IBS

Question 1

Give an example of a functional bowel disorder.

Answer 1

IBS.

Question 2

What is IBS?

Answer 2

Irritable Bowel Syndrome:
A chronic functional bowel disorder characterised by abdominal pain and change in bowel habits; and with no organic cause found.

Question 3

Give 5 main causes of IBS.

Answer 3

1. Depression, anxiety
2. Psychological stress and trauma
3. GI infection
4. Sexual, physical or verbal abuse
5. Eating disorders

More likely in women and in younger people

Question 4

Describe the multi-factorial pathophysiology of IBS.

Answer 4

The following factors can all contribute to IBS:

• Psychological morbidity e.g. trauma in early life.
• Abnormal gut motility.
• Genetics.
• Altered gut signalling (visceral hypersensitivity).

Dysfunction in the brain-gut axis results in disorder of intestinal motility and or enhanced visceral perception (visceral hypersensitivity)

Question 5

Give 3 symptoms of IBS.

Answer 5

ABC:
1. Abdominal pain (pain improves with defecation)
2. Bloating
3. Change in bowel habits
4. Symptoms are worse after eating

Question 6

Give 3 non-intestinal symptoms of IBS.

Answer 6

• Painful period
• Urinary frequency, urgency, nocturia and incomplete emptying of bladder
• Back pain
• Joint hypermobility
• Fatigue

Question 7

Criteria of symptoms to suggest IBS.

Answer 7

Symptoms should suggest IBS:

1. Abdominal pain / discomfort:
2. Relieved on opening bowels, or
3. Associated with a change in bowel habit

AND 2 of:

• Abnormal stool passage
• Bloating
• Worse symptoms after eating
• PR mucus

Question 8

How many types of IBS are there?
What are they?

Answer 8

3 types:
* IBS-C - with constipation
* IBS-D - with diarrhoea
* IBS-M - with constipation and diarrhoea

Question 9

Investigations to diagnose IBS.

Answer 9

Since nothing physical to be found, diagnosis made by ruling out the differentials!!

Diagnosis of exclusion:

1. Anti-tTG (tissue transglutaminase antibody) or anti-EMA (endomysial antibody) = Coeliac Disease
2. Faecal calprotectin = IBD
3. Bloods
   - FBC = anaemia
   - ESR + CRP = inflammation
4. Colonoscopy = Colorectal Cancer / IBD

Question 10

Diagnostic criteria for IBS.

Answer 10

Rome IV diagnostic criteria:

• Recurrent abdominal pain/discomfort at least 3 days a month in the past 3 months, associated with two or more of the following:
• Improvement with defecation
• Onset associated with a change in frequency of stool
• Onset associated with a change in form (appearance) of stool

Question 11

Give an example of a differential diagnosis for IBS.

Answer 11

1. Coeliac disease.
2. Lactose intolerance.
3. Bile acid malabsorption.
4. IBD.
5. Colorectal cancer.

Question 12

Describe the treatment for mild IBS.

Answer 12

1. Education
2. Reassurance
3. Dietary modification e.g. FODMAP

Question 13

Describe the treatment for moderate IBS.

Answer 13

Pharmacotherapy and psychological treatments:

• Antispasmodics for pain.
• Laxatives for constipation.
• Anti-motility agents for diarrhoea.
• CBT and hypnotherapy.

Question 14

Describe the treatment for severe IBS.

Answer 14

MDT approach, referral to specialist pain treatment centres.
- Tri-cyclic anti-depressants.

Question 15

Describe the lifestyle modification advice given for IBS.

Answer 15

1. Regular or small frequent meals
2. Plenty of fluids (8 cups/day)
3. Reduce/avoid caffeinated drinks, alcohol and fizzy drinks
   For IBS-D and bloating, reduce/avoid:
   - Insoluble fibre intake
   - Fruit intake to 3 portions/day

• For wind and bloating increase:
• Soluble fibre intake

4. Fibre:
   - Soluble:
   * Good for CONSTIPATION (IBS-C)
   * Dissolves in water and broken down by bacteria
   * Softens stool
   * Slows down sugar release
   * E.g. barley, oats, beans, prunes, figs

• Insoluble:
• Makes IBS-D WORSE! so cut down
• Not dissolved in water
• Passes through the gut mostly unchanged
• Absorbs water and bulks up faeces
• Increases gut motility
• E.g. cereals, whole-wheat bread, lentils, apple, avocado

Question 16

What is the low FODMAP diet?

Answer 16

All produce a lot of gas, bloating, diarrhoea and pain:
E.g. apple, artichoke, cottage cheese, baked beans, cow milk.

• Fermentable
• Oligosaccharides
• Disaccharides
• Monosaccharides
• And
• Polyols

Question 17

Describe the pharmacological therapy for bloating, constipation and diarrhoea.

Answer 17

1. For pain/bloating:
   - Antispasmodics e.g. MEBEVERINE or BUSCOPAN
2. For constipation:
   - Laxative e.g. MAVICOL, SODIUMDOCUSATE or SENNA

• LINACLOTIDE - only for constipation for more than 12 months and not relieved by 2 different classes of max dose laxatives
• Can also use 5-HT4 receptor agonist e.g. PRUCALOPRIDE

3. For diarrhoea:
   - Anti-motility agents e.g. LOPERAMIDE

Question 18

What can be used if the initial methods of pharmacotherapy don’t work?

Answer 18

Tricyclic antidepressants e.g. AMITRIPTYLINE or NORTRIPTYLINE

• But warn about drowsiness!
• Need to take it for 4-6 weeks to take effect!
• Not to treat depression (although these drugs are used in
  depression) but to dampen down gut sensitivity
• If not tolerated then move to SSRI
• Can also use psychological therapy e.g. cognitive behavioural
  therapy in conjunction