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1. UPDATES IN MANAGEMENT OF IBS
Presenter: Dr. Pritom Das
Registrar, Medicine, DAMCH
Organized By:
Society of Medicine,
Faridpur
Powered By:
Renata
Pharmaceuticals
Ltd.
2. UPDATES IN MANAGEMENT OF IBS
Section 1
Definition
Epidemiology
Pathophysiology
Diagnosis
Investigations
Section 2
Ways of
intervention
Lifestyle changes
and Dietary
approaches
1st and 2nd line
drugs
Approach to
refractory case
Section 3
Prognosis
Follow-up
Take-home
messages
Quiz
3. GUIDELINES REVIEWED
• World Gastroenterology Organisation Global Guidelines - Irritable
Bowel Syndrome: a Global Perspective [WGO]
• American College of Gastroenterologists Clinical Guideline:
Management of Irritable Bowel Syndrome [ACG]
• British Society of Gastroenterology guidelines on the management of
irritable bowel syndrome [BSG]
• NICE Irritable bowel syndrome in adults: diagnosis and management
• Canadian Association of Gastroenterology Clinical Practice Guideline
for the Management of Irritable Bowel Syndrome
4. DEFINITION
World Gastroenterology Organization defines Irritable
Bowel Syndrome as
“a functional bowel disorder in which
abdominal pain or discomfort is
associated with defecation and/or a
change in bowel habit.”
5. EPIDEMIOLOGY
• Irritable bowel syndrome (IBS) remains one of the most common
gastrointestinal disorders seen by clinicians in both primary and
secondary care.
• The prevalence of IBS in the global population is estimated at 11% and
in Asians ranges from 4% to 9% depending on the criteria used.
• The prevalence of IBS in women is about twice as high as in men and
make up 80% of the population with severe IBS.
• However, there is no sex predilection in South Asia, South America,
and Africa.
• Half of patients report their first symptoms before the age of 35.
6. ETIOLOGY - A DISORDER OF GUT-BRAIN
INTERACTION
• In the multifactorial pathogenesis of IBS a key role is played by
disorders of gut-brain interactions (DGBI).
• The intestinal microbiota is an essential element of these
interactions, and its dysregulation directly affects the other
pathogenic mechanisms of IBS.
• Genetics, and epigenetic changes, infection and early adverse
life events may predispose an individual to developing IBS, and
chronic stress, psychological symptoms, negative beliefs about
symptoms and illness and maladaptive coping mechanisms can
increase the frequency and severity of symptoms.
7. ETIOLOGY - A DISORDER OF GUT-BRAIN
INTERACTION
• IBS is a disorder of altered bidirectional communication between
the gut and brain (via the gut-brain axis), and has a biopsychosocial
aetiology.
• Major Components of this complex pathophysiology includes-
Central nervous system and autonomic nervous system
modulation
Altered visceral perception
Transit and motility
Immune regulation, inflammation and epithelial permeability
The microbiome
8. ETIOLOGY
• Activation of the immune system of the intestinal mucosa
associated with dysbiosis, diet, stress and endogenous factors
results in increased permeability of the intestinal barrier and the
induction of motor-sensory functions of the gastrointestinal tract.
• In patients with IBS there are qualitative and quantitative changes
in the composition of the gut microbiota, which has significant
therapeutic implications. SIBO plays a special role in the
pathogenesis of intestinal symptoms.
• Disturbed motor activity of the gastrointestinal tract and visceral
hypersensitivity are typical but not completely specific features of
IBS.
9. ETIOLOGY
• Central nervous system disorders occurring in patients with IBS
may cause increased reactivity to stress stimuli and influence the
severity of symptoms.
• Dietary factors, with particular emphasis on poorly absorbed,
easily fermentable oligo-, di-, monosaccharides and polyols
(FODMAPs), may influence the occurrence and severity of IBS
symptoms.
• Psychosocial factors and coexisting psychiatric disorders have a
significant impact on the course and results of IBS treatment.
13. FOLLOWING CHANGES ARE NOTABLE IN ROME IV AS
COMPARED TO ROME III
„
„ Term abdominal discomfort has been deleted considering the
dubious nature of the term and also that it is not present in every
language.
„
„ Abdominal pain to be present on at least 1 day/week based on
scientific evidence
„
„ Bloating and distention are recognized as common symptoms
„
„ Improvement with defecation has been replaced with related to
defecation as it has been found that many patients report increase in
pain with defecation
„
„ Rome IV also mentions about the location of pain, which can be
present anywhere in the abdomen in contrast to the older criteria which
considered lower abdominal pain as consistent with IBS
14. NICE ABC MNEMONIC FOR DIAGNOSIS
• The diagnosis of IBS should be considered if the patient has had the
following for at least 6 months:
• Abdominal pain, and/or
• Bloating, and/or
• Change in bowel habit
“Although the Rome IV criteria are the gold standard to define IBS for research purposes,
they are probably overly restrictive for use, even in secondary care, and a pragmatic
definition in line with that used in the NICE guideline, and outlined above, should be
preferred.” [BSG]
15.
16. CLASSIFICATION
• IBS is categorized into four main subtypes based on
the predominant bowel habit:
1. IBS with constipation (IBC-C);
2. IBS with diarrhea (IBS-D);
3. IBS with mixed symptomology (IBSM);
4. Unclassified IBS
18. NON-GASTROINTESTINAL FEATURES OF IBS
• IBS patients suffer from a number of non-intestinal symptoms, which
may be more intrusive than the classical features. IBS coexists with
chronic fatigue syndrome, fibromyalgia and temporomandibular joint
dysfunction.
Gynaecological
symptoms
• Painful periods
(dysmenorrhoea)
• Pain following
sexual
intercourse
(dyspareunia)
Urinary symptoms
• Frequency
• Urgency
• Passing urine at
night (nocturia)
• Incomplete emptying
of bladder
Other symptoms
• Joint hypermobility
• Back pain
• Headaches
• Bad breath,
unpleasant taste in the
mouth
• Poor sleeping
• Fatigue
19. INVESTIGATIONS
• Clinicians should make a positive diagnosis of IBS based on symptoms, in
the absence of alarm symptoms or signs, and abnormalities on simple
blood and stool tests
• In people who meet the IBS diagnostic criteria, the following tests should be
undertaken to exclude other diagnoses:
FBC
ESR or CRP
patients <45 years of age with diarrhoea, a faecal calprotectin to
exclude IBD
antibody testing for coeliac disease
20. INVESTIGATIONS
• All guidelines suggest serologic testing be performed to rule out
celiac disease (CD) in patients with IBS and diarrhea symptoms.
• There is no role for colonoscopy in IBS, other than in those with
alarm symptoms or signs, or those with symptoms suggestive of IBS
with diarrhoea who have atypical features and/or relevant risk
factors that increase the likelihood of them having microscopic colitis.
24. EXERCISE, DIET AND DIETARY
MANIPULATION
• All guidelines suggest Exercise helps overall symptom improvement in
IBS patients, particularly for constipation, with beneficial effects still apparent
at 5 years in one trial.
• A low FODMAP diet helps with overall symptom improvement in IBS
patients.
• Guidelines suggest against a gluten-free or exclusion diet.
• Poorly fermentable, soluble fiber such as psyllium (ispaghula) remains an
evidence- based treatment for IBS. Insoluble fiber may exacerbate in and
bloating in IBS, and has no evidence for efficacy. Osmotic laxatives shouldn’t
be used.
• Soluble fiber should be commenced at a low dose (3–4 g/day) and built up
gradually to avoid bloating
25. DIET AND DIETARY MANIPULATION
•First-line dietary advice should be offered to all patients
with IBS.
• Which includes - adopting healthy eating patterns, such as
regular meals, maintaining adequate nutrition, limiting alcohol
and caffeine intake, adjusting fiber intake, and reducing
consumption of fatty and spicy foods.
26. WHAT STEPS CAN I TAKE IF I HAVE IBS?
• eat three regular meals a
day
• try not to skip any meals
or eat late at night
(smaller meal sizes may
ease symptoms)
• reduce intake of
caffeine-containing
drinks e.g. no more than
two mugs (three cups) a
day
• reduce intake of soft
drinks
• drink at least eight cups
of fluid per day,
especially water or other
non-caffeinated drinks,
for example herbal teas
• cut down on rich or fatty
foods
• reduce your intake of
manufactured foods and
cook from fresh
ingredients where
possible
• limit fresh fruit to three
portions per day.
27. HELPFUL TIPS
If symptoms include
bloating and wind
If symptoms include constipation If symptoms include diarrhoea
• Limit intake of
gas producing
foods e.g. beans
pulses,
cauliflower, and
also sugar-free
mints/chewing
gum.
• You may find it
helpful to eat
• Try to gradually increase
your fibre intake – any
sudden increase may
make symptoms worse.
Rich sources include
wholegrains, oats,
vegetables, fruit and
linseeds. They help to
soften stools and make it
easier to pass.
• Replace lost fluids by drinking
plenty.
• Limit caffeine intake from tea,
coffee and soft drinks to three
drinks per day.
• Try reducing intake of high-
food
• Avoid sugar-free sweets, mints,
gum and drinks containing
sorbitol, mannitol and xylitol.
•Take time to relax – relaxation tapes, yoga, aromatherapy or massage may help
•Take regular exercise such as walking, cycling, swimming
•Take time to eat meals – chew your food well
•Keep a food and symptom diary whilst you are making changes so you can see what has helped
28. WHAT IS A LOW FODMAP DIET?
• The catchy acronym stands for fermentable oligosaccharides,
disaccharides, monosaccharides and polyols, which are more commonly
known as carbohydrates.
• These can be further divided into five groups called fructans, galacto-
oligosaccharides, lactose, excess fructose and polyols.
• These sugars are poorly absorbed and pass through the small intestine
and enter the colon, where they are fermented by bacteria.
• Gas is then produced, which stretches the sensitive bowel causing
bloating, wind and pain.
• This can also cause water to move into and out of the colon, causing
diarrhoea, constipation or a combination of both.
30. INTERVENTIONS THAT MODIFY THE MICROBIOTA:
PREBIOTICS, SYNBIOTICS, PROBIOTICS AND
ANTIBIOTICS
• Prebiotics are food or dietary supplements that result in specific
changes in the composition and/or activity of the GI microbiota.
• Probiotics have been defined as “live microorganisms that, when
administered in adequate amounts, confer a health benefit on
the host”.
• Synbiotics, which are also food or dietary supplements, are a
mixture of probiotics and prebiotics that act synergistically to
promote the growth and survival of beneficial organisms.
31. INTERVENTIONS THAT MODIFY THE MICROBIOTA:
PREBIOTICS, SYNBIOTICS, PROBIOTICS AND
ANTIBIOTICS
• Guidelines suggest against the use of prebiotics and synbiotics for
overall symptom improvement in IBS patients.
• All Guidelines suggest probiotics, taken as a group, to improve
global symptoms, as well as bloating and flatulence in IBS patients.
• It is reasonable to advise patients wishing to try probiotics to take
them for up to 12 weeks, and to discontinue them if there is no
improvement in symptoms. [BSG]
• ACG suggest the non-absorbable antibiotic rifaximin for reduction in
global IBS symptoms, as well as bloating in non-constipated IBS
patients.
32. DRUGS USED FIRST LINE FOR IBS -
ANTISPASMODICS AND PEPPERMINT OIL
• All guidelines suggest Certain antispasmodics [antimuscarinics
and smooth muscle relaxants- (trimebutine- TRITIN, otilonium, hyoscine,
cimetropium, pinaverium, dicyclomine and mebeverine, alverine citrate- ALRIN]
as an effective treatment for global symptoms and
abdominal pain in IBS. Dry mouth, visual disturbance and
dizziness are common side effects.
• All guidelines suggest Peppermint oil as an effective
treatment for global symptoms and abdominal pain in IBS.
Gastro-oesophageal reflux is a common side effect. The risk
of adverse events is no greater with peppermint oil than
with a placebo.
33. DRUGS USED FIRST LINE FOR IBS –
RECOMMENDATION AGAINST CONTINUOUS
LOPERAMIDE USE
• All guidelines recommend against continuous
Loperamide(synthetic μ-opioid agonist) except for diarrhea
in IBS. It is no more effective than a placebo in reducing
pain, bloating, and global symptoms of IBS, but it is an
effective agent for the treatment of diarrhea.
• Abdominal pain, bloating, nausea and constipation are
common, and may limit tolerability. Titrating the dose
carefully may avoid this.
34. DRUGS USED FIRST LINE FOR IBS
GUT-BRAIN NEUROMODULATORS
• Dysfunction within the bidirectional gut-brain axis is considered to play an
important role in the genesis and maintenance of symptoms in IBS.
• Although IBS is often considered a functional gastrointestinal disorder, it
has been re-termed as disorders of gut-brain interaction.
• Patients with IBS often have comorbid anxiety and depression, and these
are also risk factors for the subsequent development of IBS in healthy
people.
• This, together with their peripheral effects on gastrointestinal function, is
part of the rationale for the use of gut-brain neuromodulators, such as
TCAs and SSRIs.
35. GUT BRAIN MODULATORS
TCA AND SSRI
• TCAs and SSRIs impact on bowel function, with TCAs improving diarrhea
by slowing GI transit, and SSRIs ameliorating constipation by accelerating
GI transit.
• Tricyclic antidepressants used as gut-brain neuromodulators are an
effective second-line drug for global symptoms and abdominal pain in
IBS. [BSG]
• They should be commenced at a low dose (eg, 10 mg amitriptyline once a
day) and titrated slowly to a maximum of 30–50 mg once a day. [BSG]
• TCAs are associated with significant adverse effects in treating IBS-D and
should be avoided in IBS-C; clinicians should expect one adverse effect for
every three patients who benefit from therapy [WGO]
36. GUT BRAIN MODULATORS
TCA AND SSRI
• SSRIs may be considered in resistant IBS-C, although it is not
currently recommended that SSRIs should be routinely prescribed for
IBS in patients without comorbid psychiatric conditions. [WGO]
• Selective serotonin reuptake inhibitors used as gut-brain
neuromodulators may be an effective second-line drug for global
symptoms in IBS. [BSG/ ACG]
• Whether all IBS sufferers, or only certain sub-populations, respond to
anti-depressants is also unclear, and therapy with these agents may
be limited by patient acceptance and adverse events.
37. DRUGS USED SECOND LINE FOR THE
TREATMENT OF IBS-D
• Who do not experience symptom improvement with antidiarrhoeals
• 5-Hydroxytryptamine 3 receptor antagonists are efficacious second-
line drugs for IBS with diarrhoea in secondary care. [Ondansetron
titrated from a dose of 4 mg once a day to a maximum of 8 mg tds]
Constipation is the most common side effect. (EMEREN/EMESET)
• The non-absorbable antibiotic rifaximin is an efficacious second-line
drug for IBS with diarrhoea in secondary care.
• Other options- Eluxadoline, a mixed opioid receptor drug;
contraindicated in patients with cholecystectomy, pancreatitis or
severe liver impairment
38. DRUGS USED SECOND LINE FOR THE
TREATMENT OF IBS-C
• Who do not experience symptom improvement with laxatives
• Lubiprostone, a chloride channel activator, is an efficacious second-
line drug for IBS with constipation in secondary care. (LAXANA)
• This secretagogue is less likely to cause diarrhoea than others.
However, patients should be warned that nausea is a frequent side
effect
• Other options: Linaclotide and Plecanatide (guanylate cyclase-C
agonist), Tenapanor (sodium-hydrogen exchange inhibitor), Tegaserod
(5-Hydroxytryptamine 4 receptor agonist) – not available in the market
yet
39. PSYCHOLOGICAL THERAPIES
• All guidelines suggest IBS-specific cognitive behavioural therapy as an
efficacious treatment for global symptoms in IBS.
• Psychological therapies should be considered when symptoms have not
improved after 12 months of drug treatment. [BSG]
• General nonpharmacological recommendations
• Discuss the patient’s anxieties. This reduces complaints; aim to eliminate
unnecessary worries.
• Aim to reduce avoidance behavior. Patients may avoid activities that they fear
are causing the symptoms, but avoidance behavior has a negative influence on
the prognosis.
• Discuss and aim to resolve stressful factors.
40. NOVEL APPROACHES FOR THE FUTURE
• Fecal Microbiota Transplant (FMT)
• Mast Cell Stabilizer and Other Anti-
inflammatory Drugs
• Ghrelin Receptor Agonists: Relamorelin
• 5-HT3 Antagonists: Ramosteron
• Drugs Acting on Bile Acids
• Modulating the Central Pain Mechanism -
IBStim Device: The Cranial Nerve Stimulator
IBStim device
41. BSG Treatment algorithm for IBS
*Review efficacy after 3 months of
treatment and discontinue if no
response
TCAs should be first choice,
starting at a dose of 10 mg at night,
and titrating slowly (eg, by 10
mg/week) according to response and
tolerability. Continue for at least 6
months if the patient reports
recommended strongly when
symptoms are refractory to
drug treatment for 12
months
SUMMARY OF SECTION 2
43. PROGNOSIS
• For most patients with IBS, symptoms are likely to
persist, but not worsen. Symptoms will deteriorate in
a smaller proportion, and some patients will recover
completely.
• Factors that may negatively affect the prognosis
include:
• Avoidance behavior related to IBS symptoms
• Anxiety about certain medical conditions
• Impaired function as a result of symptoms
• A long history of IBS symptoms
• Chronic ongoing life stress
44. FOLLOW-UP
In mild cases, there is generally no medical need for follow-up consultations in the
long term, unless:
• Symptoms persist, with considerable inconvenience or dysfunction.
• The patient is seriously worried about the condition.
• Persistent diarrhea > 2 weeks.
• Constipation persists and does not respond to therapy.
• Warning signs for possibly serious gastrointestinal disease developing
• One should beware of eating disorders developing:
— The tendency for eating disorders to develop is more common in female IBS
patients.
45. TAKE HOME MESSAGES
1) IBS is a very common illness that can hamper productivity and
reduce the quality of life.
2) Previously thought to be a functional disorder, now it’s more
commonly recognized as complex result of intestinal dysbiosis
causing altered gut-brain interaction.
3) Usually a clinical diagnosis and intervention needs to be managed
with empathy and sharing as much information as possible with the
patient.
4) Dietary and lifestyle modifications, soluble fibers, antispasmodics
and probiotics are universally proven to improve global symptoms.
5) Antidepressant and anti-diarrheal drugs need to be used judiciously
keeping respective side effects in mind.
6) Any refractory case should be managed with psychotherapy and
needs long-term follow up.
46. QUIZ
• Suspected IBS patients will need colonoscopy to
confirm the diagnosis. (T/F)
• Previous gastroenteritis can be a risk factor for IBS.
(T/F)
• Probiotics have no role managing IBS. (T/F)
• Psychotherapy is usually offered as a first-line
treatment. (T/F)
• TCAs should be offered in IBS patients with Diarrhea as
predominant symptom. (T/F)
