Transcript World Prevalence of IBS

Functional GI Disorders
Yousif A. Qari MD,FRCPC
Functional GI Disorders
Irritable Bowel Syndrome
Functional Dyspepsia
Irritable Bowel Syndrome
Definition
Irritable bowel syndrome (IBS):
is a chronic medical disorder characterized by
abdominal pain and altered bowel function
World Prevalence of IBS
10%
and 20% around the globe.
20% -50% of GI referrals
Prevalence of IBS Diagnosis in Primary
Care and Gastroenterology Practices
12%
28%
IBS
IBS
Other diagnosis
Other GI
diagnsis
72%
88%
Prevalence in
general practice
Prevalence in
Gastroenterology
Prevalence in the US of IBS Compared
to Other Chronic Diseases
20
Prevalence(%)
20
10.2
3.9
3.6
1.3
0
IBS
Hypertention
Asthma
Diabetes
Heart disease
Rates of Self-Reported IBS in the USA
by Sex and Age
Rate per 1,000 subjects
20
15
Male
Female
10
5
0
< 45
45-65
Age (years)
65
The "Rome“ Diagnostic Criteria for IBS
At least 3 months of abdominal pain
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2.
3.
Relieved with defecation
Associated with a change in the frequency of stool
Or
Associated with a change in consistency of stool
AND
Two or more of the following for at least 25% of days
1.
2.
3.
4.
5.
Disturbed defecation
Altered stool form
Altered stool passage
Passage of mucus
Bloating or feeling of abdominal distention
IBS: A Chronic Condition
No change in
diagnosis :
97%
Pathophysiology
Pathogenesis of IBS remains obscure
Pathophysiology
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deregulation of the gut's serotonin
transporter
Post-enteritis IBS
IBS is a "real" gut disease
Constipation
Diarrhea
chemical or mechanical stimulation of the gut
Serotonin release
reduced capacity to reuptake serotonin
serotonin uptake is normal
excess free serotonin
desensitization of the receptors
reducing motor function
Moses PL et al. Am J Gastroenterol. 2002;97:240.
Patients concerns
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Too much pain
Nothing works
Helpless
Worried
Frustrated
Depressed
Socially isolated
Can't work
Physicians concerns
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Listen
Main symptom
Alarming symptoms
Medications
Worried ?
Depressed ?
Wants a sick leave ?
Hypochondriac ?
Social problems ?
Alarm symptoms
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Hematochezia,
Weight loss > 10 pounds
Family history of colon cancer OR IBD
Recurrent fever
Anemia
Chronic severe unrelenting diarrhea
Nocturnal symptoms
Always do
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Proper examination
Reassurance
Explain the nature of the disease
Set a clear prospective therapeutic goal
with the patient
Lower the expectations of the patient
Encourage active participation by the
patient in her/his well being.
Diagnosis
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Good history and physical
CBC
ESR
Stoolanalysis
Sigmoidoscopy
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Spastic colon
Inflammation
Tumors
Melanosis coli
Scybala
Colonoscopy or Barium enema
Therapy
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Constipation predominant
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Diarrhea predominant
Key Clinical Implications
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Treatment of individuals with IBS is indicated if
the patient and physician believe that the IBS
symptoms diminish the patient's quality of life.
Most diagnostic tests are unnecessary in
patients with IBS who do not have "alarm"
symptoms. such an individual has < 1%
likelihood of being diagnosed with an organic
gastrointestinal disorder.
bulking agent in IBS
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Thirteen trials were conducted
7 were high quality
3 showed a benefit
Benefit limited to constipation only
Can be useful placebos
Gradual increase of dose
Dietary Advice
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Patients often say certain foods upset
them
Two large studies reported remission in
patients on elimination diets
48% response
Anticholinergics
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Dicyclomine
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Efficacy supported by only 1 trial
Global improvement
Improvement in abdominal pain and constipation.
64% anticholinergic side effects vs 16% in controls
hyoscyamine.
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2 combination trials reported global improvement
without measuring improvement in specific symptoms
Smooth Muscle Relaxants
Mebeverine (Duspataline)
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Improvement in abdominal pain
Short term benefit
Heterogeneous ?
publication bias ?
Antidepressants
Metaanalysis
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14 Randomized control trials, 1970 – 1999
 849 patients
 19 TCAs, 4 others
Effective for primary, global, and pain control
measures ( p <0.001 )
Low-Dose Tricyclic Antidepressants
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7 trials: 1 met high quality criteria¹
4 out of the 7 trials, showed significant improvement in:
 Abdominal pain
 Diarreah¹
The number needed to treat (NNT) for the TCAs is 3,
This means that if you treat 3 people, 1 will get a
benefit. ²
¹Jailwala et al, Ann Interrn Med 2000;133:136
²Jackson et al, Am J Med 2000: 108: 65
Drugs for the Treatment of Bloating
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We have little to offer here
Eliminating dietary factors including excess
sorbitol, fructose, and lactose-containing foods if
patients are lactase-deficient helps a few .
Simethicone (Disflatyl), charcoal, or beanase are
probably useless.
Prokinetics / Alosetron :useless
No proven treatment for bloating
Loperamide for IBS With Diarrhea
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Improves diarrhea, urgency, and borborygmi²
Increases frequency of bowel movements, and
improves stools consistency³
Does not affect abdominal pain or distention³
² Cann et al, Dig Dis SCI 1984; 29:239
³ ailwala et al, Ann Interrn Med 2000;133:136
5HT3 Receptor Antagonist Therapy
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IBS with diarrhea
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Five randomized, controlled trials
(1mg given twice/D)
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Improves
 stool frequency
 stool consistency
 abdominal discomfort
 and global IBS symptoms
?? Ischemic colitis
Alosetron
5HT4 Receptor Agonist Therapy
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Four randomized, controlled trials in female patients
with IBS with constipation
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Significant improvement in:
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Diarrhea (9% vs 4.5% in plaebo)
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Global IBS symptoms
Individual IBS symptoms of abdominal pain, bloating,
and constipation
usually occurred in the first week of treatment
transient
2% discontinue medication
Tegaserod is effective for the treatment of IBS in
female patients with constipation
Tegaserod
celiac sprue Prevalence in IBS
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prevalence (5%)
it may be appropriate to obtain
endomysial and antigliadin antibodies in
IBS patients with diarrhea
Functional Dyspepsia
Definition: Poorly understood
Abdominal pain or discomfort that occurs in
relation to meals
Episodic or persistent pain or discomfort localized
to the epigastrium or upper abdomen
Chronic or recurrent upper abdominal pain or
nausea that may not be related to meals.
Pathophysiology of Dyspepsia
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Purely speculative
Motor abnormality
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Delayed gastric emptying 30 -80%
Antral hypomotility in 25%
? Abnormal function or abnormal perception.
H.pylori role??
High acid production??
Billiary dysmotility
Esophageal spasm
Psychological background
Diagnosis of Dyspepsia
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Good history & physical
Alarming symptoms
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Wt loss
Dysphagia
Anemia
Nocturnal pain
Endoscopy
Serology for H.pylori
Trial of therapy
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Motility-like dyspepsia
Reflux-like dyspepsiaq
Ulcer-like Dyspepsia
Therapy for Dyspepsia
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Reassurance
Change in life style
Trial of therapy:
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Anti-acid
PPI
Prokinetics
Antideppressants
Psychotherapy
conclusion
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Although bulking agents are effective for the treatment
of constipation and loperamide is effective for the
treatment of diarrhea, neither agent is effective for the
treatment of IBS, Therefore, these medications cannot
be recommended as first-line therapy for IBS
These agents have not been shown to be effective for
improvement in individual IBS symptoms of abdominal
discomfort or bloating.
These agents were ineffective for improvement in global
IBS symptom
Conclusion cont´d
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Tegaserod is the only currently available US Food and
Drug Administration-approved agent for the treatment of
IBS with constipation
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TCAs may be beneficial for the improvement of
abdominal discomfort
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Patients with IBS who do not have alarm symptoms
should not undergo multiple diagnostic tests.
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Alosetron is approved by the FDA for the treatment of
women with severe IBS with diarrhea that has failed to
respond to conventional therapy
Therapy of IBS
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Antispasmodic Agents
Only 3 randomized, controlled trials
(dicyclomine and hyoscyamine)
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Only 1 of these trials demonstrated beneficial effects
side effects in 80%
available evidence does not support the efficacy of
antispasmodic agents for the management of IBS.
Thankyou
Bulking Agents
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Good treatments for constipation
Improve the frequency and form of bowel
movements in constipated patients
Do not improve global IBS symptoms,
abdominal discomfort or bloating
Antidiarrheal Therapy
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3 poorly designed randomized, controlled
trials examining the efficacy of loperamide
for the treatment of IBS.
loperamide is a very effective therapy for
diarrhea,
no effect on the abdominal discomfort and
bloating
No effects on global IBS symptoms
Antidepressant Agents
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Six randomized, controlled trials examining the
efficacy of tricyclic antidepressants (TCAs) at low
dose
not well designed
conflicting evidence for improvement of
abdominal pain
No efficacy of these agents for global IBS
symptom improvement.
should be used with extreme caution in patients
with IBS with constipation.