IBS

Question 1

Characteristic sx of IBS

Answer 1

Functional bowel disease with:
1- recurrent abdo pain
2 - altered bowel habits
3- bloating

Question 2

Common hx of pt with IBS

Answer 2

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

Question 3

Alarm sx for IBS

Answer 3

Vomiting
Dysphagia
Abdominal mass
Anemia
Gi bleed
Unexplained weight loss

Question 4

What sx are inconsistent with IBS

Answer 4

Nocturnal sx
Fever
Older age
Acute - progressive
Anorexia, weight loss
Rectal bleed
Painless diarrhea
Steatorrhea
Travel

Question 5

What are the subtypes of IBS

Answer 5

• 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

Question 6

Nice criteria for IBS

Answer 6

Aldo pain /discomfort associate with altered bowel habits x 6 months with no alarm sx

Question 7

Rome iv criteria for IBS

Answer 7

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

Question 8

Rome iv supportive but not diagnostic criteria for IBS

Answer 8

• 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

Question 9

Aggravating factors for IBS

Answer 9

• Caffeine
• ethanol
• stress
• menstruation
• fibre
  -Fat
• sorbitol

Question 10

Investigations for IBS

Answer 10

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

Question 11

Management of IBS

Answer 11

1. Reassurance, education
2. 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
3. Exercise (helps bloating and constipation)
4. CBT or hypnotherapy professionally
5. Peppermint oil 0.2-0.4 ml TID for bloating
   6- pharmacotherapay based on IBS subtype

Question 12

Pharmacotherapy for IBS related bloating

Answer 12

1-peppermint oil 0.2 - 0.4 ml TID
2- antispasmodic (dicycloverine, buscopan, pinaverium)
3- TCA (amitryptiline 10 mg QHS)

Question 13

Pharmacotherapy for IBS related diarrhea

Answer 13

• TCA (amitryptiline 10-100 mg qhs)
• eluxadoline (refer to gf for initiation)
• rifaximin
• alosetran (under gi guidance)

Symptomatic relief PRN → loperamide 2-12mg/d

Question 14

Pharmacotherapy for IBS -c

Answer 14

• Linaclotide
• SSRI ( fluoxetine, paroxetine and citalopram)
• lubiprostone
• tenaponor, plecanatide, tegaserod under gi guidance

Question 15

Therapies to AVOID in IBS

Answer 15

Gluten free diet
Wheat bran supplementation
Acupuncture
Chalestyramine, bile acid sequestrants
Stimulant, osmotic laxatives
Prucalopride