1 ibs dr. matt w. johnson bsc mbbs mrcp md. 2 l&d

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  • Slide 1
  • 1 IBS Dr. Matt W. Johnson BSc MBBS MRCP MD
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  • 2 L&D
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  • 3 Graham Hollands the optimism and the frustration of living in a metropolis
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  • 4 IBS is a Diagnosis of Exclusion......or is it ? If in doubt go see your local Shamen..occasionally they come to see you
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  • 6 British Society of Gastroenterology Guidelines 2000
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  • 7 IBS 9-12% of adult population 40-60% of all Gastro OPA referrals 1M : 2.5F Aetiology Psychological (Increased incidence of Psych Hx) Stress (ppt in 50%) Post infective(ppt in 10-20%) Consulting behaviour / Abnormal illness behaviour Gut motility(no consistent evidence) Visceral hypersensitivity Diet (lactose + wheat intolerance)
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  • 8 IBS Rome Criteria 3 3m of Abdominal Pain / Discomfort Associated with 2 of 3 Altered frequency Altered consistency Improves with defaecation
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  • 9 IBS - Associated symptoms Tiredness / lethargy Poor sleep Backpain Fybromyalgia Urinary urgency and frequency Dysguesia - Unpleasant taste in mouth
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  • 10 IBS - Investigation FBC + ESR (1%) TFT (6%) Coeliac (2-15%) Ca + Albumin Stool MCS + COP Faecal elastase US (incidental gallstones and fibroids 8%) Lactose intolerance testing (21-25%) Flexible sig / BaEnema / Colonoscopy SeHCAT scan - Bile acid malabsorption (8%)
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  • 11 Gastro Psychiatrist
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  • 12 IBS Management Positive diagnosis Listen Lifestyle advice Placebo (50%) Dietary advice (exclude lactulose, wheat, caffeine, CHO) Psychological therapies Diagnosis + Psych referral Relaxation, Biofeedback, Hypnotherapy, Cognitive behavioural, Psychotherapy Pharmacological Rx PTO
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  • 13 Give me a Gastro patient that doesnt fit these criteria ! Pancreatic Ca, Crohns stricture, Colonic Ca Rome Criteria 3 - Surely we can all relate personally to these 3m of Abdominal Pain / Discomfort Associated with 2 of 3 Altered frequency Altered consistency Improves with defaecation But what about bloaty woman, I hear you cry ?????
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  • 14 Warning - Before you diagnose someone with IBS - be aware Ford AC. ArchIntMed 2009 4.1% of all IBS = Coeliac disease Garcia-Rodriguez LA. ScanJGastro. 2000: 35; 306 IBS patients have a 6x risk of Ca in 1st year IBS patients after 5y have >20x risk of CrD Hamilton W. BMJ. 2009: 339 2.5% Ovarian Ca present with bloating
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  • 15 IBS Facts Google = 6.5 million entries for IBS Heaton. GUT. 1992 Only 58% of normal pop conformed to producing normal stool on Bristol Stool Chart Piessevaux. DDW. 2009 80% of Belgiums have lower GI symptoms 10% reach IBS criteria
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  • 16 New IBS referral What does it mean to me? Could be anything gastroenterological, that hasnt yet been given a label
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  • 17 IBS - Is there better terminology to explain what we mean? Non-organic disorder or Functional bowel symptoms (FBS) My preference
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  • 18 The Secret of Treating IBS / Functional Bowel Syndrome Dont treat the symptoms - Treat the root cause
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  • 19 Functional Bowel Syndrome What are the main symptoms 1) Chronic Diarrhoea (rare) 2) Classic Constipation 3) Constipation Cycle Functional Bowel Syndrome (C-IBS) Diverticulosis, Coeliac Right sided faecal loading 4) Pain Faecal loading (Left Vs Right or Pan-colonic) Bloating / Aerophagia 5) Bloating
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  • 20 1) Chronic Diarrhoea
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  • 21 Probably not the healthiest curry house in town
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  • 22 D-IBS > 3x/d Fernandez-Banares F. AmJGastro. 2007: 102; 2520 62 Colonoscopy -ive patients 82% had an underlying diagnosis Coeliac + sb Crohns Lactose + Fructose intolerance Small bowel bacterial overgrowth Bile acid malabsorption Pancreatic insufficiency 18% had functional IBS (?psych / PI-IBS)
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  • 23 Post-Infectious IBS Meta-analysis = 5-10% develop PI-IBS Halvarson AmJG. 2006; 101: 1994 Campylobacter - 27% Parry S. AmJGastro 2003:98;1970 Salmonella - 18% Mearin F. Gastro. 2005: 129; 98 E.coli - (63% with ETEC/EATC) 18% of these suffered IBS after 6m Okhuysen PC AmJGastro. 2004:99;1774
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  • 24 Chronic Diarrhoea All patients need to be actively investigated All patients should be referred to a gastroenterologist NB- IBS symptoms can still be experienced in patients with organic disease 60% of UC patients 39% of CrD patients Keohane J. AmJGastro. 2010: 105; 1788
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  • 25 2) Left sided Constipation 1) LIF pain (exclude DD) 2) Reduced frequency 3) Harder consistency with Straining +/- Haemorrhoids or Fissure Mx 1) Increase fluid intake >2L/day 2) High fibre diet (not if DD present) 3) Laxatives 4) Stimulants
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  • 26 Some slides have be borrowed with kind regards to;- Dr. Anton Emmanuel of UK/BU/RES/11/0051n Date of preparation: September 2011 and also to the SHIRE Team and the Advanced Constipation Training Course
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  • 32 3) Constipation cycle functional bowel syndrome - Proximal / Right sided faecal loading 1) Altered bowel habits = Hard pellets + episodic loose 2) Bloating / Flatulence / Borborygmi 3) Sense on incomplete emptying 4) Straining +/- Haemorrhoids Mx 1) Increase fluid intake >2L/day 2) Low residue (high soluble fibre) diet 3) Osmotic agents (Movicol) +/- Laxatives 4) Stimulants +/- 5HT4 agonists (Prucalopride)
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  • 33 Right sided faecal loading
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  • 43 4) Abdominal Pain
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  • 44 Abdominal Pain a) Faecal Loading Left sided Right sided Pan-colonic b) Diverticulosis c) Bloating Aerophagia
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  • 45 Bloating
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  • 46 3 Main Causes 1) Air swallowed = Aerophagia 2) Gas production = SBBO 3) Air trapped = Faecal Loading Mx 1) Awareness / Exercise / Positional deflation /Anti-anxiety agents 2) H2 Lactulose breath test + Abs 3) Rx to soften and shift the bowel
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  • 47 Aerophagia
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  • 48 One remedy
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  • 49 Low FODMAP Diet FODMAPs = Fermentable Oligo-, Di-, and Mono-saccharides, And Polyols. Typical symptoms would include abdominal bloating excessive gas chronic diarrhea or constipation Strict FODMAP avoidance
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  • 50 Low FODMAP Diet
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  • 53 Algorithm for chronic constipation 35 1. Camilleri & Bharucha. Gut 2010;59(9):1288-96
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  • 54 Diverticulosis
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  • 55 Complications Bleeding (15%) 40% of all LGIBleeds Assoc colitis Stricture Obstruction Diverticulitis inflammation itis Fistula Sepsis Perforation
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  • 56 DD Re-Bleeding Rates Year Percentage 1 9% 210% 319% 425% 1 Longstreth Am J Gastro 1997
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  • 58 Use of surrogate markers of inflammation and Rome criteria to distinguish organic from non- organic intestinal disease Tibble J. Gastro. 2002; (123): 450-460 602 new referrals with bowel symptoms All patients had FC, intestinal permeability studies and either Ba enema or colonoscopy 263 had organic disease, 339 diagnosed with IBS FC OR=27.8 p
  • 60 Can FCalp reduce unnecessary colonoscopy in IBS Whitehead SJ. GUT. 2010; (59): A36 2419 patients 1750 -ives 669 +ives (FC > 50mcg/g) = 58% pathology Cheaper + more effective at differentiating between IBS and IBD Same price as doing a ESR + CRP
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  • 61 Graham Hollands Vision of Luton
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  • Further Information www.drmattwjohnson.com Oesophageal Laboratory Small bowel capsule enteroscopy Faecal calprotectin IBD-SSHAMP Spire - 07889 219806 L&D - 01582 497242
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  • 63 Learning objective 1 Tests expected pre-referral FBC + ESR (1%) TFT (6%) Coeliac (2-15%) Ca + Albumin Stool MCS + COP Consider AXR Pelvic US Faecal Calprotectin
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  • 64 Learning objective2 European Constipation Treatment Algorithm
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