and abdominal
discomfort.
• It has not been associated with significant untoward effects.
Pharmacologic Therapy
Agents for Pain and Bloating:
• Botanicals Peppermint oil is widely advocated;
• it acts as an antispasmodic agent due to its ability to relax GI smooth
muscle.
• However, it also relaxes the lower esophageal sphincter, which could
allow reflux of gastric contents into the esophagus.
 Antispasmodics:
• Dicyclomine and hyoscyamine have been among the most frequently
used medications for treating abdominal pain in patients with IBS.
• Side effects include blurred vision, constipation, urinary retention,
and (rarely) psychosis.
• These drugs may be used in patients with intermittent postprandial
pain.
 Antidepressants:
• Tricyclic antidepressants (TCAs) such as amitriptyline and doxepin
have been used with some success for treatment of IBS-related pain.
• They modulate pain principally through effects on neurotransmitter
reuptake, especially norepinephrine and serotonin.
• Low-dose TCAs (eg, amitriptyline, desipramine, or doxepin 10–25 mg
daily) may help patients with IBS who predominantly experience
diarrhea or pain.
 The selective serotonin-reuptake inhibitors (SSRIs):
• Paroxetine, fluoxetine, and sertraline are potentially useful due to the
significant effect of serotonin in the gut.
• SSRIs principally act on 5-HT1 or 5-HT2 receptors, but they can also have
some effect on gut-predominant 5-HT3 and 5-HT4 receptors, perhaps
reducing visceral hypersensitivity.
• They may be beneficial for patients with IBS-C or when the patient
presents with IBS complicated by a mood disorder.
• Serotonin–norepinephrine reuptake inhibitors may offer some benefit in
IBS patients who also have depression or anxiety accompanied by
significant pain (Venlafaxine,Desvenlafaxine & Duloxetine).
Agents for Constipation Predominance
Bulk Producers:
• These agents may improve stool passage in IBS-C but are unlikely to
have a favorable effect on pain or global IBS symptoms.
• Psyllium may increase flatulence, which may worsen discomfort in
some patients.
• Methylcellulose products are less likely than psyllium to increase gas
production.
• Although fiber-based supplement use is common in IBS-C,
methylcellulose may be dose adjusted in diarrhea to increase stool
consistency.
 Linaclotide:
• This drug is a guanylate cyclase-C (GC-C) agonist indicated for
treatment of IBS-C in adults.
• Linaclotide relieves the abdominal pain, bloating and constipation
associated with IBS-C while exhibiting a low tendency for systemic
side effects.
• However, diarrhea may prove troublesome in some patients.
• Clinical trials have demonstrated improved quality of life in treated
patients.
 Lubiprostone:
• This agent is also FDA approved for treatment of IBS-C, but only in
women age 18 years and older.
• Lubiprostone is generally well tolerated in such patients.
• It is typically given in smaller doses than used in chronic idiopathic
constipation.
• However, as with treatment for constipation, nausea may be an
adverse effect that limits use
 Tegaserod Maleate:
• This 5-HT4 receptor agonist was shown to be effective in IBS-C but
was withdrawn from the market because of the risk of heart attack,
stroke, and unstable angina (heart/chest pain).
• The FDA can authorize its availability and use for emergency
situations only.
Agents for Diarrhea Predominance
Eluxadoline:
• This agent is a mu-opioid receptor agonist that reduces bowel
contractions.
• In July 2015, the FDA approved eluxadoline for treatment of adults
with IBS-D.
• The most common adverse effects are constipation, nausea, and
abdominal pain.
 Rifaximin:
• This is a semisynthetic antibiotic with very low systemic absorption.
• Research suggests bacterial overgrowth plays a role in producing
bloating experienced by some IBS patients.
• Rifaximin has proven to be better than placebo in relieving bloating,
and its lack of absorption reduces the likelihood of adverse effects.
• In July 2015, the FDA approved rifaximin for treatment of IBS-D in
adults
 Loperamide:
• Loperamide stimulates enteric nervous system receptors, inhibiting
peristalsis and fluid secretion.
• It improves stool consistency and reduces the number of stools.
• Consequently, it is most useful in patients who have diarrhea as a
prominent symptom.
• However, it does not lessen abdominal pain and can occasionally
aggravate pain
 Alosetron:
• Stimulation of 5-HT3 receptors triggers hypersensitivity and hyperactivity of the large
intestine.
• Alosetron, a selective 5-HT3 antagonist, blocks these receptors and is indicated for
treatment of women with severe IBS-D.
• To be eligible for treatment, patients should have frequent and severe abdominal pain,
frequent bowel urgency or incontinence, and restricted daily activities.
• Alosetron has been shown to improve overall symptoms and quality of life.
• It can cause constipation in some patients.
• Because of an association with ischemic colitis, alosetron can be prescribed only within
strict guidelines, including signing of a consent form by both patient and physician.
• Patients selected for treatment must exhibit severe chronic IBS symptoms and have
failed to respond to conventional therapy.
THANK YOU