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home - Colon - Colonic Motility Disorders - Irritable Bowel Syndrome Classification Written by Dr Sebastian Zeki
Knowledge

Shows understanding of contemporary knowledge of the range of
factors that control gastrointestinal motility, as well as the means by
which symptoms arising from the GI tract are perceived.

In particular, can describe the enteric nervous system and
understands the ways in which drugs can modify its functioning

Can describe the brain-gut axis and the role of psychological factors
in the genesis of symptoms

Can describe the symptomatology and range of clinical presentations
of patients with irritable bowel syndrome

Knows the diagnostic criteria
Realises the importance of careful clinical assessment as well as the
need for appropriate selection of investigations

Knows the evidence-based treatment options for IBS and the
importance of a holistic and individualised approach to patient
management

Skills
Can make an accurate clinical assessment of patients with irritable
bowel syndrome

Uses investigations selectively
Communicates the diagnosis clearly and sympathetically
Appreciates the degree to which functional gut problems can impair
quality of life. Involves patients in making choice of treatment options

Can explain, where appropriate, that a psychological treatment might
be helpful and refer appropriately

Behaviours
Show a sympathetic understanding of the relevance of symptoms to
the individual and never appears dismissive

Takes time to explain nature of the condition, the treatment options
and appreciates their (often) limited effectiveness

AL

Irritable Bowel Syndrome Classification

Extraintestinal symp-toms — Patients often have other functional non-GI complaints. Microscopic inflammationMucosal immune system activation can occur in diarrhea predominant IBS and psotinfectious IBS. General Principles of Treatment:Establish a therapeutic relationship — Patients with established, positive physician interactions have fewer IBS-related follow-up visits.Patient education.Dietary modification —Try lactose exclusion/ fructose exclusion/ reduce flatulogens .Fibre useful for constip-tion.Psychosocial therapies — Behavioral treatments may be considered for motivated patients who associate symptoms with stressors. GI motility This may be increased.No particular pattern has been isolated. Visceral afferent hypersensitivityVisceral hyperalgesia occurs in other functional problems.CNS processing of visceral afferent impulses may be important in IBS. IBS can occur in up to 20% after acute bacterial infection Risk factors: Young ageProlonged feverAnxiety DepressionPathogenesis of Post-infectious IBS:?Bile salt malabsorption?Irritated nerves?More likely to present to doctor with gastroenteritis as have pre-exisiting IBS Psychosocial dysfunc-tionIBS patients more likely than controls to have a history of physical or sexual abuse and/or a learned pattern of illness behavior originating in childhood.Overactivity in the brain CRF (corticotrophin releasing hormone- from paraventricular nucleus) and CRF-receptor signaling system contributes to anxiety disorders and depression.IV CRF causes increased colonic motility and abdominal pain. Irritable Bowel Syndrome MedicationsAntispasmodic agents directly affect intestinal smooth muscle relaxation (eg, mebeverine and pinaverine).May be beneficial in patients with postprandial abdominal pain, gas, bloating, and fecal urgency by reducing colonic activity.Antidepressants are good for neuropathic pain.Tricyclic agents, via their anticholinergic properties, also slow intestinal transit time -They may therefore be beneficial in diarrhea-predominant IBS.Antidepressants are also useful if depression is a cofactor.Antidiarrheal agents (eg loperamide) are good for diarrhoea but not for global symptoms.Benzodiazepines are not useful and can lower the pain threshold.5-hydroxytryptamine (serotonin) 3 receptor antagonists eg. alosetron, cilansetron ondansetron and granisetron) modulate visceral afferent activity from the gastrointestinal tract and may improve abdominal pain.Alosetron is most effective in female patients in whom diarrhoea was predominant. However, it is associated with ischaemic colitis.5-hydroxytryptamine (serotonin) 4 receptor agonists — (tegaserod {Zelnorm}) - stimulate the release of neurotransmitters and increase colonic motility, providing a rationale for their use in constipation predominant IBS. It has cardiovascular side effects.Lubiprostone — Lubiprostone is a locally acting chloride channel activator that enhances chloride-rich intestinal fluid secretion. it may be useful for constipation predom IBS. Early life-Genetic -Environment Psychosocial factors-Life stress-Psychological state-Coping-Social support Physiology-Motility-Sensation IBS-Symptom experience-Behaviour Other possible aetiologies:Carbohydrate malabsorption (such as lactose or fructose intolerance).Bile acid malabsorption .Neurohumoral or neuroimmune stress responses.Elevated levels of short chain fatty acids in the stool.Bacterial overgrowth .An increased concentration of intestinal serine proteases. Alteration in faecal microflora Emerging data suggest that the fecal micribiota in individuals with IBS differs from healthy controls.It is unknown if this is significant. Chronic abdominal pain It is usually crampy.It is often in the left lower abdomen but can vary.It has variable intensity and periodic exacerbations.Stress, emotion and eating can exacerbate pain. Diarrhoea — Diarrhoea is characterised by frequent loose stools of small to moderate volume during waking hours, most often in the morning or after meals.Diarrhoea is often preceded by lower abdominal cramps and urgency and sometines tenesmus.50% complain of mucus discharge with stools. Clinical Manifestations Constipation — Patients can have pellet stools intermittently sometimes alternating with diarrhoea. Other GI symptoms — Reflux, dysphagia, early satiety, intermittent dyspepsia, nausea, and non-cardiac chest pain are common.Patients can also get abdominal bloating and increased gas production in the form of flatulence or belching. Postinfectious Treatment Rome III criteriaRecurrent abdominal pain or discomfort at least 3 d/month in the last 3 months associated with 2 or more of the following (1) Improvement with defecation (2) Onset associated with a change in frequency of stool (3) Onset associated with a change in form (appearance) of stool. Irritable bowel syndrome Criteria IBS Subtypes:IBS with constipation -hard or lumpy stools ≥25 % and loose (mushy) or watery stools <25 % of bowel movements.IBS with diarrhoea- loose (mushy) or water stools ≥25 % and hard or lumpy stools <5 % of bowel movements.Mixed IBS- hard or lumpy stools ≥25 % and loose (mushy) or watery stools ≥25 % of bowel movements.Unsubtyped IBS -insufficient abnormality of stool consistency to meet the above subtypes. Written by Dr Sebastian Zeki

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