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Irritable bowel syndrome (IBS)
Discuss IBS?
Discuss the diagnosis of IBS?
The diagnosis of IBS is based on ROME III criterion. The criteria should be fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis.
A positive diagnosis of IBS can be made by using ROME III criteria:
Recurrent abdominal pain or discomfort at least 3 days per month in the last 3 months associated with 2 or more of the following:
NICE recommends a positive diagnosis of IBS based on
Consider diagnosing IBS only if the person has abdominal pain or discomfort that is:
Lethargy, nausea, backache and bladder symptoms are common in IBS and may be used to support diagnosis.
Discuss the investigations for suspected IBS?
All patients who met the diagnostic criterion for IBS should have
The following tests are not needed to confirm a diagnosis of IBS:
Discuss the symptoms (red flag indicators) that warrant further investigations?
Discuss the management of IBS?
Treatment for IBS is individualized on the basis of the type and severity of symptoms.
Dietary advice should be offered to all
First line treatment- single or in combination are antispasmodics, laxatives and loperamide.
Second line treatment- Tricyclic antidepressants, SSRI
Third line treatment- cognitive behavioural therapy (CBT), hypnotherapy, psychological therapy.
Diet
Specific diets or elimination diets have not been proven effective.
Exercise
Exercise has been associated with improved outcomes in uncontrolled studies and is reasonable as a general recommendation.
Fiber supplements
Controlled trials suggest that fiber supplements are effective for the constipation symptoms of irritable bowel syndrome, but not for pain or diarrhea.
Some patients who take fiber, particularly those with diarrhea-predominant irritable bowel syndrome, have worsening of symptoms. Intake of insoluble fibre (like bran) should be discouraged. If more fibre is needed, recommend soluble fibre such as ispaghula powder, or foods high in soluble fibre (for example, oats).
Treatment of constipation
Treatment of diarrhea
Abdominal pain
Tricyclic antidepressants
Tricyclic antidepressants are recommended for moderate-to-severe IBS in which pain is prominent or when other therapies have failed. Benefits are seen within two weeks. A number of RCT’s have demonstrated decreased symptoms in patients taking low-dose tricyclic antidepressants such as amitriptyline, desipramine, clomipramine, doxepin, and trimipramine. Side effects include constipation, fatigue, somnolence, dry mouth, and urinary retention. Since somnolence may occur, the drugs should be taken at bedtime. Daily administration starting at a dose of 10 to 25 mg for any of the tricyclic antidepressants, with a gradual escalation to a dose of 25 to 100 mg, is suggested. Tricyclic antidepressants may be continued for 6 to 12 months, after which an attempt to taper the dose should be made.
Selective serotonin-reuptake inhibitors do not have the same anti nociceptive effects as tricyclic antidepressants and have yet to be proved effective for irritable bowel syndrome or any other functional gastrointestinal disorder. Although evidence to support its use is lacking, this class of drug may also be tried if a tricyclic antidepressant fails.
Psychotherapy
Psychotherapy is useful for selected patients with severe IBS. Diarrhea and pain appear to respond to psychotherapy, whereas constipation does not. A variety of psychotherapy techniques, including cognitive behavioral therapy (directed at maladaptive perceptions of illness and behavior), dynamic psychotherapy (directed at interpersonal problems), relaxation therapy, and hypnotherapy, alone or in combination, are reportedly effective for symptoms.
Discuss other therapies for IBS?
Serotonin-3 receptors antagonist- Alosetron
Serotonin is released by GI entero endocrine cells stimulates peristalsis by binding to serotonin- 3 and serotonin-4 receptors located on enteric nerves. Alosetron reduces diarrhea and urgency. It can cause ischaemic colitis and was withdrawn from the market by the manufacturer. However it is still available on a named patient basis. Given its known side effects, alosetron therapy should be limited to women with irritable bowel syndrome without constipation who have symptoms severe enough to justify the risk of drug-induced ischemic colitis and who have had no response to other therapy.
Serotonin-4–receptor agonists- Tegaserod
Tegaserod is approved by the FDA for use for up to 12 weeks in women with constipation-predominant irritable bowel syndrome. Given its cost and its relatively moderate advantages over placebo, tegaserod should be reserved for female patients with constipation-predominant IBS pain who have no response to fiber or laxatives and antispasmodic agents.
Both alosetron and tegaserod are not available in UK.
Ref
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