Irritable Bowel Syndrome Do you have recurrent abdominal pain or discomfort? Do you often feel bloated? Are you frequently constipated? Do you have frequent diarrhea? Have you talked to your doctor?

What is irritable bowel syndrome (IBS?) What are the symptoms of IBS? What causes IBS? How is IBS diagnosed? What is the treatment for IBS?

What is irritable bowel syndrome? Irritable bowel syndrome (IBS) is chronic functional bowel disorder with usually prolonged history (persist 12 weeks out of 12 months) characterized by constellation of symptoms that occur when the nerves and muscles in a person's bowel (the colon, or large intestine) do not work like they should. With IBS, a person's bowel is extra sensitive, causing discomfort and changes in bowel activity . .

Epidemiology: As many as 20 percent of the adult population, or one in five Americans, have symptoms of IBS, making it one of the most common disorders diagnosed by doctors. It occurs more often in women than in men, and it begins before the age of 35 in about 50 percent of people. Studie suggest that those who seek care are more likely to have behavioral and psychiatric problems than those who do not seek care.

IBS is the most common cause of : Gastrointestinal referral Accounts for frequent absenteeism from work. Impaired quality of life .

What are the symptoms of IBS? Recurrent crampy abdominal pain or discomfort for at least 12 weeks out of the previous 12 months. These 12 weeks do not have to be consecutive. -

Sensation of incomplete evacuation Abdominal bloating and distension -Altered bowel habit ( diarrhea only , constipation only or combination ) *Diarrhea-predominant IBS is characterized by diarrhea which occurs immediately after waking up or immediately after eating. Other common symptoms include pain, bloating, urgency, and urinary incontinence. *Constipation-predominant (or 'spastic colon' type) IBS manifests with pain over at least one area of the colon and periodic constipation. This pain may be continuous or it may come in bouts, and is frequently relieved by moving the bowels. There may be constipation alternating with normal stools or constipation alternating with diarrhea. . Eating can commonly trigger these symptoms. Sensation of incomplete evacuation Abdominal bloating and distension Rectal mucus (without bleeding ) -pt look well and healthy , they don’t lose weight ,not complaint of fever or presistent severe pain (If these symptoms are present YOU have to think of another problems like inflammation or rarely cancer)

What causes IBS? Researchers have yet to discover any specific cause for IBS. One theory is that people who suffer from IBS have a colon, or large intestine, that is particularly sensitive and reactive to certain foods and stress. The immune system, which fights infection, may also be involved.

Normal motility, or movement, may not be present in the colon of a person who has IBS. It can be spasmodic or can even stop working temporarily. Spasms are sudden strong muscle contractions that come and go. The lining of the colon called the epithelium, which is affected by the immune and nervous systems, regulates the flow of fluids in and out of the colon. In IBS, the epithelium appears to work properly. However, when the contents inside the colon move too quickly, the colon loses its ability to absorb fluids. The result is too much fluid in the stool. In other people, the movement inside the colon is too slow, which causes extra fluid to be absorbed. As a result, a person develops constipation. A person’s colon may respond strongly to stimuli such as certain foods or stress that would not bother most people Abnormal visceral sensation Luminal factors : following episods of gastroentritis or intolerent of spesfic diatery component (lactose and wheat)

Predisposing factors; -low fiber diet . -emotional stress. Use of laxative . Infectious diarrhea. A comprehensive reading of the literature suggests that the major predisposing factors to IBS may be interactions between genetic weaknesses, nutrient deficiencies and environmental toxins resulting in dysfunctional cellular structures and function, not only in the gut but quite possibly in the brain.

How is IBS diagnosed? Pt history Clinical examination Dignostic criteria

Physical Examination: Usually normal May include: -Abdominal bloating Variable tenderness to palpation.

Investigations: Investigations are normal Young pts with classic symptoms do not requires investigations CBC, ESR and Sigmoidoscopy are usually done routinely. Barium enema or colonoscopy should only be done in older pts to exclude colorectal CA , and in all pts with a Hx of rectal bleeding to exclude colonic CA or inflammatory bowel disease .

Treatment Investigation Disease Anti-inflammatory drugs ,immunsuppresion,corticosteriod Stool culture, Endoscopy,Barium,rectal biopsy inflammatory bowel disease Gluten –free diet +/- corticosteroid IgA antiendomysial Ab Malabsorption (coeliac disease). High fiber diet, antibiotic ,IV antibiotic Rectal exam,stool analysis,blood test Diverticular disease Pancreatic enzymes,dec fat Endoscopic ultrasound, MRCP Chronic pancreatitis Treat underlying cause TFT Thyrotoxicosis Nuterion support,IV HYDRATION,antibiotic c/s, ova and cyst, Rota virues Infective enteritis AVOID DAIRY PRODUCTS XYLOSE TEST Lactose intolerance H2R B,PPI ,ANTACIDES,SURGICAL GASTROSCOPY Duodenal ulcer Surgical bypass Angiography ,MRA, Chronic mesenteric ischemia CHEMOTHERAPY+/SURGERY TUMOR MARKERS,COLONOSCOPY=BIOPSY Colon cancer in old age

-onset of pain linked to more frequent bowel movements Dignostic criteria : -Manning criteria : -onset of pain linked to more frequent bowel movements -looser stool associated with onset of pain . -pain relived by passage of stool . -noticeable abdominal bloating . -sensation of incomplete evacuation more than 25% of the time. -Diarrhea with mucous more than 25% of the time.

Rome I criteria: 3months of continuous or recurring symptoms of abdominal pain or irritation that: -may be relived with a bowel movement -may be coupled with a change in frequency -may be related to a change in the consistency of stools ***tow or more of the following are present at least 25% of the time : -change in stool frequency (more than 3 bowel movement per day or fewer than 3 bowel movements per week) -noticeable difference in stool from (hard , loose and watery stools or poorly formed stools) -passage of mucous in stool -bloating or feeling of abdominal distension -altered bowel passage

-relief by defecation Rome II criteria: At least 12 weeks (which need not be consecutive) in preceding 12 months of abdominal discomfort or pain with tow of 3 features: -relief by defecation -When it starts, there is a change in how often you have a bowel movement. -When it starts, there is a change in the form of the stool or the way it looks.

Management: Reaaaurance : -Decrease anxiety Counseling: -Explain that symptoms are not due to organic diease but are the result of altered bowel motility and sensation -Discussion of lifestyle and diet. Counseling: 1-Diet: -Increase fibers in your diet -Drink plenty of water . -Avoid food that makes you feel worse (fatty food, caffeine ,alcohol,choclate,,,,est) -Eat smaller but more frequent meals (example:6 small meals instead of 3 large ones ). 2-Life style: -regular exercise -Avoid stress

3-Your disease is not curable but manageable . 4-there is recurrence but your disease is not getting worse ,will not convert to cancer and you will not need any surgical intervention . 5- avoid laxatives as they worse your condition. Prognosis: IBS is chronic ,relapsing , and life-long disorder Symptoms can be improved or relived through treatment

References: Davidson principle and practice of medicine Medstudy –internal medicine review gastroenterology) http://www.aafp.org American academy of family physician http://digestive.niddk.nih.gov/ddiseases/pubs/ibs/ digestive disease home http://en.wikipedia.org/wiki/Irritable_bowel_syndrome http://www.nlm.nih.gov/medlineplus/irritablebowelsyndrome.html Medline plus