Irritable Bowel Syndrome: Symptoms, Diagnosis, and Management
1-Abdulelah alqahtani
2-Abdulmajeed almutairi
3- Fahad alamri
CHANGES IN BOWEL MOVMENTS
(
IBS
)
OBJECTIVES:
Define
constipation
and
diarrhea
Discuss the
definition , etiology
and
classification
of IBS
Explain how to diagnose IBS
List the alarm symptoms and differential diagnosis
Provide a management plan and follow up
Recognize when to refer to specialist
MCQ
People with irritable bowel syndrome may
suffer from either constipation only or
diarrhea only
True
False
MCQ
Once other disease condition have been ruled
out, a person can be considered for the
diagnosis of irritable bowel syndrome if the
symptoms were present for the last
A.
One week
B.
One fortnight
C.
One month
D.
Three months
Which of the following is not recognized as a
symptom that supports the diagnosis of IBS
according to the
Rome criteria
?
Altered stool frequency
Mucorrhea
Abdominal bloating or subjective distention
Frequent nausea
MCQ
Which of the following symptoms indicates a need
for laboratory testing or diagnostic imaging in
patients with IBS younger than 50 years?
Iron deficiency anemia
Abdominal pain
Amenorrhea
Hypokalemia
MCQ
bowel movement Disorders
•
Diarrhea
Passage of loose or watery stools, typically at least three
times in a 24-hour period
•
Constipation
Stool frequency of less than three per week
•
Irritable Bowel Syndrome
DIARRHEA
Diarrhea is
defined by the
World Health Organization as having three or
more loose or liquid stools per day, or as having more stools than is
normal for that person
*
Diarrhea is a symptom, not a disease
Acute diarrhea :
is defined as an abnormally frequent discharge of
semisolid or fluid fecal matter from the bowel, lasting less than 14 days,
by World Gastroenterology Organization.
diarrhea
Acute
:
:
is defined as an abnormally
frequent discharge of
semisolid
or
fluid
fecal matter from the bowel,
lasting
less than 14 days
, by World
Gastroenterology Organization
Chronic :
more than 4 weeks.
Causes of diarrhea
•
I
n
f
e
c
t
i
o
n
:
Most common cause
of acute diarrhea
is viral infection (rotavirus
and the
Norwalk
virus
are the most common).
•
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Constipation
Constipation
is a
symptom
, not a disease.
Different patients have different perceptions of symptoms. Some patients
regard constipation as
straining
, while for others, it means
hard, pellet-like
stools
or an
inability to defecate when desired
, or
infrequent defecation
.
Being constipated means your bowel movements are tough or happen less
often than normal.
Causes of Constipation
C
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Or psychological factors like : stress – anixity – fear …
Irritable bowel syndrome
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Present in 10-20% of the population
Twice as common in women compared to men
Most commonly affects people between 20-30 years
Etiology
Etiology
It's not known exactly what causes irritable bowel syndrome, but a variety
of factors play a role.
-
contractions may be stronger and last longer than normal, causing gas,
bloating and diarrhea. Or the opposite may occur
-
Abnormalities in your gastrointestinal nervous system also may play a role
•
Triggers vary from person to person
-
Food
:
is not yet clearly understood, but many people have more severe symptoms when
they eat certain things
.
-
Stress
-
Hormones
:
women are twice as likely to have IBS
Classification of IBS
Four bowel patterns may be seen with irritable bowel syndrome
:
-
IBS-D :
(diarrhea predominant)
-
IBS-C :
(constipation predominant)
-IBS-M :
(mixed diarrhea and constipation)
-IBS-U :
(unclassified; the symptoms cannot be categorized into one of the
above three subtypes)
Diagnosis
•
It is Difficult.
•
It Needs to balance between few and many
investigations.
•
Red flag symptoms should be ruled out.
•
The Diseases that causing similar symptoms should
ruled out.
Rome IV Ibs Criteria
According to
the Rome IV criteria
,
IBS
is
defined as
recurrent abdominal pain, on average, at least one day
per week in the last three months, associated with two
or more of the following criteria:
Related to defecation
Associated with a change in stool frequency
Associated with a change in stool form (appearance)
Diagnosis (NICE Guidelines)
Irritable bowel syndrome should be
considered
if an adult presents with abdominal pain or
discomfort, bloating or a change in bowel habit for
at least 6 months
.
A diagnosis should be considered only if the person has
abdominal pain or discomfort
that is
either
relieved by
defecation or is associated with altered bowel frequency or stool form. This
should be accompanied by
at least
2 of the following 5 symptoms
:
altered stool passage
(straining, urgency, incomplete evacuation)
abdominal bloating
(more common in women than men), distension, tension or
hardness
symptoms made worse by eating
passage of mucus
.
Lethargy, nausea, backache and bladder symptoms
are also common in people
with irritable bowel syndrome, and may be used to support the diagnosis.
Alarming Symptoms !!!
Unintentional and unexplained weight loss.
Rectal bleeding.
A family history of bowel or ovarian cancer.
In people aged
over 60
, a change in bowel habit lasting
more than 6 weeks
with looser
and/or more frequent stool.
Anemia.
Abdominal masses.
Rectal masses.
Physical Examination
•
anaemia
•
abdominal masses
•
rectal masses
Abdominal examination
I
n
s
p
e
c
t
i
o
n
Bloatness
P
a
l
p
i
t
a
t
i
o
n
Organmegaly
masses
Rectal
Percussion
Auscultation
Bowel movements
investigations
inflammatory markers
for inflammatory bowel disease.
In addition, women with symptoms that suggest
ovarian cancer should have their serum
CA125 measured
.
When the above have been excluded, the following tests
should be done
to exclude other
diagnoses:
•
full blood count
•
erythrocyte sedimentation rate (ESR) or plasma viscosity
•
C reactive protein (CRP)
•
antibodies for coeliac disease (endomysial antibodies [EMA] or tissue
transglutaminase [TTG]).
investigations
T
h
e
f
o
l
l
o
w
i
n
g
t
e
s
t
s
a
r
e
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b
l
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b
o
w
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l
s
y
n
d
r
o
m
e
:
•
ultrasound
•
rigid/flexible sigmoidoscopy
•
colonoscopy, barium enema
•
thyroid function test
•
faecal ova and parasite test
•
faecal occult blood
•
hydrogen breath test (for lactose intolerance
and bacterial overgrowth).
Management
Patients need “Basic” and “Beyond Basic” education regarding IBS
Help seeking behavior need to be modified to decrease costs spent on acute attacks.
Dealing with symptoms
What are the worrying symptoms?
When to seek help?
E
d
u
c
a
t
i
o
n
Management
Life style
:
Diet:
•
Regular meals
•
Decrease caffeine
•
Increase fiber?
•
Probiotics
•
If persistent
specific food avoidance
- Reduce stress, increase leisure and relaxation time
- Increase physical activity
Management
Pharmacological:
Psychological:
Mainly in refractory IBS
•
Antispasmodics
(otilonium, hyoscine)
•
Constipation
laxatives (osmotic,
linaclotide)
•
Diarrhea
antimotility (loperamide)
•
TCAs
(amitriptyline) or SSRIs
•
Cognitive behavioral therapy (CBT)
•
Hypnotherapy
•
Psychotherapy
Management
In general:
Does not affect quality of life
Diet and life style
changes only
Effects quality of life
Diet, life style changes and
pharmacological therapy
Follow up
•
Agreed between physician and patient.
•
Depends on response of the person’s
symptoms to intervention.
•
‘Red flag’
symptoms should prompt
further
investigation and/or referral to secondary
care.
When to Refer to a specialist?
Refer when there is:
•
More than minimal rectal bleeding
•
Weight loss
•
Unexplained iron deficiency anemia
•
Nocturnal symptoms
•
Family history of Colorectal cancer IBD Celiac disease
MCQ
People with irritable bowel syndrome may
suffer from either constipation only or
diarrhea only
True
False
MCQ
Once other disease condition have been ruled
out, a person can be considered for the
diagnosis of irritable bowel syndrome if the
symptoms were present for the last
A.
One week
B.
One fortnight
C.
One month
D.
Three months
Which of the following is not recognized as a
symptom that supports the diagnosis of IBS
according to the
Rome criteria
?
Altered stool frequency
Mucorrhea
Abdominal bloating or subjective distention
Frequent nausea
MCQ
Which of the following symptoms indicates a need
for laboratory testing or diagnostic imaging in
patients with IBS younger than 50 years?
Iron deficiency anemia
Abdominal pain
Amenorrhea
Hypokalemia
MCQ
Thank You
For Your Attention
Define constipation and diarrhea, discuss the definition, etiology, and classification of IBS, explain how to diagnose IBS, list alarm symptoms and differential diagnosis, provide a management plan and follow-up, and recognize when to refer to a specialist. People with irritable bowel syndrome may suffer from constipation only, diarrhea only, or both. Criteria for diagnosing IBS include the duration of symptoms and certain recognized symptoms. Laboratory testing may be needed in patients with IBS younger than 50 years presenting with specific symptoms.
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Presentation Transcript
CHANGES IN BOWEL MOVMENTS (IBS) 1-Abdulelah alqahtani 2-Abdulmajeed almutairi 3- Fahad alamri
OBJECTIVES: Define constipation and diarrhea Discuss the definition , etiology and classification of IBS Explain how to diagnose IBS List the alarm symptoms and differential diagnosis Provide a management plan and follow up Recognize when to refer to specialist
MCQ People with irritable bowel syndrome may suffer from either constipation only or diarrhea only True False
MCQ Once other disease condition have been ruled out, a person can be considered for the diagnosis of irritable bowel syndrome if the symptoms were present for the last A. B. C. D. One week One fortnight One month Three months
MCQ Which of the following is not recognized as a symptom that supports the diagnosis of IBS according to the Rome criteria? Altered stool frequency Mucorrhea Abdominal bloating or subjective distention Frequent nausea
MCQ Which of the following symptoms indicates a need for laboratory testing or diagnostic imaging in patients with IBS younger than 50 years? Iron deficiency anemia Abdominal pain Amenorrhea Hypokalemia
bowel movement Disorders Diarrhea Passage of loose or watery stools, typically at least three times in a 24-hour period Constipation Stool frequency of less than three per week Irritable Bowel Syndrome
DIARRHEA Diarrhea is defined by the World Health Organization as having three or more loose or liquid stools per day, or as having more stools than is normal for that person * Diarrhea is a symptom, not a disease Acute diarrhea : is defined as an abnormally frequent discharge of semisolid or fluid fecal matter from the bowel, lasting less than 14 days, by World Gastroenterology Organization.
diarrhea Chronic : Acute: more than 4 weeks. : is defined as an abnormally frequent discharge of semisolid or fluid fecal matter from the bowel, lasting less than 14 days, by World Gastroenterology Organization
Causes of diarrhea Infection: Most common cause of acute diarrhea is viral infection (rotavirus and the Norwalk virus are the most common). Malabsorption Lactose intolerance: People who have difficulty digesting lactose have diarrhea after eating dairy products inflammatory bowel disease Medication : antibiotics Irritable bowl syndrome (Ibs)
Constipation Constipation is a symptom, not a disease. Different patients have different perceptions of symptoms. Some patients regard constipation as straining, while for others, it means hard, pellet-like stools or an inability to defecate when desired, or infrequent defecation. Being constipated means your bowel movements are tough or happen less often than normal.
Causes of Constipation Constipation may result from several causes : Poor diet Poor diet - -Inadequate fluid Inadequate fluid intake intake - -Caffeine and Caffeine and alcohol alcohol - Medications Medications - -Intestinal Intestinal obstruction obstruction - -Mechanical problems of the anus and Mechanical problems of the anus and rectum - - rectum Or psychological factors like : stress anixity fear
Irritable bowel syndrome Irritable bowel syndrome (IBS) : Idiopathic Syndrome of Intrinsic Bowel; motility dysfunction and can have both diarrhea ,constipation or both. characterized by recurrent abdominal pain or discomfort at least three days per month in the last three months with two or more of the following: improvement with defecation, onet associated with a change in frequency of stool, or onset associated with a change in form (appearance) of stool. Present in 10-20% of the population Twice as common in women compared to men Most commonly affects people between 20-30 years
Etiology Psychosocial Inflammation Genetics Sensitivity Microflora Alterations Motility Postinfecious
Etiology It's not known exactly what causes irritable bowel syndrome, but a variety of factors play a role. - contractions may be stronger and last longer than normal, causing gas, bloating and diarrhea. Or the opposite may occur - Abnormalities in your gastrointestinal nervous system also may play a role Triggers vary from person to person Food :is not yet clearly understood, but many people have more severe symptoms when they eat certain things Stress Hormones : : women are twice as likely to have IBS - is not yet clearly understood, but many people have more severe symptoms when they eat certain things. - -
Classification of IBS Four bowel patterns may be seen with irritable bowel syndrome: - IBS-D :(diarrhea predominant) -IBS-C : (constipation predominant) -IBS-M :(mixed diarrhea and constipation) -IBS-U :(unclassified; the symptoms cannot be categorized into one of the above three subtypes)
Diagnosis It is Difficult. It Needs to balance between few and many investigations. Red flag symptoms should be ruled out. The Diseases that causing similar symptoms should ruled out.
Rome IV IbsCriteria According to the Rome IV criteria, IBS is defined as recurrent abdominal pain, on average, at least one day per week in the last three months, associated with two or more of the following criteria: Related to defecation Associated with a change in stool frequency Associated with a change in stool form (appearance)
Diagnosis (NICE Guidelines) Irritable bowel syndrome should be considered if an adult presents with abdominal pain or discomfort, bloating or a change in bowel habit for at least 6 months. A diagnosis should be considered only if the person has abdominal pain or discomfort that is either relieved by defecation or is associated with altered bowel frequency or stool form. This should be accompanied by at least 2 of the following 5 symptoms: altered stool passage (straining, urgency, incomplete evacuation) abdominal bloating (more common in women than men), distension, tension or hardness symptoms made worse by eating passage of mucus. Lethargy, nausea, backache and bladder symptoms are also common in people with irritable bowel syndrome, and may be used to support the diagnosis.
Alarming Symptoms !!! Unintentional and unexplained weight loss. Rectal bleeding. A family history of bowel or ovarian cancer. In people aged over 60, a change in bowel habit lasting more than 6 weeks with looser and/or more frequent stool. Anemia. Abdominal masses. Rectal masses.
Physical Examination anaemia abdominal masses rectal masses
Abdominal examination Inspection Bloatness Palpitation Organmegaly masses Rectal Percussion Auscultation Bowel movements
investigations inflammatory markers for inflammatory bowel disease. In addition, women with symptoms that suggest ovarian cancer should have their serum CA125 measured. When the above have been excluded, the following tests should be done to exclude other diagnoses: full blood count erythrocyte sedimentation rate (ESR) or plasma viscosity C reactive protein (CRP) antibodies for coeliac disease (endomysial antibodies [EMA] or tissue transglutaminase [TTG]).
investigations The following tests are not necessary to confirm diagnosis in people who meet the diagnostic criteria for irritable bowel syndrome: ultrasound rigid/flexible sigmoidoscopy colonoscopy, barium enema thyroid function test faecal ova and parasite test faecal occult blood hydrogen breath test (for lactose intolerance and bacterial overgrowth).
Management Education Patients need Basic and Beyond Basic education regarding IBS Help seeking behavior need to be modified to decrease costs spent on acute attacks. Dealing with symptoms What are the worrying symptoms? When to seek help?
Management Life style: - Reduce stress, increase leisure and relaxation time - Increase physical activity Diet: Regular meals Decrease caffeine Increase fiber? Probiotics If persistent specific food avoidance
Management Pharmacological: Antispasmodics (otilonium, hyoscine) Constipation laxatives (osmotic, linaclotide) Diarrhea antimotility (loperamide) TCAs (amitriptyline) or SSRIs Psychological: Mainly in refractory IBS Cognitive behavioral therapy (CBT) Hypnotherapy Psychotherapy
Management In general: Does not affect quality of life Diet and life style changes only Effects quality of life Diet, life style changes and pharmacological therapy
Follow up Agreed between physician and patient. Depends on response of the person s symptoms to intervention. Red flag symptoms should prompt further investigation and/or referral to secondary care.
When to Refer to a specialist? Refer when there is: More than minimal rectal bleeding Weight loss Unexplained iron deficiency anemia Nocturnal symptoms Family history of Colorectal cancer IBD Celiac disease
MCQ People with irritable bowel syndrome may suffer from either constipation only or diarrhea only True False
MCQ Once other disease condition have been ruled out, a person can be considered for the diagnosis of irritable bowel syndrome if the symptoms were present for the last A. B. C. D. One week One fortnight One month Three months
MCQ Which of the following is not recognized as a symptom that supports the diagnosis of IBS according to the Rome criteria? Altered stool frequency Mucorrhea Abdominal bloating or subjective distention Frequent nausea
MCQ Which of the following symptoms indicates a need for laboratory testing or diagnostic imaging in patients with IBS younger than 50 years? Iron deficiency anemia Abdominal pain Amenorrhea Hypokalemia
Thank You For Your Attention
