Transcript Models of care in IBS

Models of care in IBS
Outline
• Complex aetiology
• Pain sensitizers
• Clues to an organic
disease: serotonin
• Other theories
• Proven therapies
• FODMAPs
• NICE guidance
• Models of care
– Expectations of
secondary care
– Weaknesses of
secondary care
– Cases
Aetiology:biopsychosocial model
Genes
External stressors
•Adverse life events
•Chronic psychological stress
•Gastrointestinal infection
•Changes in diet
Psychological
disturbance
Early learning
Family influences
Susceptible
individual
Physiological
disturbance
IBS symptoms
Slide courtesy of Prof Robin Spiller
Rome III Criteria
• Recurrent abdominal pain or discomfort at least 3
days/month in the last
• 3 months associated with two or more of the following:
– Improvement with defecation
– Onset associated with a change in frequency of stool
– Onset associated with a change in form (appearance) of
stool
– * Criterion fulfilled for the last 3 months with symptom
onset
– at least 6 months prior to diagnosis
Pain regulation I
Brain functional MRI
showing regions
activated during
endogenous pain
modulation by
heterotopic
stimulation (painful
rectal distension with
foot cold pain) in
healthy controls.
Wilder-Smith C H Gut 2011;60:1589-1599
Copyright © BMJ Publishing Group Ltd & British Society of Gastroenterology. All rights reserved.
Pain regulation II
“A majority of patients with IBS have diminished
pain inhibition or even pain facilitation compared
with healthy controls. “
“Brain imaging during specific activation of
endogenous pain modulation demonstrates a
fairly consistent functional hub of mainly frontal,
limbic and brainstem modulatory regions in
healthy humans.”
“ Patients with IBS have a different pattern of
activation and a correlation between the imaging
and sensory changes. “
Wilder-Smith C H Gut 2011;60:1589-1599
Pain regulation III
Factors potentially
driving changes in
endogenous pain
modulation in visceral
pain syndromes.
Wilder-Smith C H Gut 2011;60:1589-1599
Copyright © BMJ Publishing Group Ltd & British Society of Gastroenterology. All rights reserved.
More than gut
The search for an ‘organic’ basis Serotonin
Camilleri Gut 2002;51:i81-i86 doi:10.1136/gut.51.suppl_1.i81
Serotonergic modulation of visceral sensation: lower gut
Effect of alosetron 1 mg twice daily and placebo on adequate relief of pain (A) and stool
consistency (B) in female patients with symptoms of diarrhoea.
Camilleri M Gut 2002;51:i81-i86
Copyright © BMJ Publishing Group Ltd & British Society of Gastroenterology. All rights reserved.
Effect of alosetron 1 mg twice daily and placebo on adequate relief of pain (A) and stool
consistency (B) in female patients with symptoms of diarrhoea.
Camilleri M Gut 2002;51:i81-i86
Copyright © BMJ Publishing Group Ltd & British Society of Gastroenterology. All rights reserved.
Numerous investigations possible
IBS-D Bile salt malabsorption –
Sehcat scan; present in 10%
Wedlake et al, APT 2009
(n=1223), 15 trials
Small bowel overgrowth –
Hydrogen breath test
Candida overgrowth
Professor ----- takes an
individualised broad-based and
holistic approach to each patient....
[However] when this is ineffectual,
such as may be the case in patients
with the Irritable Bowel Syndrome,
then he does not hesitate to try
unconventional treatments such as
wheat-free diets (effective for
bloating in IBS) and mould free
diets (effective for the Intestinal
Candida Syndrome), etc. In the
most resistant cases he has
established a sound collaboration
with medically-trained
homeopaths...
What definitely works: TCA
Effect of tricyclic antidepressants on “overall
symptom improvement with therapy.” Trials
included used a validated pain scale to quantify
improvement
TCA
Effect of tricyclic antidepressants on
abdominal pain scores
Cognitive-Behavioural therapy
Meta-analysis of the efficacy of cognitive
behaviour therapy:
(50% reduction of symptoms) gave an odds ratio of
12 (95% confidence interval 5.56 to 25.96) in favour
of cognitive behaviour therapy, with a number
needed to treat of 2.16.
CBT
Authors
Size
Description
Results
Bennett and
Wilkinson
RCT; 12 CBT, 12 usual care
Eight week package: stress
management
training, cognitive therapy,
and contingency
management v medical
treatment
Anxiety reduced in treatment
group but not in
control group; both achieved
improvement in IBS
symptoms, restriction of
activities, and fatigue
Lynch and Zamble
RCT; 12 CBT, 12 waiting list
Coping skills, assertiveness
training, education, and
progressive relaxation v
waiting list controls
Significantly greater
improvement of IBS
symptoms and anxiety in
treatment group
Guthrie et al
RCT; n=102
Psychotherapy v “supportive
listening,” 12 week study.
After study, 33 patients
from control group accepted
Psychotherapy
Psychotherapy significantly
superior in terms of
physical and psychological
symptoms. Results sustained
at 12 month follow-up
Boyce et al
RCT; n=105
Three arm trial: all groups
received standard care, plus
either CBT or relaxation
training.Patients with
“resistant IBS” not included
Significant improvements for
all groups in IBS symptoms,
physical/social functioning
and general wellbeing, but
no significant differences
between groups.
Greene and
Blanchard
RCT; 10 CBT, 10 symptom
monitoring
Individualised CBT for 10
sessions v daily
gastrointestinal symptom
monitoring over eight weeks
80% of treatment group
showed clinical
improvement compared with
10% of controls.
CBT
Authors
Size
Description
Results
Bennett and
Wilkinson
RCT; 12 CBT, 12 usual care
Eight week package: stress
management
training, cognitive therapy,
and contingency
management v medical
treatment
Anxiety reduced in treatment
group but not in
control group; both achieved
improvement in IBS
symptoms, restriction of
activities, and fatigue
Lynch and Zamble
RCT; 12 CBT, 12 waiting list
Coping skills, assertiveness
training, education, and
progressive relaxation v
waiting list controls
Significantly greater
improvement of IBS
symptoms and anxiety in
treatment group
Guthrie et al
RCT; n=102
Psychotherapy v “supportive
listening,” 12 week study.
After study, 33 patients
from control group accepted
Psychotherapy
Psychotherapy significantly
superior in terms of
physical and psychological
symptoms. Results sustained
at 12 month follow-up
Boyce et al
RCT; n=105
Three arm trial: all groups
received standard care, plus
either CBT or relaxation
training.Patients with
“resistant IBS” not included
Significant improvements for
all groups in IBS symptoms,
physical/social functioning
and general wellbeing, but
no significant differences
between groups.
Greene and
Blanchard
RCT; 10 CBT, 10 symptom
monitoring
Individualised CBT for 10
sessions v daily
gastrointestinal symptom
monitoring over eight weeks
80% of treatment group
showed clinical
improvement compared with
10% of controls.
FODMAPs
Fermentable, Oligo-, Di- and Mono-saccharides and Polyols,
Evidence suggests that reducing global intake of FODMAPs to manage
functional gut symptoms provides symptom relief for about 75% of
patients with FGDs.
Despite its apparent complexity, the FODMAPs approach can be effective
when delivered by a dietitian skilled in its intricacies.
Patient compliance with this diet is very good, likely due to quality-of-life
improvements
Gibson PR, Shepherd SJ. Evidence-based dietary management of functional gastrointestinal symptoms: The
FODMAP approach. J Gastroenterol Hepatol. 2010;25(2):252-258
Shepherd SJ, Parker FC, Muir JG, Gibson PR. Dietary triggers of abdominal symptoms in patients with irritable
bowel syndrome: Randomized placebo-controlled evidence. Clin Gastroenterol Hepatol. 2008;6(7):765-771
FODMAPs
Fructans
Oligosaccharides made of fructose molecule chains that are completely malabsorbed
Can contribute to bloating, gas, and pain. Wheat accounts for the majority of fructan intake.
Galactans
Galactans are oligosaccharides containing chains of the sugar galactose.
Dietary sources of galactans include lentils, chickpeas, kidney beans, black-eyed peas,
broccoli, and soy-based products.
Polyols
Sugar alcohols.
Too large for simple diffusion from the small intestine, creating a laxative effect on the GI
tract.
They are found naturally in some fruits and vegetables and added as sweeteners to sugarfree gums, mints, cough drops, and medications.
NICE guidance - 1
First-line pharmacological treatment
– Choose single or combination medication based on
the predominant symptom(s).
– Consider offering antispasmodic agents - alongside
dietary and lifestyle advice.
– Laxatives for constipation, but discourage use of
lactulose.
– Offer loperamide as the first choice of antimotility
agent for diarrhoea.
– Advise people how to adjust doses of laxative or
antimotility agent according to response, shown by
stool consistency. The aim is a soft, well-formed stool.
NICE guidance - 2
Second-line pharmacological treatment
– Consider tricyclic antidepressants (TCAs) for their analgesic
effect if first-line treatments do not help.
– Start at a low dose (5–10 mg equivalent of amitriptyline)
taken once at night and review regularly.
– The dose may be increased (but should not usually exceed
30 mg).
– Consider selective serotonin reuptake inhibitors (SSRIs)
only if TCAs are ineffective.
– Take into account the possible side effects of TCAs and
SSRIs.
– If prescribing these drugs for the first time, follow up after
4 weeks and then every 6–12 months.
Expectations of primary care
• Make positive diagnosis and prescribe trial of
first line therapy
• Clarify the psychological context
• Identify difficult to treat cases
• If confident of diagnosis, commence TCA
therapy
Expectations of secondary care
• Make a positive diagnosis and be honest
• Do not over-investigate
• Set out a management plan to facilitate
ongoing care in the community
• Decide who to refer to psychologist
• Identify who to refer to tertiary centre
Weaknesses of secondary care
• Not many gastroenterologists are interested in
the disease
• There may be an empathy problem (easy for
cancer and Crohn’s, not so for something we
can’t see, feel or understand)
• If psychological support and continuity are
important aspects, a ‘normal’ clinic is not the
best place to access them
So, what do we really think our role is?
• Exclude ‘serious’ disease
• Assess severity of the case
• Deliver a ‘positive’ diagnosis and conceptual
model
• Start the ball rolling and provide a basic route
map
• ....and discharge
But not:
• Regular assessments of response
• Titration of TCA
• De facto psychological therapy in the clinic
Example cases
1
2
3
Case 1
• 20 year old
• Previously seen at another
hospital 2009
• Longstanding abdominal
pain and bloating
• Episode gastroenteritis in
South America treated with
antibiotics (U/S)
• Sx worse with wheat
Case 1
• AXR – fecal loading +++
• MRI small bowel normal
• Treated with Movicol
• End 2009 – re-referred
• Long discussion about
IBS and laxatives
• Dietician review
Case 1
• Review in clinic
• Now more confident in managing constipation
and no need for further follow-up
Case 2
• Very worried man
• 2007 – abnormal LFTs, foul
wind and abdominal pain.
Liver biopsy –nil of concern
• 2008 – foul wind,
something inside – he feels
he needs an endoscopy –
not organised
• 2008 – re-referred new
consultant - colonoscopy
NAD
Case 2
• New consultant- requesting second opinion –
very angry, something is wrong and no-one
will help. Wants an MRI abdo. Has been seen
by many consultants in more than one
hospital.
Case 2
• Main symptoms: abdominal bloating, worse when
walking or lifting and feels that all his symptoms
started after he tried herbal body enhancers
approximately 4 years ago.
• Abnormal liver function tests but has had a normal
liver biopsy and has found that Amitriptyline, a
wheat-free diet, a dairy-free diet and a Dietitian
review have been unhelpful.
• In addition to this 3 ultrasounds, colonoscopy and an
OGD that he has had, although they have not
revealed any significant abnormality, do still leave
him concerned
Case 2
• Rebook appointment – ask for relative to be
present. MRI organised as contract – no
further investigations
• Explain – irritable bowel to both
• Attitiude starts to change
• Controlled in secondary care.. for now.
Case 3
• Mild asthma &
bronchomalacia,
overweight – bariatric
surgery – may help with
airway control
• Background – fibromyalgia,
depression,
cholecystectomy
• Post operative C Diff
• Subsequent severe
diarrhoea
Case 3
• Had already tried – probiotics, loperamide,
cholestyramine, some benefit from codeine.
• Colonoscopy NAD, surgeon says short bowel
not possible
• Extreme distress – over course of time has
SeCHAT (borderline but no benefit from
treatment), CT, and MRI – all normal
Case 3
• LFTs obstructive – no suggestion of stones on
MRCP, liver fatty on U/S
• Suggestion post infective irritable bowel –
dietician, amitryptilline – do not control
• UCH suggest creon as stool fatty, with no
benefit (fecal elastase normal)
Case 3
• Extreme distress and
some pathology
• Referral to tertiary
centre
• They say……..
• Creon + PPI
• Treat for bacterial
OG
• Treat with clonidine
in case of autonomic
dysfunction
• Try octreotide
Summary
Can be very challenging
Require time that is often not available
Try not to over-medicalize
Psychological support can help
Dietary modification
How to deal with false expectations
Return onus of control to patient.