IRRITABLE BOWEL SYNDROME

DR. MARIUM SIDDIQUI

 INTRODUCTION

• Functional bowel disorder

• A chronic relapsing disease in which
symptoms may vary overtime
• The most common cause of all the
gastrointestinal referals
• Accounts for frequent absenteeism from
work
• Leads to markedly impaired quality of life
 EPIDEMIOLOGY

• affects around 20% of the general population but only

10% seeks treatment of the GI symptoms.
• It is 1.2 to 2 times common in young women than in
men.
• More common in South America with an estimated
prevalence of about 21% and least common in South
Asia- 7%.
• The incidence decreases with the advancing age.
 SUB-TYPES

 IBS- D

 IBS-C

 IBS-M
 PATHOPHYSIOLOGY

1. Psychosocial factors:
 verbal, physical and sexual abuse
 Inappropriately learned behaviors during childhood
 Hypervigilance and catastrophizing leading to
amplification of gastrointestinal as well non
gastrointestinal symptoms
 Co-morbid psychiatric illness mainly anxiety, depression,
stress and somatization
 Abnormal behavior of seeking consultations for minor
illnesses
 Abnormal or reduced stress coping ability
2. Altered gastrointestinal motility:
IN DIARRHOEA PREDOMINANT SUBSETS:
 clusters of rapid jejunal contraction waves,
 rapid intestinal transit and an increased number of
fast and propagated colonic contractions
IN CONSTIPATION PREDOMINANT SUBSETS:
 decreased orocaecal
 transit and a reduced number of high-amplitude,
propagated colonic contraction waves
3. Abnormal visceral perception:
 Altered central nervous system processing
of visceral sensation
 Increased sensitivity to intestinal distension
 More common in women and the diarrhea
predominant IBS
4. Altered gut immune activation:
 Increased activation of the innate and adaptive
immune systems in the intestinal mucosa
 Supporting evidence is the association of IBS with
IBD
 Post infectious IBS
 Food allergies- rapidly fermentable, osmotically
active, short-chain carbohydrates (including fructose,
lactose, fructans and galactans, and sugar alcohols)
have been recognized as an important trigger of IBS
symptoms
5. Increased gut permeability:
 Visceral hypersensitivity
 IBS-D

6. Colonic dysbiosis:
 The fecal microbiota of IBS patients differ
significantly from that of controls, likely reflecting
the influence of genetics, diet, stress, infection, and
drugs or antibiotics
 CLINICAL FEATURES

Typical Features
 Loose/frequent stools
 Constipation
 Bloating which worsens throughout the day
 Recurrent Abdominal cramping, discomfort, or
colicky pain felt in lower abdomen, relieved by
defecation.
 Symptom brought on by food intake/specific food
sensitivities
 Symptoms dynamic over time (change in pain
location, change in stool pattern)
Concerning Features for Organic Disease:
 Symptom onset after age 50 y
 Severe or progressively worsening symptoms
 Unexplained weight loss
 Nocturnal diarrhea
 Family history of organic gastroenterological
diseases, including colon cancer, celiac disease, or
inflammatory bowel disease
 Rectal bleeding or melena
 Unexplained iron-deficiency anemia
 DIAGNOSIS

ROME III CRITERIA FOR IRRITABLE BOWEL SYNDROME

(IBS) WITH
SUBTYPES:
Recurrent abdominal pain or discomfort at least 3 d/mo
in the last 3 mo associated with 2 or more of the
following: (symptom onset, before diagnosis, should be
atleast ≥ 6 months)
 1. Improvement with defecation
 2. Onset associated with a change in frequency of
stool
 3. Onset associated with a change in form
(appearance) of stool
SUBTYPING IBS BY PREDOMINANT STOOL PATTERN:
1. IBS with constipation—hard or lumpy stools25% and
loose or watery stools <25% of bowel movements
2. IBS with diarrhea—loose or watery stools25% and
hard or lumpy
stools <25% of bowel movements
3. Mixed IBS—hard or lumpy stools 25% and loose or
watery stools
25% of bowel movements
 INVESTIGATIONS

 Full blood count

 Fecal calprotectin
 Sigmoidoscopy
 Abdominal x-ray to look for fecal loading
 Bristol stool form scale
ALL INVESTIGATIONS ARE USUALLY NORMAL IN CASES
OF IBS.
 TREATMENT

 Initial response of a caregiver to a positive diagnosis

of IBS should be reassurance to curb down the
illness associated anxiety which in turn exacerbates
IBS symptoms.
 Life style modification:
• exercise
• dietary modification- gluten free diet and low
FODMAP diet
 PHARMACOLOGICAL TREATMENT:
1. Antidiarrheals
inhibit peristalsis, prolong gut transit, reduce fecal
volume
can be used prophylactically when a patient
anticipates diarrhea.

2. Serotonin Agents: 5-HT3 Receptor Antagonists

The gut hormone serotonin influences gastrointestinal
motility and visceral sensation.
3. Antispasmodics
• include drugs with anticholinergic or calciumchannel
blocking properties.
• may improve IBS symptoms by relaxing gut smooth
muscle.
• provide symptomatic short-term relief in IBS.
• Because some IBS patients have an exaggerated
gastrocolonic reflex that is in part cholinergically
mediated, these drugs may be best suited for
postprandial abdominal cramping and loose stools.
4. Fiber Supplements
• soluble fiber (psyllium and ispaghula husk) but not
insoluble fiber (wheat bran) was associated with
improved IBS symptoms.
• should be started at a nominal dose and gradually
titrated upward during weeks to a total daily intake
of 20 to 30 g.

5) Laxative Agents
Osmotic and stimulant laxatives
6. Prosecretory Agents
• Lubiprostone is a chloride-channel (ClC-2) activator that
stimulates intestinal fluid secretion and improves
global, bowel, and abdominal symptoms in IBS-C
patients.
• A higher dosage of 24 μg has proven effective in
patients with chronic idiopathic constipation.
• Linaclotide is a guanylate cyclase-C agonist that
increases production of cyclic guanosine
monophosphate. Intracellularly, cyclic guanosine
monophosphate increases intestinal chloride secretion
via the cystic fibrosis transmembrane regulator,
whereas extracellularly it reduces firing of visceral
afferent pain fibers.
7. Modification of the Microbiota: Probiotics and
Rifaximin
8. Centrally Acting Interventions
• TCAs
• SSRIs
• SNRIs
 PSYCOLOGICAL TREATMENT:
• cognitive behavioral therapy
• hypnotherapy
• Mindfulness meditation
• dynamic psychotherapy
• reflexology