Dr Yoon-Kyo An

Gastroenterologist

Holistic approach to IBS & Food Intolerance

Bridges Gastroenterology

Dr Jakob Begun Dr Yoon-Kyo An

Dr Paul Clark Dr Marianne Mortimore

Overview

1. Reaching a positive diagnosis of IBS

2. IBS Management algorithm

3. Food intolerance and allergies (coeliac, lactose intolerance, EoE)

4. IBS and Diet – Presentation by Alex Burke (Dietician)

A common presentation

33F, business analyst

6 month history of worsening abdominal pain, bloating and diarrhoea

• Always had gut issues since childhood

• Denies rectal bleeding or nocturnal symptom

• No weight loss

• Certain food can make her symptoms worse but not always – avoiding gluten and lactose

PMH – Anxiety/Depression

FH – None

Promoted in February this year and has been highly stressed out

A little epidemiology...

Prevalence affects “pre-test” probability

• Infectious gastroenteritis → ~100% over lifetime & > 1 episode

• Functional GIDs → ~40% lifetime prevalence

• IBS→ 8-15% point prevalence

• CRC→ 1:12 men & 1:20 women lifetime risk

• IBD→ <1% population

IBS – Rome IV criteria

❑ Recurrent abdominal pain, on average ≥ 1 d/wk in the past 3 mo, related to 2 of the following:

• Defecation

• Change in the stool frequency

• Change in stool form

❑ Criteria should be fulfilled for the last 3 mo with symptom onset ≥ 6 mo prior to diagnosis

Mearin et al (2016) Gastroenterology

Hx:

Initial patient assessments

• Identify symptom triggers (e.g. diet, stress)

• Assess impact on daily life

• Assess for psychological comorbidities

• Assess for other physical comorbidities (e.g. gynae, urological)

• Explore patient’s value and preferences

What is the utility of the physical examination?

• Physical exam usually normal in patients with IBS

❑ Mild abdominal tenderness may be present

❑ Symptoms that suggest other diagnosis

• Fever, weight loss

• Lymph node enlargement

• Abdominal mass, hepatosplenomegaly

• Digital rectal examination

❑ Evaluate for dyssynergic defecation

❑ Rule out rectal cancer

IBS – Limited Screening Tests

• FBC, Albumin, CRP

• Iron studies

• Coeliac serology

• Stool MCS, c.diff toxin

• Faecal calprotectin

IBS/FGIDs Gastroenteritis IBD CRC

Hb Normal Normal Often low Normal/Low

Plt Normal Normal/High High Normal/High

WCC Normal Normal/High High Normal

MCV/MCH Normal Normal Low Normal/Low

CRP/ESR Normal Normal/High High Normal

Ferritin Normal Normal/High High Normal/Low

Albumin Normal Normal/Low Low Normal/Low

Stool infection Negative Positive Negative Negative

Calprotectin Normal Raised Raised Raised

Effectiveness of FC to identify patients with OGIDs

• Meta-analysis on the diagnostic accuracy of faecal calprotectin to distinguish between organic and functional gastrointestinal diseases

• 18 studies (n=8150 patients)

• Diagnostic accuracy using FC cut-offs of 50 vs 100: non-significant (p=0.77)

• 1% prevalence: PPV 4.2%; NPV 100%; 0.1% prevalence PPV 4.2%; NPV 100%

YK An, J Begun et al (2019) MJA

Accuracy OGID v FGID IBD v FGID OGID or IBD v FGID

Sensitivity (95% CI) 81% (74–86%) 88% (80–93%) 80% (73–85%)

Specificity (95% CI) 81% (71–88%) 72% (59–82%) 81% (70–86%)

Log diagnostic odds ratio (95% CI) 3.0 (2.4–3.6) 3.2 (2.5–3.9) 3.1 (2.5–3.6)

Area under the curve 0.87 0.89 0.86

To scope or not to scope?

• In general, reserve colonoscopy for

• One or more alarm features

• Persistent non-response to symptom directed therapies

• Chronic persistent diarrhoea

• No support for structural colonic abnormalities being higher in IBS than in healthy persons (Chey et al, 2010)

• Value of routine colonoscopy & bx to exclude microscopic colitis in patients with typical IBS symptoms and no alarm features remain uncertain

• Endoscopic investigations performed in 79% FGiD vs 63% OGiD (Linedale et al, 2016)

Simplified algorithm for IBS diagnosis

IBS Sub-types

❑ IBS-C: Constipation-predominant

❑ IBS-D: Diarrhoea-predominant

❑ IBS- M: Mixed – alternating between diarrhoea and constipation

Linedale EC, Andrews JM (2017) MJA

IBS – Communicating the IBS Dx to Patient

Problem

• Drs don’t make a proactive positive dx

• Drs don’t communicate the dx well• Letter audit showed organic dx “X has IBD/PUD”; functional dx “X possibly, may, have sx

consistent with”

• Only 1/13 patients owned/acknowledged their functional GIDs, despite all having a clearly documented functional GIDs Dx

Pathogenesis of IBS - Multifactorial

1. Altered motility

2. Visceral hypersensitivity

3. Alteration in the gut-brain axis

4. Altered microbiome composition/

small intestinal bacterial overgrowth

5. Low grade inflammation

6. Altered gut permeability

Pathogenesis of IBS - Triggers

1. Infection – persistent bowel symptom post gastroenteritis

2. Food intolerance – e.g. lactose, fructose or sorbitol

3. General diet – e.g. low fibre diet can exacerbate constipation

4. Stress – strong emotions can affect the nerves of the bowel in susceptible people

5. Medications – e.g. antibiotics, antacids, pain killers

IBS Management Algorithmgesa.org.au/resources

IBS – Lifestyle and dietary modification

• Food is a common trigger for IBS symptoms

• Healthy eating habits – e.g. modifying the alcohol intake, fat and spicy food

• Remove trigger foods & Re-introduce “trigger” foods in a controlled manner

• Low FODMAP diet – overseen by dietician

• Certified dietician: healthcert.com

• Exercise!!

• Pelvic floor physiotherapy

IBS – Psychological therapy

• FGiD are associated with psychological morbidity (80%)

• Psychologically based therapies provide long term improvement in

these disorders

• Early life risk factors for IBS

• Physical and psychological childhood trauma

• Learned illness behaviour

• Chronic pain = Trauma

IBS – Psychological therapy

• Psychoeducation/ stress mx (SM)• Problem solving, relaxation, breathing, autogenic training, coping techniques,

exercise, self-care, diet, progressive muscle relaxation

• Behavioural therapy (BT)• Controlled breathing and relaxation training

• Biofeedback (BF)• A process enabling an individual to learn how to change physiological activity

for the purpose of improving health and performance

• Hypnotherapy (HYP)• Hypnotic induction and suggestions

IBS – Pharmacotherapy

Placebo works!15-72% response

IBS – Pharmacotherapy

Regulating bowel motion!

Constipation

• Water-soluble Fibre 20-30g/day

• Laxative

• Prokinetics: Prucalopride 2mg (not in IBS but in chronic constipation)

Diarrhoea

• Loperamide 2-4mg up to QID

• Cholestyramine 4g 1-6x/day

• Rifaximin 440mg TDS for 14 days

• Pancreatic enzyme ?benefit

IBS - Pharmacotherapy

Abdo pain

• Antispasmodics – hyoscine and peppermint oil capsules

• Herbal preparation STW5 (Iberogast)

• Antidepressant

• IBS-D: TCAs as it increases colonic transit time (amitriptyline 10mg nocte, titrate up)

• IBS-C: SSRIs due to prokinetic effects (citalopram or fluoxetine 20mg daily)

Bloating

• Treat constipation

• Low-FODMAP diet

• Rifaximin 440mg TDS for 14 days

• Probiotic

Food intolerance

• Food intolerance is the general term used to describe a range of adverse responses to food including allergic reactions (e.g. peanut allergy, coeliac disease), adverse reactions (e.g. those resulting from enzyme deficiencies such as lactose intolerance).

• Food allergy can be described as an inappropriate reaction by the body's immune system to the ingestion of a food.

• Any food has the potential to cause an adverse reaction. Foods that commonly induce adverse reactions include milk, gluten containing cereals, nuts, peanuts, eggs and shellfish.

Coeliac disease

• An autoimmune disease; it is the main form of wheat intolerance

• Common - affects 1/100 people, but only 24% diagnosed

• Symptom: range from mild to severe (can be similar to IBS)

• Diagnosis:

1. Gluten challenge

2. Blood test (tTg-IgA, DGP-IgG, HLA-DQ2/8 genotyping)

3. Small bowel biopsy (villous atrophy)

• Treatment: strict gluten-free diet (wheat, barley, rye, +/- oats)

• Test for any vitamin or mineral deficiencies or associated conditions

Lactose intolerance

• Northern European – 5% prevalence

• Black and Asiatic communities – up to 100% prevalence

• Lactase deficiency → lactose (milk sugar) stays in the digestive system where it is fermented by bacteria.

• Symptom: flatulence, bloating, diarrhoea (similar to IBS)

• Management: Limit dairy products

• Mild intolerance →moderating milk intake, taking milk with meals, fermented dairy over fresh dairy (live yogurts),

• Hard cheese (cheddar, Edam) contains very little or no lactose

• Calcium supplements: vegetable, canned fish, soya products, bread

Eosinophilic Eosophagitis

Strong association with allergic conditions (e.g. food allergies, asthma, atopic dermatitis)

Symptoms: food bolus, swallowing difficulty, heartburn, abdo pain

Diagnosis: >15 eosinophils per high power field

Management:

• Diet – 6 food elimination (diary, wheat, egg, soy, nuts, seafood)

• PPI – standard dose for 8 weeks & assess (50% response)

• Fluticasone – 250-500mcg OD or BD

• Budesonide slurry 1mg OD

IBS and Diet

Alexandra Burke, APD

Gastroenterology Dietitian

OverviewCoeliac disease Eosinophilic Oesophagitis

(EOE)IBS

Constipation

Diarrhoea

FODMAPs

Mechanisms of some food induced symptoms

De Giorgio et al. Gut 2016

• What does a dietitian provide• Education and support

• Assess diet carefully

• Label reading

• Cross-contamination, food preparation, eating out

• Coexisting conditions

• Coeliac Society• https://www.coeliac.org.au

Coeliac Disease

Shepherd, S & Gibson, P. Understanding the gluten free diet for teaching in Australia. Nutrition & Dietetics 2006; 63: 155-165

• Symptoms

• Diet manipulation• 6 food elimination diet

• https://www.allergy.org.au/patients/food-other-adverse-reactions/eosinophilic-oesophagitis

Eosinophilic Oesophagitis (EOE)

Irritable Bowel Syndrome

• Diet• Timing of meals

• Fibre & Fluid

• Fatty/rich foods

• Spicy foods

• Fizzy drinks

• Excessive alcohol

• Caffeine containing drinks

• Excessive fruit intake

• Physical inactivity

• Stress

• Constipation• Fluid – 1.5-2L water or non caffeinated drinks

• Fibre – 25-30g fibre• Fibre supplements

• Physical inactivity

• Positioning and allowing time on the toilet • Squatty Potty

Irritable Bowel Syndrome

X 4

1 cup

• Lactose, Fructans, Galactooligosaccharides, Sorbitol, Mannitol, Fructose• Monash University FODMAPs and IBS video

• 3 out of 4 people improvement in symptoms• Reduce pain and discomfort

• Reduced bloating and distention

• Improved bowel movements

• Improved quality of life

• 4-6 weeks of Low FODMAP diet

• Challenge/Reintroduction Phase

• FODMAP personalisation

FODMAPsFermentable Oligo-, Di-, Monosaccharides and Polyols

• De Giorgio R, Volta U, Gibson PR Sensitivity to wheat, gluten and FODMAPs in IBS: facts or fiction? Gut 2016;65:169-178

• Shepherd, S & Gibson, P. Understanding the gluten free diet for teaching in Australia. Nutrition & Dietetics 2006; 63: 155-165

• https://www.allergy.org.au/patients/food-other-adverse-reactions/eosinophilic-oesophagitis

References

Bridges Gastroenterology

Dr Jakob Begun Dr Yoon-Kyo An

Dr Paul Clark Dr Marianne Mortimore