Characteristic sx of IBS
Functional bowel disease with:
1- recurrent abdo pain
2 - altered bowel habits
3- bloating
Common hx of pt with IBS
Altered bowels: constipation ( hard, narrow, infrequent painful) - diarrhea (small volume, frequent, loose, urgency) tenesmus common, clear white mucous
Abdo pain (diffuse or left lower quadrant, no radiation, precipitated by meals/stress, improved by defecation )
Distension / bloating / gas
Dyspepsia , nausea, vomiting (uncommon)
Urinary frequency / urgency
Always ask about → Family hx of bowel CA, IBD, celiac, nocturnal defecation, New sx in pt > 45
Alarm sx for IBS
Vomiting
Dysphagia
Abdominal mass
Anemia
Gi bleed
Unexplained weight loss
What sx are inconsistent with IBS
Nocturnal sx
Fever
Older age
Acute - progressive
Anorexia, weight loss
Rectal bleed
Painless diarrhea
Steatorrhea
Travel
What are the subtypes of IBS
- Constipation predominant (IBS -C) → > 25% hard stool, < 25% loose
- diarrhea predominant (IBS-D) → > 25% loose, <25% hard
- mixed ( IBS-M) → > 25% hard, > 25% loose
- unclassified (IBS-U) → < 25% hard, < 25% loose
Nice criteria for IBS
Aldo pain /discomfort associate with altered bowel habits x 6 months with no alarm sx
Rome iv criteria for IBS
Recurrent abdo pain atleast 1x per week in the last 3 months assoc. With 2 of the following
- related to defecation
- assoc. With change in frequency of stool
- assoc. With change in form of stool
Rome iv supportive but not diagnostic criteria for IBS
- Abnormal frequency >3/d or < 3/wk
- abnormal form (lumpy, hard, loose, watery) > 1/4 of stools
- abnormal passage (urgency, tenesmus - strain) > 1/4 of stool
- passage of mucus > 1/4 of stools
- bloating / abdominal distension
Aggravating factors for IBS
- Caffeine
- ethanol
- stress
- menstruation
- fibre
-Fat - sorbitol
Investigations for IBS
Ix are generally not needed as x is based on hx and Rome iv criteria
- routine testing of celiac serology recommended esp.in IBS-d
- colonoscopy if >50 with new onset sx or if combination / pronounce alarm symptoms or nocturnal symptoms
- consider if clinically indicated→ CBC, ash, albumin, crp, stool C+S O+P
Management of IBS
- Reassurance, education
- Diet →
low FODMAP x 4Wk with a dietician followed by reintroduction 6-10 wk
Fibre 25gld (ispaghula, psyllium avoid wheat bran and other insoluble fibres
Probiotics
Avoid triggers - Exercise (helps bloating and constipation)
- CBT or hypnotherapy professionally
- Peppermint oil 0.2-0.4 ml TID for bloating
6- pharmacotherapay based on IBS subtype
Pharmacotherapy for IBS related bloating
1-peppermint oil 0.2 - 0.4 ml TID
2- antispasmodic (dicycloverine, buscopan, pinaverium)
3- TCA (amitryptiline 10 mg QHS)
Pharmacotherapy for IBS related diarrhea
- TCA (amitryptiline 10-100 mg qhs)
- eluxadoline (refer to gf for initiation)
- rifaximin
- alosetran (under gi guidance)
Symptomatic relief PRN → loperamide 2-12mg/d
Pharmacotherapy for IBS -c
- Linaclotide
- SSRI ( fluoxetine, paroxetine and citalopram)
- lubiprostone
- tenaponor, plecanatide, tegaserod under gi guidance
Therapies to AVOID in IBS
Gluten free diet
Wheat bran supplementation
Acupuncture
Chalestyramine, bile acid sequestrants
Stimulant, osmotic laxatives
Prucalopride
