Irritable bowel syndrome(IBS)

Marcellus Simadibrata Kolopaking

SpPD KGEH MD PhD FINASIM FACG FASGE

Division Gastroenterology Department of Internal Medicine

University of Indonesia

Seminar Prodia, Jakarta, 1 Desember 2018

 Outline
* Introduction
* Epidemiology
* Definition
* Pathophysiology/Etiology
* Diagnosis Criteria
* Treatment
 Introduction

* Irritable bowel syndrome(IBS) à frequent lower

gastrointestinal tract diseases in daily practice.
* IBS à functional abnormalities.
* IBS: combination dysmotility, visceral hypersensitivity,
mucosal immune dysregulation, alterations of
bacterial flora & CNS-ENS dysreguation.
Rome IV Criteria

http://www.romecriteria.org/pdfs/launch.pdf
Drossman DA. Gastroenterology 2016;150:1257–1261
Definition of Irritable Bowel Syndrome
(IBS)

* Syndrome of functional lower gastrointestinal

disorder characterized by chronic or recurrens lower
abdominal pain and discomfort.
 Classification of IBS

Editorial team IBS. https://irritablebowelsyndrome.net/author/editorial-team/

 Epidemiology

Chang FY, Lu CL. Irritable bowel syndrome in the 21st century: Perspectives from Asia or South-east Asia. J
Gastroenterolo Hepatol. 2007; 22: 4-12
 Epidemiology

Gwee KA, Ghoshal UC, Chen M. J Gastroenterol Hepatol. 2018; 33: 99–110.
 Patopysiology & Etiology

* Psychososial factor
* Physiolofic factor via brain (Brain-Gut axis)
* Abnormal motility
* Visceral hypersensitivity
* Hereditery
* Infection/inflammation factor
* Intestinal micfoflora factor
* etc.
 Diagnosis

* Anamnesis/History taking
* Physical examination
* Supporting examination/diagnstic test
 Anamnesis

* Symptoms: abdmonal pain or discomfort, bowel disfunction,

bloating, uncomplete defication & exclusion of similar
intestinal diseases/condition.
* Other IBS criteria according to: Manning, Roma I, Roma II &
Roma III. Roma IV
Diagnosis of IBS: ROME IV criteria
The Rome IV Criteria for IBS are:
"Recurrent abdominal pain, on average, at least 1
day/week in the last 3 months, associated with two 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.
* *Criterion fulfilled for the last 3 months with
symptom onset at least 6 months prior to diagnosis."

Tresca AJ. Rome IV criteria. https://www.verywellhealth.com/the-rome-criteria-for-ibs-

1941670?utm_term=Rome+IV+criteria+for+diagnosis+IBS&utm_content=p1-main-1-
Gwee KA, Ghoshal UC, Chen M. J Gastroenterol Hepatol. 2018; 33: 99–110.
Red flags(alarm symptoms) for organic
disease exclusion.

* History of rectal bleeding or blood in the stool(visible or

occult)
* Weight loss
* Fever
* Age > 50 years, esp. new onset patients or change of
symptoms
* Pain that often awakens/interferes with sleep
* Diarrhea that often awakens/interferes with sleep
* Abnormal physical examination
* Family history of colon cancer or Inflammatory Bowel
disease(IBD)
 Physical Examination

* Exclusion of organic diseases.

* Left lower abdominal tenderness on the sigmoid
region.
* Anorectal digital examination: exclude anorectal
diseases and evaluate the pelvicfloor muscle
function.Pemeriksaan digiti anorektal.
Supporting examination/ diagnostic test

* Without alarm symptoms à initial examination: Complete blood count,

ESR, TSH, stool examinations(parasites, ova & giardia lamblia), stool
digestion.
* With alarm symptoms or permanent clinical symptom à Advanced
supporting examinations: colonoscopy/rectosigmoidoscopy o
* Exclude organic GI disease(cancer, iBD etc) with fecal calprotectin,fecal
M2PK, stool FOBT etc.
* Exclude Gluten enteropathy with Endomysial antibody serum, Anti TTG,
Anti gliadin.co
* Test for dysbiosis in the gut with stool healthy gut(pattern of short
chain fatty acid)
* Test for food sensitivity: food allergy(IgG antibody).
* Small intestinal bacterial overgrowth(SIBO) with H2 breathtest.n barium
x-ray etc.
 Differential Diagnosis

* Inflammatory Bowel Disease(IBD) esp. Crohn

* Microscopic colitis(Collagenous & Lymphocytic colitis)
* Gastrointestinal infection(bacterial,parasit)
* Maldigestion
* Emotional Stress
 Management

* Management of IBS according severeity.

* Mild with symptoms seldom à only diet and
reassurance(advice/education).
* Constan & Severe symptoms à antidepressant &
frequent follow up.
Spectrum of the clinical manifestation severity of IBS
patient
Clinical symptoms Mild Moderate Severe

Prevalencei(%) 70 25 5
Place of service Primary Secondary Tertiary
Physiological +++ ++ +
Symptom 0 + +++
Activity disorder 0 + +++
Using help + ++ +++
Health
Level of disase 0 + +++
Psychiatry diagnosis 0 + +++

0 = absen semua ; + = kadang-kadang ; ++ = sering ; +++ biasa atau selalu

Drossman et.al. Ann Intern Med 1992; 116: 1009-16.
 Low FODMAP diet
• Low of FODMAP food: low of :
Fermentable – meaning they are broken down
(fermented) by bacteria in the large bowel
Oligosaccharides – “oligo” means “few” and “saccharide”
means sugar. These molecules are made up
of individual sugars joined together in a chain
Disaccharides – “di” means two. This is a double sugar molecule
Monosaccharides – “mono” means single. This is a single sugar
molecule
Polyols – these are sugar alcohols (however, they don’t lead to
intoxication!)

Leech J. https://www.dietvsdisease.org/diy-low-fodmap-
diet/#What_Are_FODMAPs
Three phases of the low FODMAP diet.

• Phase 1 – Elimination/Strict low FODMAP Diet: For 3-8

weeks (depends on how you respond) you strictly exclude
all high FODMAP foods from your diet.
• Phase 2 – Reintroduction/Rechallenge: You will reintroduce
each FODMAP group one at a time to see what triggers
symptoms. For example, you may first reintroduce fructose
for three days. If you have no symptoms, you may then
reintroduce lactose too, and so on.
• Phase 3 – Modified/Adapted FODMAP Diet: Once the
trigger FODMAPs have been identified, you will know what
you can and cannot eat. You can then use this information
to formulate your own personalised diet that keeps your
symptoms to a minimum.

Leech J. https://www.dietvsdisease.org/diy-
low-fodmap-diet/#What_Are_FODMAPs
 Treatment of Mild IBS

* Mild or infrequent symptoms à most frequent in

primary service.
* Aim of treatment à education, reassurance, follow
good /healthy daily life.
 Moderate symptoms

* Treatment includes: symptomatic,

pharmacologic &/or pshycological.
* Patient must write their daily living activity,
diet and other factors(stress, sleep disorder).
* Pharmacological treatment to treat
abdominal pain/or discomfort, diarrhea or
constipation.
* Psychological treatment: relaxation/stress
treatment, cognitive-behavioral treatment,
hypnosis.
 Severe Symptoms

* Treatment: combination of psychologycal,

pharmacological and psychopharmacological
treatment.
* Antidepressant to reduce pain, diarrhea or
pscychiatry disorder.
Pharmacological Treatment for Diarrheal
type of IBS

* Anti diarrheal: loperamide, diphenoxylate, or

cholestyramine / 5-HT3 antagonist.
* others.
- Crefelemer:reduce chloride secretion
- R-verapamil: calcium channel antagonist reduce
diarrhea
- Corticotropin releasing factor(CRF) antagonist:
reduce abdominal pain and anxiety
 Pharmacological Treatment for
constipation type of IBS
* Dietary Fibre
* Osmotic laxatives: sorbitol, lactulose, polyethylene glycol, 5-HT4 agonist.
* Others:
= Rensapride(5HT3 antagonist/5HT4 agonist): increased colonic transit,
stool consistency, increase stool frequency
= Lubiprostone: aktivator channel chloride activator , efective for
chronic constipationk.
= MD-1100(Lincaclotide): Guanylae cyclass-C agonist
= Asimadoline: K-opioid agonist reduce colon perception
= Alvimopan dan Naltrexone: opioid antagonist.
 Abdominal Pain

* Antispasmodic: dicyclomine, hyoscyamine, otilonium

bromide,
* Antidepressant(tricyclic antidepresan) or
Selective serotonin reuptake inhibitor(SSRI),
* 5-HT4 agonist or 5-HT3 antagonist.
Gwee KA, Ghoshal UC, Chen M. J Gastroenterol Hepatol. 2018; 33: 99–110
HAWBOLDT J. GASTROENTEROLOGY. 2009. www.uspharmacist.com/…icle/ibs-treatment-guidelines
 Other medicine for IBS

* Intestinal immune modulator: antibiotic(rifaximin)

* probiotic(Bifidobacter infantis, VSL.#3 dan
Lactobacillus plantarum, lactobacillus acidophillus).
* Herbal Medicine: Chinese Herbal, Peppermint, etc.
Gwee KA, Ghoshal UC, Chen M. J Gastroenterol Hepatol. 2018; 33: 99–110
Diagnostic Algorithm on Irritable Bowel Syndrome

IV

AGA Technical Review. Gastroenterology 2002;123:2108-31

Algorithm of Functional Bowel Disorder
 Conclusion

* Diagnosis of IBS according history, physical

examination, supporting examinations, & absence of
alarm signs.
* IBS treatment depends on severity.
* Antispasmodic can be used to abdominal pain due to
IBS.
*