Irritable Bowel Syndrome

Dr Abiodun C. Jemilohun
MB;BS, FWACP, MNCP, Cert Gastro Endo
Associate Professor/Consultant Gastroenterologist
Definition
• IBS is a chronic functional bowel disorder characterized by recurrent
abdominal pain that is associated with defecation or a change in
bowel habit.
• Disordered bowel habits (constipation, diarrhea, or a mix of
constipation and diarrhea) are usually present
• Symptoms of abdominal bloating/distention may be present.
• Symptom onset should occur at least 6 months before diagnosis and
symptoms should be present during the last 3 months.
Epidemiology
• Estimated incidence of IBS is 1.35% - 1.5% per annum
• Globally, prevalence varies from one region to another
• Lowest prevalence in South Asia (7.0%) and the highest in South
America (21.0%)
• It adversely affects the quality of life and the socio-economic value of
patients through increased morbidity, medical consultation rate,
healthcare cost and work absenteeism
World map of IBS prevalence (2000–2004) based on the Rome II and III criteria, with figures for
the Manning criteria in brackets where available. Adapted from Neurogastroenterol Motil
4
2005;17:317–24.
Risk factors
• Age- younger age
• Gender- Female gender
• Family history (genetics)- a family history of IBS, greater concordance
in monozygotic twins
• Psychosocial factors- previous history of physical, emotional or sexual
abuse, psychological stress; anxiety; depression; dietary factors; and
sleep disorders
• Prior intestinal infection
Pathophysiology
• Multifactorial disorder with a complex pathophysiology
• Best understood in the context of the bio-psychosocial model of
disease
• Identified mechanisms
• Altered gastrointestinal motility
• Visceral hyperalgesia- increased sensitivity to pain
• Psychopathology
• Microscopic inflammation
• Small bowel bacterial overgrowth
Clinical features

Symptoms
• Bloating
• Abnormal stool form (hard and/or loose)
• Abnormal stool frequency (less than three times per week or over three times
per day)
• Straining at defecation
• Urgency
• Feeling of incomplete evacuation
• The passage of mucus per rectum
Clinical features
Behavioral features
• Symptoms present for > 6 months
• Stress aggravates symptoms
• Frequent consultations for non-gastrointestinal symptoms
• History of previous medically unexplained symptoms
• Aggravation after meals
• Associated anxiety and/or depression
Clinical features
Non-colonic (GI) symptoms
• Could occur with other functional GIDs
• Dyspepsia
• Nausea
• Heartburn
• Vomiting
Clinical features

Non-GI symptoms
• Lethargy
• Backache and other muscle and joint pains
• Headache
• Urinary symptoms: nocturia, frequency and urgency of micturition, incomplete
bladder emptying
• Sexual dysfunction (including dyspareunia and poor libido), perimenstrual
syndrome
• Fibromyalgia is a common comorbidity
• Insomnia
• Low tolerance to medication
 Alarm Features
History
• Blood in the stool
• Family H/O colon cancer, IBD, celiac disease
• Fever
• Onset after age 50 years
• Nocturnal symptoms (awakening the patient from
sleep)
• Recurrent vomiting
• Painless chronic diarrhea
• Severe chronic constipation
• Short history of symptoms
• Travel history to locations endemic for parasitic
diseases
• Weight loss
Alarm Features
Physical Examination
• Abdominal mass
• Arthritis (active)
• Occult or overt blood on rectal examination
• Signs of anemia
• Signs of intestinal obstruction
• Signs of intestinal malabsorption
• Signs of thyroid dysfunction
All these are suggestive of alternative
diagnoses
Diagnosis

• Based on history & clinical examination

• Matching patient’s profile to clinical criteria
Rome IV Diagnostic Criteria* for Irritable Bowel
Syndrome

• Recurrent abdominal pain, on average, at least 1 day per week in the

last 3 months, associated with 2 or more of the following criteria:
• Related to defecation
• Associated with a change in frequency of stool
• Associated with a change in form (appearance) of stool
*
Criteria fulfilled for the last 3 months with symptom onset at least 6 months
before diagnosis
Subgroups of IBS
• IBS is classified into four subgroups by Rome IV depending on the
associated predominant bowel habit disorder:
• IBS with constipation (IBS-C)
• IBS with diarrhea (IBS-D)
• IBS with mixed bowel habit (IBS-M)
• IBS unclassified (IBS-U)
Bristol Stool Chart
Differential Diagnosis

• Celiac sprue/ gluten enteropathy

• Lactose intolerance
• Inflammatory bowel disease
• Colorectal carcinoma
• Acute diarrhea ( protozoal / bacterial)
• Small-intestinal bacterial overgrowth (SIBO)
• Diverticulitis
• Pelvic inflammatory disease /Endometriosis
Laboratory tests
• May be needed to R/O organic bowel disorders
• FBC
• Stool occult blood
• Stool MCS
• ESR or C-reactive protein
• Fecal inflammation marker (e.g. calprotectin)
• Colonoscopy
Treatment
• Education
• Reassurance
• Lifestyle modification- stress reduction, exercise and treatment of
impaired sleep
• Dietary management- high fiber diet in IBS-C
• Drug therapy
Drug therapy
• Smooth muscle antispasmodics like dicyclomine
• Peppermint oil
• Tricyclic antidepressants like desipramine and amitriptyline
• Selective serotonin reuptake inhibitors like paroxetine, sertraline and
citalopram
• Chloride channel activators like Lubiprostone
• Guanylate cyclase C agonists like Linaclotide
• 5-HT3 antagonists like Alosetron.
Measures to address specific bowel habit disorder

Specific therapy for IBS-D

• Dietary restrictions of gluten and FODMAP (fermentable
oligosaccharides, disaccharides, monosaccharides, and polyols)
• Opioid agonists like Loperamide
• Bile salt sequestrants like cholestyramine, Cholestipol and Colesevelam
• Probiotics therapy
• Antibiotics like rifaximin
• 5-HT3 antagonists like Alosetron and Cilansetron
• Mixed opioid agonists/antagonists like Eluxadoline.
Measures to address specific bowel habit
disorder
Specific therapy for IBS-C
• Psyllium
• Polyethylene glycol
• Chloride channel activators like lubiprostone
• Guanylate cyclase C agonists like linaclotide
Prognosis
• Prognosis is Good
• Life expectancy remains similar to that of the general population