CPT2: GI 6 (Irrital bowel syndrome)

Question 1

What is irritable bowel syndrome?

Answer 1

A chronic relapsing/remitting syndrome that presents with abdominal pain and bowel dysfunction. There is no identifiable underlying structural abnormality to explain the pain and dysfunction.

It is a diagnosis of exclusion, after other conditions have been investigated and excluded.

Question 2

Alarm signs can indicate a different cause, for example:

Answer 2

Remember red flag symptoms (potential symptoms of other diseases)

• Crohn’s Disease/Ulcerative colitis
• Colon Cancer
• Coeliac disease
• Infection
• Medication induced constipation/diarrhoea

Red Flag symptoms (suggestive of serious illness) – bloody stool, fever, multiple episodes of watery diarrhoea, weight loss, fatigue/lethargy, pallor

Coeliac disease – autoimmune disease trigged by ingestion of gluten (abdo pain, diarrhoea, bloating). Also malnourishment – iron deficiency, B12/folate deficiency, calcium malabsorption, weight loss), skin rash (dermatitis herpetiformis)

Medications causing constipation – opiates, loperamide, tricyclic antidepressants, antimuscarinics (oxybutynin/hyoscine), iron preparations

Medications causing diarrhoea – SSRIs, PPIs, colchicine, cytotoxics, antibiotics, laxatives, magnesium supplements (magnasparate)

Question 3

What are the sypmtoms?

Answer 3

Abdominal pain

• Cramping in mid or lower abdomen (both RLQ and LLQ) relieved by defecation. Can range from mild to severe pain.

Bloating

Variable bowel habit

• Some patients will be more prone to either constipation (IBS-C) or diarrhoea (IBS-D), whereas some with have a mixed bowel habit.

Question 4

What helpe exculde other diseases?

Answer 4

• Patients don’t generally lose weight and are constitutionally well
• Normal investigations when examined
  
  • e.g. RBC, endoscopy, screen culture

Question 5

Epidemiology

Answer 5

Underestimated as many patients don’t seek medical help/have a formal diagnosis

• 10-20% prevalence in the UK
• Tends to be diagnosed in younger patients age 20-30
• Prevalence decreases with age
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Question 6

Aetiology

Answer 6

• •Abnormal hypersensitivity to visceral pain
  
  • Increased sensitivity to intestinal distension
• •Psychosocial factors
  
  • Anxiety, depression, somatisation and neurosis, panic attacks, acute stress.
• •Altered GI motility
  
  • Rapid contractions and increased/decreased transit time
• •Luminal Factors
  
  • Previous gastroenteritis, dietary components (wheat & lactose), gut micro-flora disturbances, trigger foods (coffee, spicy food, alcohol)

Question 7

Lifestyle treatment

Answer 7

Lifestyle interventions:

• Reassure and provide information
• Identify and eliminate dietary triggers
• If diarrhoea predominant symptom: Decrease insoluble fibre (wholemeal flour/bread, bran, brown rice/pasta), avoid sorbitol containing foods (sugar free sweets, chewing gum)
• If constipation predominant symptom: Increase soluble fibre (oats, linseed)
• Consider stress reduction therapies
• Avoid trigger factors and food

Question 8

Treatment pharmacological

Answer 8

Patients with mixed IBS may require a combination of the above treatment strategies - both loperamide and laxatives along with antispasmodics/anticholinergics.

Patients should be counselled about adjusting laxative/anti-motility/anti-spasmodic therapy according to response.