Irritable Bowel SyndromeA functional or an organic condition?Ferrara, September 27th, 2014Reinhold W. StockbruggerEm. Prof. Gastroenterology and Hepatology, University Maastricht/NLContract Prof. Internal Medicine, University Ferrara/IEditor European Journal of Gastroenterology & Hepatology

rstockbrugger635@gmail.com

What is a functional condition?? I do not function ?? It functions me ?? Am I healthy ?? Sick leave for functional disorders ?? Do I need a psychologist ?? Or a pension ?? Why has the doctor said that that (s)he cannot help me? I think (s)he does not function !!!

RS: body + soul?Fortunately much more!My parents (or the lack of them)The alcoholThe politicsThe bugsMy bossThe weatherThe fast and slow foodThe sexThe moneyThe musicThe diabetesThe sportsThe future and the anxiety

IBS Critical Review 2014

epidemiology

etiology, pathogenesis

clinical presentation and diagnosis

treatment

outcome

future needs

The IBS Manual, 1999Copyright 1999 Harcourt Publishers Limited

Prevalence of IBS in community-based populations

Fig 2.4

IBS EpidemiologyIn Northern GreeceKatsinelos et al. Eur J Gastroenterol Hepatol 2009; 21: 183-9

Setting: Primary Care, 2004 - 2007N= 2397 (f: 70.6%; mean age 46.1 years)

IBS in 15.7% (D-IBS 36.5%; C-IBS 44.2%; M-IBS 19.3%)

IBS patients more likely to be:femalefrom urban areas

IBS EpidemiologyIn Asia

Gwee et al. J Gastroenterol Hepatol 2009; 24: 1601-7

Early studies: prevalence

IBSEtiology, pathogenesisThe times, they are changing

1980 Motility1990 Psychology2000 Microbiology Neurophysiology2009Motility, Metabolism, Diet2014FODMAPs (Fermentable Oligosaccharides Disaccharides Monosaccharaides And Polyols)

The Newcomer: FODMAPsA diet low in FODMAPs reduces symptoms of Irritable Bowel SyndromeHalmos E.P. et al. Gastroenterology 2014; 146: 67 75

High FODMAP food (things to avoid / reduce)Vegetables and LegumesGarlic avoid entirely if possibleOnions avoid entirely if possibleArtichokeAsparagusBaked beansBeetrootBlack eyed peas For this you really could need a dietician!Broad beansButter beans CauliflowerCelery greater than 5cm of stalkKidney beansLeeksMange ToutMushroomsPeasFruit fruits can contain high fructose + other 121 items!ApplesApricotsAvocadoBlackberriesCherriesCurrantsDatesGrapefruitLycheeMangoNectarinesPeachesPearsPersimmonPlumsPrunesRaisinsTinned fruit in apple / pear juiceWatermelonCereals, Grains, Breads, Biscuits, Pasta, Nuts and CakesWheat containing products such (be sure to check labels):BiscuitsBreadcrumbsCashewsCakesEgg noodlesRegular noodlesPastriesPasta made from wheatUdon noodlesWheat breadWheat cerealsWheat rollsBarleyBran cerealsCouscousPistachiosRyeSemolinaSweets, Sweeteners and SpreadsAgavaeFructoseHigh fructose corn syrup (HFCS)HoneyMilk chocolateSugar free sweetsInulinIsomaltMaltitolMannitolSorbitolXylitolPrebiotic FoodsThe follow items can be added to yoghurts, snack bars etc:FOS fructooligosaccharidesInulinOligofructoseDrinksBeer if drinking more than one bottleDandelion teaFruit and herbal teas with apple addedOrange juice in quantities over 100mlRumSugar free fizzy drinks such as diet cokeSports drinksWine if drinking more than one glassDairy FoodsButtermilkCream cheeseCreamCustardIce creamMargarineMilk cow, goat and sheepSour creamYoghurt including greek yogurt

Diet and IBS

Fig 6.3

COLONIC FERMENTATION

Hypothesis: Is over-eating one further cause of increasing IBS in the wealthy part of the Western world?

Entrez PubMed: irritable bowel syndrome + diet: 150 hits

www.google.com: irritable bowel syndrome + diet: 46.100 hits

A pleasant Limburgian gentleman!

Mr. Alphonse de X., date of birth 1934, a retired official of the Limburgian provincial government is happily married and calls himself a gourmet. He consults 1/1999: occasional nausea, abdominal cramping, heartburn, intermittend diarrhoea of watery to porridgy consistency with urgency

Previous history: Guillain-Barres disease, completely recovered. 1987 possible cardiac infarction; stopped smoking at a weight of 82 kg at a length of 1.84 m (BMI 24.2). After that (and retirement!) weight increase to 102 kg. Family history: CRC in 2 first-degree relatives; several colonoscopies without pathological findings

Examination: BMI 30.1; 102 kg; serum triglycerides 2.37 mmol/l.

What does Alphonse suffer from? What diagnostic steps are You taking?

72-hour faecal collection some days later:

faecal mass (g)312428157

faecal fat (g)65.3 per 72 hours

chymotrypsin U/g19.840.220.1

osmotic gap (mosmol/kg)150240 64

Your diagnosis? Your treatment?

Alphonse, two years after: no symptoms, 94 kg = BMI 27.7

72-hour faecal collection 12/2000

faecal mass (g):144212 222

faecal fat (g):25 g per 72 hours

chymotrypsin (U/g)18.417.6 16.4

osmotic gap (mosmol/kg) 00 18

Au revoir, Alphonse?

Post-infectious IBS7-30 % of patients with a proven bacterial gastroenteritis will develop IBS. Definition:PI-IBS is an acute Rome II criteria positive IBS developing after an infectious illness, characterised by two or more of the following:

-fever-vomiting-acute diarrhoea-positive stool culturePI-IBS: clinically distinct subgroup characterized by more diarrheal symptoms, less psychiatric illness, and increased serotonin-containing Enterochromaffin cells (EC cells) compared to those with nonPI-IBS.

unlike most other IBS there is a clearly defined start date

The pathogenesis of post-infectious Irritable Bowel Syndrome:

Inflammation increased production of serotonin by EC cells impairment of expression of SERT impaired clearance of serotonin from the gut

Consequences:- enhanced motility- increased intestinal permeability- increased sensitivity

Gut. 2002 Sep;51(3):410-3.Prognosis in post-infective irritable bowel syndrome: a six year follow up study.Neal KR, Barker L, Spiller RC.

IBS and the diagnosispositive diagnostic criteriavs.exclusion diagnosis?

WRONG QUESTION:DIAGNOSIS IS ABOUT PROBABILITIES!

Twelve key clinical questions have been suggested by Drossman to be asked during a first consultation to help to determine the nature of the condition and to help plan management. These include questions about the type of pain experienced by the patient and its history, the patients understanding of the illness, and the possible involvement of psychological and psychosocial factors. Other questions to be asked include the effect the disorder is having on the daily physical, psychological, and social activity of the patient and the reason for the patients visit or referral.Reasons for the visit may include a worsening of functional status or new circumstances exacerbating the condition e.g. a change in diet or a concurrent medical disorder; concerns about having a serious disease; stress-related factors; a psychiatric co-morbidity such as depression or anxiety; impaired daily function e.g. recent inability to work or to socialise; a hidden agenda e.g. laxative abuse, to obtain narcotics, to gain disability benefits or the justification of illness to family or co-workers; or any combination of these. The physician may also have to consider referral, perhaps because a colonoscopy or other procedure is required to complete an evaluation or because additional assessments are needed (e.g. psychological or psychiatric).

References:Drossman DA. Diagnosing and treating patients with refractory functional gastrointestinal disorders. Ann Intern Med 1995; 123: 688-97.Drossman DA, Whitehead WE, Camilleri M. Irritable bowel syndrome: A technical review for practice guideline development. Gastroenterology 1997; 112: 2120-37.

MY WAY:

The IBS Manual, 1999Copyright 1999 Harcourt Publishers Limited

Time heals everything

Fig 1.12

IBSClinical presentation and diagnosisTo consider (depending on history, physical and mental examination, basic lab, and environment):

Postinfectious IBS (onset!)Lactose intoleranceOther nutritional causes (fructose, BMI)Chronic parasitic infectionInflammatory Bowel DiseaseEarly childhood traumaPsychosocial stress/events (chronic > acute)

IBSClinical diagnosisUseless:

Genetic testingExplorative allergy testingExtended microbiology of the faecesSophisticated motility tests (barostat)Primary psychiatry consultation

IBSClinical presentation and diagnosisUseful:

- Comorbidity (fibromyalgia; dyspepsia; dysuria; etc)- Assessment anxiety and depression (HADS)- Assessment Health-Related Quality of Life (HRQoL)

Relation between concurrent anxiety and/or depression and SF-36Mean scoreSF-36 subscales

Grafiek3

82.05178.52970.341

68.84658.40328.409

58.08753.15146.258

65.63555.26942.33

63.35951.38734.831

80.70567.96250.843

86.49669.11826.136

78.52361.79842.292

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A0D082.05168.84658.08765.63563.35980.70586.49678.523

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IBSTreatmentIs there a standard treatment for IBS?

NO (and YES)

Overlap FD and IBS

Therapy: the SCEPT concept

Sincerity Compassion Education Patience Time

IBSTreatment, some progress (1) Bijkerk et al. BMJ 2009; 339: b3154

Soluble or insoluble fibre in irritable bowel syndrome in primary care? Randomised placebo controlled trial

Setting: General practice, NetherlandsN= 275Treatment: psyllium 10 g or bran 10 g or placebo 10 gOutcome: psyllium better than both alternatives, with the best symptom reduction after 3 months

IBSTreatment, some progress (2)Simren et al. Aliment Pharmacol Ther 2010; 31: 217-27

Clinical trial: the effects of a fermented milk containing three probiotic bacteria in patients with irritable bowel syndrome, a randomized, double-blind, controlled trial

Setting: outpatientN= 74Probiotic: 2 lactobacilli, 1 bifidobacter, in acidified milkDuration: 8 weeks; weekly assessmentResponse: probiotic 38%, placebo 27% (n.s.); probiotics better in the initial 2 weeks

The last meta-analysisAm J Gastroenterol. 2014 Jul 29. doi: 10.1038/ajg.2014.202. [Epub ahead of print]

Efficacy of Prebiotics, Probiotics, and Synbiotics in Irritable Bowel Syndrome and Chronic Idiopathic Constipation: Systematic Review and Meta-analysis.

Ford AC1, Quigley EM2, Lacy BE3, Lembo AJ4, Saito YA5, Schiller LR6, Soffer EE7, Spiegel BM8, Moayyedi P9

Postinfectious IBSOutcome (1)Good hope:

Jung et al. J Clin Gastroenterol 2009; 43: 534-40The clinical course of postinfectious irritable bowel syndrome: a five-year follow-up study

Setting: Hospital personnel; 5 years after Shigella infection outbreak

N= 119 (Shigella exposed 60; controls 59)

Follow-up at 1, 3, 5 years

Postinfectious IBSOutcome (2)IBS after infection (in %)

TimeShigella +Shigella

1 year13,81.1s.

3 years14.94.5s.

5 years20.812.2n.s.

IBSFuture needs (1)At short term:

Knowledge about causes and natural history

Capacity to apply a bio-psycho-social model to diagnosis, therapy and follow-up (SPECT)

Patient-orientated healthcare organisation

More public information about functional gastrointestinal disorders and their comorbidity

IBSFuture needs (2)At longer term, individualised care:

Markers for the pathogenetic contribution of Central and Peripheral Nervous System, gut flora and immune system, as well as for the psycho-social risks factors

Drugs and clinical techniques that can interfere at central, intermediate and/or peripheral levels

There is always hope!

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