Academic base Harrisons 19th Edition

1. IRRITABLE
BOWEL
SYNDROME
BY
DR.KIRANKUMAR BIKKAD

3. DEFINITION
It is a functional bowel disorder characterised by :
 Abdominal pain/discomfort
 Altered bowel habits
 Absence of detectable structural abnormality.

4.  Diagnosis is clinical.
 Prevalence 10-20% in total population
 Femal>male
 Adolescents and adult age group

5. Associated /overlapping symptoms:
 Headache
 Backache
 Fibromyalgia
 Genitourinary symptoms
 Can impair quality of life

6. Etiology:
 Altered GI motility
 Visceral hyperalgesia
 Gut brain interaction disturbance
 Autonomic and hormonal disturbances
 Environmental factors
 Psychiological and social factors

7. Clinical features
 First symptom <45yrs
 Severity increased in females
 PAIN and DISCOMFORT
 IMPROVES WITH DEFAECATION
 Change in FREQUENCY and FORM of stool

8. Supportive symptoms:
 Urgency
 Straining
 Incomplete evacuation
 Mucoid stools
 Bloating

9. ABDOMINAL PAIN
 Episodic and crammpy or superimposed with
background over constant ache.
 No nutritional/sleep deprivation
 Present only during waking hours
 Exacerbated by : eating & emotional stress
 Relieved by: passage of flatus/stools

10.  Association with premenstrual & menstrual
phase

11. ALTERED BOWEL HABITS
 M/c presenting pattern:
Alternating constipation and diarrhoea.
 Episodic----------persistent--------intractable
 Hard and narrow caliber (d/t dehydration and
colonic spasm)
 Incomplete evacuation-------repeated visits to
the toilets in short span

12.  Stool volume <200ml
 Nocturnal diarrhoea –ve
 Bleeding –ve
 Unstable bowel pattern
 Patterns: Ibs-d, Ibs-m, Ibs-c
 75% change subtypes
 33% Ibs –d

13. GAS AND FLATULENCE
 Abdominal distension
 Belching
 Impaired transit and tolerance to GI load
 Distal-----proximal <gas reflux>

14. UPPER GI SYMPTOMS
 Dyspepsia
 Heartburn
 Nausea
 Vomiting

16. Pathophysiology
 GI motor abnormality:
 Increased recto-sigmoid activity upto 3hrs
after eating
 Prolonged distension evoked contractility
 High amplitude propogating contractions

17.  GI visceral hypersensitivity:
o Increased sensory response to visceral
stimulation
o Increased end organ sensitivity due to silent
nociceceptors
o Fasting improves symptoms
o Increased with lipid rich diet

18.  Central neural disregulation:
o Increased activity of mid cingulate cortex

19.  Abnormal psychological features:
o Associated with prior physical and sexual
abuse
o Greater activation of dorsal cingulate cortex

20.  Post infectious :
 Bacterial gastroenteritis
 Young females
 CAMPYLOBACTER, SALMONELLA AND
SHIGELLA

21.  Immune activation and mucosal
inflammation:
 Activated lymphocytes, mass cells and
cytokines--abnormal mucosal secretion
--increased expression of TRP V1 channels in
neurons --visceral hyperactivity

22.  Altered gut flora:
 Firmicutes: bacteriods >>bifidobacterium,
lactobacillus
 Positive lactulose hydrogen breath test
 Nonveg>veg

23.  Abnormal serotonin pathway

24. APPROACH TO THE
PATIENT
 Diagnosis by exclusion and clinical basis
 Criteria: ROME I/II/III
 Careful history and physical examination

26.  Recurrent lower abdominal pain with altered
bowel habits without progressive deterioration
 Onset of symptoms during stress / emotional
upset
 Absence of other systemic symptoms {fever and
weight loss}
 Small-volume stool without evidence of blood

27. Points against the diagnosis of
IBS
 Appearance of disorder 1st time in old age
 Progressive course from time of onset
 Persistent diarrhoea after a 48-h fast
 Nocturnal diarrhoea

28.  Quality, location & timing of pain may be
helpful to suggest specific disorders
 Pain in epigastric/periumbilical area
1. Biliary tract disease,
2. Peptic ulcer disorders
3. Intestinal ischemia &
4. Carcinoma of stomach and pancreas.

29.  Pain in lower abdomen
1. Diverticular disease of the colon
2. Inflammatory bowel disease (Ulcerative
colitis/Crohn’s disease)
3. Carcinoma colon

30.  Postprandial pain accompanied by bloating,
nausea, vomiting
1. Gastroparesis
2. Partial intestinal obstruction
3. Intestinal infestation with Giardia lamblia
cause similar symptoms.

31.  When diarrhoea is major complaint
1. Lactase deficiency
2. Laxative abuse
3. Malabsorption
4. Celiac sprue
5. Hyperthyroidism
6. Inflammatory bowel disease
7. Infectious diarrhoea

32.  When Constipation is major complaint:-
1. Drug side effect (anticholinergic,
antihypertensive, antidepressant medication)
2. Endocrinopathies (hypothyroidism & hypo-
parathyroidism)
3. Acute intermittent porphyria
4. Lead poisoning (appropriate serum & urine
tests)

33.  complete blood count
 Sigmoidoscopic examination
 Stool for ova & parasites in diarrhoea.
 Persistent diarrhoea not responding to
antidiarrheal agents, a sigmoid colon biopsy
should be performed to R/O microscopic
colitis

34. MANAGEMENT

35. ROME 3

43. Thank you