Changes in bowel movement IBS Mohammed Alwahibi Khalid

Changes in bowel movement. IBS Mohammed Alwahibi Khalid Alsadhan Walid Alkhamis

Content Unsolved 5 MCQ Introduction IBS Diagnosis Management and follow up Refer to specialist Abdominal examination Lactose Intolerance Solved 5 MCQ Page 2

1) Which of the following is an IBS diagnostic criteria ? A. Rome III criteria Unsolved 5 MCQ B. Ronaldo criteria C. donald trump D. none of above Page 3

Unsolved 5 MCQ 2) Which of the following characteristics has not been identified as a risk factor for the development of IBS? A. female B. stress C. Age (Young) D. none of above Page 4

Unsolved 5 MCQ 3) first choice of antimotility agent for diarrhoea in people with IBS? A. Loperamide B. Linaclotide C. TCA D. SSRI Page 5

Unsolved 5 MCQ 4) which one of the following statement for a patient with IBS considered we should refer the patient to specialist? A. diarrhea alternating with constipation B. rectal bleeding C. who take ASPIRIN D. none Page 6

Unsolved 5 MCQ 5) Which psychological treatment option for irritable bowel syndrome (IBS) is supported by the best evidence? A. Cognitive–behavioral psychotherapy B. TAD with group meeting C. A + B D. none Page 7

Unsolved 5 MCQ Introduction IBS Diagnosis Management and follow up Refer to specialist Abdominal examination Lactose Intolerance Solved 5 MCQ Page 8

Changes in bowel movement: Abnormal changes in the frequency, consistency and the color of the stool Introduction Irritable bowel syndrome (IBS) is a chronic, relapsing and often life-long disorder. Symptoms may include disordered defaecation (constipation or diarrhoea or both) and abdominal distension, usually referred to as bloating. People with IBS present to primary care with a wide range of symptoms, some of which they may be reluctant to disclose without sensitive questioning. Page 9

Abdominal pain, bloating and bowel habits changes (diarrhea or constipation) Page 10

Pathophysiology 1 st theory Altered GI motility includes distinct aberrations in small and large bowel motility. 2 nd theory Psychopathology is the 2 nd aspect. Associations between psychiatric disturbances and irritable bowel syndrome pathogenesis are not clearly defined. Page 11

describe 1 st theory Page 12

symptoms Page 13

Gender differences: Affects up to 20% of adults (70% of them are women). Epidemiol Psychopathology: ogy Age: Young High prevalence of psychiatric disorders (anxiety and depression were the most common). Only 25% of persons with this condition seek medical care. Page 14

Irritable bowel syndrome in secondary school male students in Al. Jouf Province, north of Saudi Arabia (2011 Nov) Page 15

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Unsolved 5 MCQ Introduction IBS Diagnosis Management and follow up Refer to specialist Abdominal examination Lactose Intolerance Solved 5 MCQ Page 17

Rome III criteria Page 18

The primary aim should be to establish the person's symptom profile, with abdominal pain or discomfort being a key symptom. Diagnosis of IBS It is also necessary to establish the quantity and quality of the pain or discomfort, and to identify its site (which can be anywhere in the abdomen) Page 19

Initial assessment Healthcare professionals should consider assessment for IBS if the person reports having had any of the following symptoms for at least 6 months: 1 -Abdominal pain or discomfort 2 -Bloating 3 -Change in bowel habit. Page 20

A diagnosis of IBS should be considered only if the person has abdominal pain or discomfort that is either relieved by defaecation or associated with altered bowel frequency or stool form. This should be accompanied by at least two of the following four symptoms: altered stool passage abdominal bloating symptoms worse by eating passage of mucus Other features such as lethargy, nausea, backache and bladder symptoms are common in people with IBS Page 21

In people who meet the IBS diagnostic criteria, the following tests should be undertaken to exclude other diagnoses: 1) full blood count (FBC) 2) erythrocyte sedimentation rate (ESR) or plasma viscosity Diagnostic tests 3) c-reactive protein (CRP) 4) antibody testing for coeliac disease - endomysial antibodies [EMA] or tissue 5) transglutaminase [TTG]. Page 22

Unsolved 5 MCQ Introduction IBS Diagnosis Management and follow up Refer to specialist Abdominal examination Lactose Intolerance Solved 5 MCQ Page 23

Clinical management of IBS 1 Dietary and lifestyle advice People with IBS should be given information that explains the importance of self-help in effectively managing their IBS. This should include information on general lifestyle, physical activity, diet and symptom-targeted medication Page 24

Healthcare professionals should assess the physical activity levels of people with IBS and for the People with low activity levels should be given brief advice and counselling to encourage them to increase their activity levels. Page 25

Diet and nutrition should be assessed for people with IBS and the following general advice given: * Have regular meals and take time to eat. * Avoid missing meals or leaving long gaps between eating. * Drink at least 8 cups of fluid per day, especially water or other non-caffeinated drinks, for example herbal teas. * Restrict tea and coffee to 3 cups per day. Page 26

2 Pharmacological therapy Decisions about pharmacological management should be based on the nature and severity of symptoms. The recommendations made below assume that the choice of single or combination medication is determined by the predominant symptom(s). Page 27

- Antispasmodic (Dicyclomine hydrochloride) agents should be taken as required, alongside dietary and lifestyle advice. - Laxatives (Methylcellulose) should be considered for the treatment of constipation in people with IBS, but people should be discouraged from taking lactulose. Page 28

# Consider linaclotide (Linzess) for people with IBS only if: - optimal or maximum tolerated doses of previous laxatives from different classes have not helped - they have had constipation for at least 12 months. - Follow up people taking linaclotide after 3 months. Page 29

- Loperamide (Imodium) should be the first choice of antimotility agent for diarrhoea in people with IBS Page 30

- Consider tricyclic antidepressants (TCAs) (Imipramine) as second-line treatment for people with IBS if laxatives, loperamide or antispasmodics have not helped. Start treatment at a low dose (5– 10 mg equivalent of amitriptyline), taken once at night, and review regularly. Increase the dose if needed, but not usually beyond 30 mg. Page 31

- Consider selective serotonin reuptake inhibitors (SSRIs) for people with IBS only if TCAs are ineffective. Page 32

3 Psychotherapy o Cognitive behavioral therapy (perceptions of illness), was reportedly to be effective. o A review of psychological treatments for IBS reported positive responses to psychotherapy o Psychotherapy is considered useful for those who have relatively severe or refractory symptoms o Small studies have shown that tricyclic compounds in low doses relieve unexplained abdominal pain. Page 33

4 Psychological interventions Referral for psychological interventions (cognitive behavioural therapy [CBT], hypnotherapy and/or psychological therapy) should be considered for people with IBS who do not respond to pharmacological treatments after 12 months and who develop a continuing symptom profile (described as refractory IBS). Page 34

Patient Education Patient education remains the cornerstone of successful treatment of irritable bowel syndrome. Teach the patient to acknowledge stressors and to develop avoidance techniques. Many patients successfully manage their symptoms with attention to dietary triggers. Page 35

Unsolved 5 MCQ Introduction IBS Diagnosis Management and follow up Refer to specialist Abdominal examination Lactose Intolerance Solved 5 MCQ Page 36

if they have any of the following 'red flag' indicators and should be referred to secondary care for further investigation if any are present: - unintentional and unexplained weight loss - rectal bleeding - a family history of bowel or ovarian cancer - anaemia - abdominal masses - rectal masses - inflammatory markers for inflammatory bowel disease When to refer to specialist? Page 37

Unsolved 5 MCQ Introduction IBS Diagnosis Management and follow up Refer to specialist Abdominal examination Lactose Intolerance Solved 5 MCQ Page 38

Examination of the abdomen: how to do ? Page 39

Unsolved 5 MCQ Introduction IBS Diagnosis Management and follow up Refer to specialist Abdominal examination Lactose Intolerance Solved 5 MCQ Page 40

Lactose Intolerance Lactose intolerance is a common disorder and is due to the inability to digest lactose into its constituents, glucose and galactose, secondary to low levels of lactase enzyme in the brush border of the duodenum. Page 41

Symptoms loose stools borborygmi nausea Page 42 abdominal bloating flatulence

Diagnosis A diagnosis or even the suggestion of lactose intolerance leads many people to avoid milk Page 43

Take home message Rome III criteria is a diagnostic criteria for IBS red flag Symptoms include unintentional and unexplained weight loss, rectal bleeding, family history, anaemia, abdominal masses, rectal masses, inflammatory markers for inflammatory bowel disease Treatment of IBS include Dietary and lifestyle advice, antispasmodic, Laxatives, Loperamide, TCAs, SSRIs Page 44

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Unsolved 5 MCQ Introduction IBS Diagnosis Management and follow up Refer to specialist Abdominal examination Lactose Intolerance Solved 5 MCQ Page 46

1) Which of the following is an IBS diagnostic criteria ? A. Rome III criteria B. Ronaldo criteria C. donald trump D. none of above Page 47

2) Which of the following characteristics has not been identified as a risk factor for the development of IBS? A. female B. stress C. Age (Young) D. none of above Page 48

3) first choice of antimotility agent for diarrhoea in people with IBS? A. Loperamide B. Linaclotide C. TCA D. SSRI Page 49

4) which one of the following statement for a patient with IBS considered we should refer the patient to specialist? A. diarrhea alternating with constipation B. rectal bleeding C. who take ASPIRIN D. none Page 50

5) Which psychological treatment option for irritable bowel syndrome (IBS) is supported by the best evidence? A. Cognitive–behavioral psychotherapy B. TAD with group meeting C. A + B D. none Page 51

Reference Irritable bowel syndrome in adults: diagnosis and management of irritable bowel syndrome in primary care NICE clinical guideline http: //www. medscape. org/viewarticle/439588 http: //emedicine. medscape. com/article/187249 -differential http: //emedicine. medscape. com/article/180389 -medication#7 http: //www. ncbi. nlm. nih. gov/pubmed/22125990 Page 52

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