Chronic Abdominal Pain (Small Group Session 22)

Question 1

Describe the Rome III Criteria for the diagnosis of IBS.

Answer 1

IBS Rome III Criteria

• >12 wk in the past 12 mths of abdo discomfort or pain that has 2 out of 3 features:
  
  • Relieved with defecation
  • Onset associated with a change in frequency of stool
  • Onset associated with a change in consistency of stool

Other typical symptoms:

• Alternating bowel movements
• Improvement with bowel movement
• Cramping
• Bloating
• Passage of mucus
• Abnormal stool frequency, form and passage

Question 2

Diagnosis of IBS is less likely in the presence of “red flag” features. What are they?

Answer 2

Diagnosis of IBS is likely in the presence of “red flag” features including:

• >50 years of age
• FHx of colon cancer
• Weight loss
• Fever
• Nocturnal defecation
• Anemia
  
  • Melena
• Blood or pus in the stool
• Abnormal gross findings on flexible sigmoidoscopy
• Abnormal rectal exam
• Abdo mass
• FOBT+

Question 3

What is the current understanding of the pathophysiology of IBS?

Answer 3

The current understanding of IBS pathophysiology encompasses a strong gut-brain interaction.

• Individuals may have psychosocial factors including anxiety, stress and personal traits that affect gut motility and the sensation of pain
  
  • Some individuals with IBS can be hyper-vigilant and/or hypersensitive to gut activity and pain
  • Hypersensitivity may result from:
    
    • 1) increased signal transduction from repeated stimulation
    • 2) decreased neuron excitation threshold and/or
    • 3) the recruitment of nociceptors (pain receptors) following tissue injury
  • Pain can feed into the patient’s anxiety and influence gut motility
• IBS is NOT just in the patient’s head!

Question 4

What are the principles of treatment for IBS?

Answer 4

IBS Treatment Principles

1. Reassurance and education; relationship with pt
   
   • IBS is a real diagnosis
   • There are treatment options to manage symptoms
   • Education on IBS: imparting an understanding of the disorder may reduce patient visits and resource utilization
2. Treatment is based on individual symptoms
   
   • Aim to reduce symptoms

Question 5

What are some common IBS treatments and their indications for use?

Answer 5

1. Dietary modifications - first line treatment
   
   • Refer to dietician. Some foods can aggravate IBS (grains, gluten, FODMAPs) and it is important to maintain a healthy diet while avoiding trigger foods
   • Diets that may alleviate IBS symptoms include a gluten free diet, low FODMAPs
2. Probiotics
   
   • Some evidence indicates a reduction in flatulence, BM frequency and pain, reduction in symptoms, modest improvement in quality of life
3. Linaclotide or prucalopride or other motility inducing drugs
   
   • To reduce constipation (indicated if constipation is an IBS symptom)
4. Tricyclic antidepressants
   
   • Pt education is important