IBS

 

History: symptoms analysis

• Abdominal pain

• Colicky, cramping, lower abdominal 
• Related to defecation 

• Bowel habit

• Variable
• Pellets stool, abdominal pain/proctalgia→ IBS-C
• Frequent defecation, low volume stool, no nocturnal symptoms → IBS-D
• Mucus, no blood with stool

• No weight loss

• Other non functional disorder of GIT

• Non GIT symptoms:

• migraine, headache, dyspareunia, interstitial cystitis

 

Dietary history:

• FODMAPs
• Dairy 
• Legumes, dietary fiber
• Gluten diet 

 

Medical history:

• Abdominal TB

 

Surgical history:

• Abdominal surgery- gut resection, cholecystectomy 

 

Psychological history:

• Anxiety, neurosis, somatisation, depression, panic attack

 

Examination:

• Unremarkable,  except variable abdominal tenderness 
• Exclusion of DD: Thyrotoxicosis, malabsorption (IBD, CD, bile acid diarrhea) CRC

 

D/D: 

1. IBD, coeliac disease
2. colorectal cancer, microscopic colitis 
3. lactose intolerance, bile acid diarrhea, 
4. parasitic infection
5. thyrotoxicosis, 

 

Investigation:

Diagnosis is based on clinical, using Rome IV criteria combined with absence of alarm features. Limited tests are performed before making a diagnosis of IBS

 

FBC	normal
Faecal calprotectin	normal
CRP	normal
colonoscopy	if alarm features present exclude other Dx like IBD, colon cancer
For IBS -D patient, exclude coeliac disease, microscopic collitis, lactose intolerance, bile acid diarrhea, thyrotoxicosis, parasitic infection

 

Management:

• Patient education
• Reassurance and explanation

• diagnostic certainty 
• symptoms are not due to serious underlying disease
• symptoms are due to 

1. behavioral & psychological
2. physical
3. luminal factors

• Diarrhea predominant

1. Avoid legumes, excessive dietary fibres
2. Antidiarrheal drugs: LCC

• loperamide
• codeine
• colestyramine

1. TCA- amitriptyline, imipramine
2. Rifaximin  
3. Final

• duloxetine 
• Psychological intervention – 

1. CBT, 
2. relaxation therapy,
3. gut directed hypnotherapy, 
4. biofeedback

 

• Constipation predominant

1. High roughage diet
2. Ispaghula/psyllium
3. Lactulose, macrogol
4. drugs (PLL)

• Prucalopride → 5-HT4 receptor agonist 
• Linaclotide → guanylate cyclase receptor agonist 
• Lubiprostone → chloride channel activator

1. Final: 

• duloxetine 
• Psychological intervention – 

1. CBT, 
2. relaxation therapy, 
3. gut directed hypnotherapy, 
4. biofeedback

 

• For pain and bloating 

• Dietary changes

1. low FODMAPs diet
2. Exclude wheat, dairy
3. Gluten free diet

• spasmolytic drugs

1. Mebeverine
2. Peppermint oil
3. Hyoscine
4. Probiotics
5. Rifaximin
6. TCA-

• final

1. duloxetine 
2. Psychological intervention – 

1. CBT, 
2. relaxation therapy, 
3. gut directed hypnotherapy, 
4. biofeedback

*** Complementary and alternative therapy.

 

Prognosis:

• Most patient have relapsing and remitting course
• Exacerbation follow stressful life events, occupational dissatisfaction, difficulties with interpersonal relationships