CC: Irritable Bowel Syndrome
TYPES OF IBS
IBS-C constipation predominant
IBS-D diarrhea predominant
IBS-A alternating constip and D
post-infectious IBS
ROME 3 CRITERIA FOR IBS
abdominal pain for 3+ mo
with any of these:
relieved by defecation
change in frequency of stool
change in form of stool
ROME 2 CRITERIA HAVE NOW BEEN DROPPED
with 2+ of these at least 25% of the time
change in frequency or form
difficult passage
mucus or bloating
PREVALENCE
US prevalence: 15%
world prevalence: 9-23%
IBS is 28% of gastroenterology practice diagnoses
IBS is 12% of US primary care diagnoses
>75% of IBS females in US seek healthcare
<20% of IBS females in India seek healthcare
PSYCH COMPONENT
hypervigilance-->IBS
abuse history including family of origin-->increased risk of IBS
abuse also leads to worse outcomes
psychosocial factors (loss, abuse, hassles)
psych conditioning (depression, anxiety)
IBS pts exhibit more time in REM sleep than controls (to process things)
children learn to relate to illness from their parents
adults with IBS have offspring with higher IBS risk,
more healthcare visits for all causes, higher outpatient healthcare costs
animal studies show sig incr in IBS following neonatal-maternal separation
ALTERED MOTILITY
IBS pts have guts that move when they shouldn't and don't move when they should
stress-->decreased migrating motor complex, delays gastric emptying (incr constipation)
stress-->increased colonic motility (incr diarrhea)
stress-->may change iliocecal valve function (incr constip)
INFLAMMATION
used to say there is none
but now they know there is moer
50% of IBS pts have increased activation of mucosal inflam cells
2002 study showd incr lymphocytes, CD3, CD25, neuts, mast cells
criteria for lymphocytic colitis is often present
INCREASED SENSATION OF PAIN
"altered visceral sensitivity"
more sensitive to peristalsis and even normal distention
IBS pts report pain
motor activity of sigmoid in response to a meal is sig greater in IBS
altered jejunal activity in response to video games, driving in traffic, delayed audio feedback more in IBS
prolonged propagated contractions (high pressure persistalsis in ileum and colon) more freq in IBS and assoc with pain in 61% of IBS vs 17% of controls
pain prolonged by rectosigmoid distention is sig more severe in IBS vs control
BRAIN ACTIVITY IN IBS PTS
do not have stim of anterio cingulate gyrus (opiate binding site)
in response to rectal dilation or anticipation of rectal dilation
IBS pts have activation of frontal lobes (vigilance network)
which increases alertness and increases pain perception
(neurologist says they say this about every disease)
INCREASED PERMEABILITY
tight junctions between enterocytes are weakened
small bowel and colonic hyper perm mb present
kids with IBS also have gastric hyperpermeability
mb induced by stress
may be transferrable btw cells
study: cultured healthy coloncytes with supernatant from colonic x speciments of pts with IBS and supernatant induced paracelluluar hyperpermeability (and decreased transcellular perm) within 48 hours. factor presumed responsible: colonic luminal serine protease.
FLORA CHANGES
rifaximin improved global sx in 33-92% of pts
rifaximin eradicated SIBO in up to 84% of pts w/IBS
20 trials with 23 probiotix tx arms:
probiotic use is assoc with improvement of IBS sx compared to placebo
probiotics also assoc with less abd pain than placebo
SIBO
small intestine bacterial overgrowth
present in 45-78% of IBS pts
present in 51% of rosacea pts
also commonly present in pts with restless legs syndrome
sx nearly identical to IBS
can cause IBS-->increases immune reactivity
can cause IBS-->activates enteric nervous system-->increases
DX by H2/methane breath test
stool cultures do not represent small intestine bacteria
Leo Galland MD says often Blastocystis hominis is causative org of IBS
RISK FACTORS FOR SIBO
altered migrating motor complex: normally aboral-mouth-->anus, 9x/day
(only works when you fast, don't eat frequent small meals, eat 3 meals a day)
(too much methane causes reverse peristalsis, anus-->mouth)
from BOOK: A New IBS Solution, Mark Pimentel MD, Health Point Press
elevation of gastric pH (proton pump inhibitors, H2 inhibitors, tums)
deficient bile salts in small bowel, pancreatic insufficiency
obstrx: Crohn dz, GI adhesions-->slowed flow
(adhes dt surgery, endometriosis, chlamydia)
GI anatomy (congenital or surgical blind loops make it harder to clear wrong bact)
altered ileocecal valve function
more fibromyalgia (mbdt hydrogen producing bacteria)
DIFFERENTIAL DIAGNOSIS FOR IBS
foods:
lactose, sorbitol intolerance
(what about fructose?)
caffeine, alcohol overuse
overconsumption of fat
gas-producing foods (crucifers, excess fiber)
individual food allergies
gluten sensitivity
practices:
belt wearing-->shallow breathing-->decreased parasymp-->poor digestion
exercising after food
stress with meals
infections:
giardia
blastocystis hominins
Entamoeba histolytica and other amoebae
yeast overgrowth (big one)
cryptosporitidum
clostridium difficile overgrowth (big one)
SIBO (big one)
pathology:
UC
Crohn's
collagenous colitis (microscopic)
lymphocytic colitis
mast cell disease
malabsorption:
post-gastrectomy or other GI surger
intestinal (Celiac, tropical sprue, Whipple's)
pancreatic insufficiency
sugar malabsorption-->bacteria make more hydrogen and methane from undigested lactose, sorbitol, fructose-->gas and bloating
(only 7% of IBS pts absorb all 3 sugars normally)
misc:
endometriosis
endocrine tumors (carcinoid, VIP, Z-E syndrome)
AIDS related diarrhea
diet
POST INFECTION IBS
this group of pts have more diarrhea, less psychiatric illness, and
increased serotonin-containing EC cells compared with non-PI-IBS
pathogenic infx-->mucosal damage and disruption of commensal flora
6-17% of IBS pts believe sx began with infx
prospective studies show 4-31% postinfx IBS following bacterial gastroenteritis
~50% of pts still have sx at 5 years
45% of IBS pts have SIBO, broad spectrum ABX often have temporary benefit
risk factors for postinfx ibs:
severity of initial illness
toxigeniticy of bact
hypochondriasis? depression and neuroticism?
adverse life events in prev 3 mo
organisms: campy, salmonella, shiggy, blastocystis hominus
changes post infx measured by biopsy confirm changes in:
serotonin-containing enterochromaffin cells
lymphocytes
increased hyperpermeability
incr in peripheral blood mononuclear cell cytokine production (probiotics tx this)
LABS TO DISTINGUISH IBD FROM IBS
fecal calprotectin (best one per SSL, decide who needs scope and BX)
lactoferrin
both low in low grade inflammation, higher with Crohn's or Ulcerative Colitis
these markers studied most, Genova does them, order separately
also neutrophil elastin
Dr T says use alpha chymotrypsin and lysozyme on GI health panel
LABS
GI Health Panel
http://www.diagnostechs.com/gi_patient.html
there are other sources for this panel out there on the web
some you can order and do at home
not sure if they are as good as the diagnostechs
for sure you need someone who understands the results to interpret for you
hydrogen/methane breath test for SIBO
not sure if this is the brand used by SSL:
http://www.metsol.com/small_intestinal_bacterial_overgrowth_SIBO.php
TREATMENT
ALLO TX
assorted drugs have been approved then pulled from market
for terrible side effects including arrhythmias, stroke
some drugs later reintroduced, only prescribed in niche markets
if your doc prescribes, know what side effects may be due to the drugs
watch yourself like a hawk
NATURO TX
ABX: (yes dear, naturopaths do prescribe antibiotics sometimes)
treat giardia, blastocystis (metronidzaole/tinidazole?)
rifaximin/xifaxan
for traveler's D
99.6% lumenal: doesn't leave GI tract
for hydrogen making bact
(breath test will tell which gas is prevalent)
1200-1600 mg 7-10 days
neomycin
more for methane makers-->constipation
500mg TID x10days
95% lumenal (not absorbed systemically)
erythromycin
50mg hs x3mo (to stim MMC=migrating motor complex)
FASTING
instead of ABX
two week water fast or Vivonex fast
(no master cleanse, no maple syrup, no honey, no sugars, 2 weeks!!!)
http://www.nestle-nutrition.com/products/Family.aspx?FamilyId=345ae4e7-5dd3-4a5e-9abb-3eca340c3c3a
treat hypo/a-chlorhydria
reduce hiatal hernia if present
if IC valve syndrome: microcurrent, viseral manipulation, NMT, diet
if functional gallbladder or sphincter of Oddi dysfx: choleretics, cholagogues
and/or ox bile with emlas
if amoebiasis: nosode or vermifuge (2TID ic x7d then 7d rest, repeat 3-6 cycles)
suspenders: stop wearing a belt
take a nap after meals
deep breathing
probiotics
DIET (composite recommends from several sources)
eat only 3x/day to allow migrating motor complex to function
drink ample water in between meals
avoid non-fermented lactose or use lactase enzyme with meals
avoid undigestible carbs: sucralose, sorbitol, lactulose, sugar-free gum, fiber supps
avoid sorbitol including candy, prunes, gum
avoid excess insoluble fiber esp wheat bran
avoid caffeine, alcohol
keep fat consumption low
avoid excess crucifers and only eat them cooked
avoid individual food allergies
omit gluten in cases of elevated anti-gliadin Abs, anti-endomysial Abs, TTG Abs
limit all simple carbs including grains
BOOK: Breaking the Vicious Cycle, Elaine Gottschall, eat only foods that don't feed small intestinal pathogenic bacteria, grain free, low lactose, low carb
Cedars-Sinai SIBO diet (Pimentel) is low carb, low lactose, avoid undigestible carbs incl sucralose, sorbitol, lactulose, sugar-free gum, fiber supplements (this is what my sis is doing except that she eats plenty of sugar), avoid beans, lentils, peas, soy, yogurt, milk, cheese, avoid between-meal snacks (this diet doesn't work well for vegetarians, esp vegans)
PSYCH
address FOO issues
manage stress
escape from abusive situations
EFT?