WEBVTT 1 00:00:15.400 --> 00:00:19.300 Thank you very much for inviting inviting me to take to take 2 00:00:19.300 --> 00:00:23.800 this session. Now what is irritable bowel syndrome? As the name suggests 3 00:00:23.900 --> 00:00:27.700 if your bowel is bowels or intestines are irritable and it's syndrome 4 00:00:27.700 --> 00:00:30.800 so it's not a disease and it's a very common thing we 5 00:00:30.800 --> 00:00:36.200 encounter in our clinical practice. Basically it's a functional bowel disorder 6 00:00:36.600 --> 00:00:41.700 but it's a bowel that that is abnormal functionally 7 00:00:41.700 --> 00:00:46.800 that means there is no definite pathophysiology or disease in intestine 8 00:00:46.900 --> 00:00:49.800 but our patients are not functional and we label them as a 9 00:00:49.800 --> 00:00:55.000 functional patients or fictional patients in this kind of a syndrome. So 10 00:00:56.000 --> 00:01:01.400 generally patients present with abdominal pain. So it's a functional bowel disorder 11 00:01:01.400 --> 00:01:05.200 in which abdominal pain is associated with defecation or change in bowel 12 00:01:05.200 --> 00:01:09.400 habit. Either patient with present with abdominal pain with constipation or diarrhea. 13 00:01:09.500 --> 00:01:12.800 There are various subtypes of IBS that we'll discuss in later slides 14 00:01:13.300 --> 00:01:17.800 whether it is IBS is associated with constipation or IBS associated with 15 00:01:18.200 --> 00:01:22.600 diarrhea and I'm not just talking about OPD patient the patient which 16 00:01:22.600 --> 00:01:27.100 come to you. 20% of general population fulfill the criteria of IBS. 17 00:01:28.700 --> 00:01:33.800 That's why in particularly these patients are very unsatisfied in patient and 18 00:01:33.900 --> 00:01:39.000 roaming to clinic to clinic will with similar complaint that my abdomen 19 00:01:39.000 --> 00:01:43.800 is bloated having abdominal pain. There are all the reports are coming 20 00:01:43.800 --> 00:01:46.800 to be normal but I am having the problem and nobody's able 21 00:01:46.800 --> 00:01:51.600 to diagnose this. So these are the typical patients and two out 22 00:01:51.600 --> 00:01:55.300 of 10 patients in the population will suffer from IBS and it 23 00:01:55.300 --> 00:02:00.400 is the most common cause of GI referral. Young females are 24 00:02:00.400 --> 00:02:07.400 more most commonly affected than men. There 25 00:02:07.400 --> 00:02:12.500 are coexisting condition with IBS generally it is non-ulcer 26 00:02:12.500 --> 00:02:17.000 dyspepsia. Again patient will complain that I am having burning but or 27 00:02:17.000 --> 00:02:21.000 the endoscopies are coming to be normal. Chronic fatigue syndrome this is 28 00:02:21.000 --> 00:02:26.700 a very bad symptoms to have patient will be chronically fatigued bloated 29 00:02:27.000 --> 00:02:32.800 severe abdominal pain dysmenorrhea fibromyalgia fibromyalgia 30 00:02:32.800 --> 00:02:35.900 mean diffuse muscle pain and you will not able to find any 31 00:02:35.900 --> 00:02:41.000 cause everything will be every investigation CT scan laparoscopy scopes 32 00:02:41.000 --> 00:02:46.200 is endoscopies everything is going to be normal. There 33 00:02:46.200 --> 00:02:50.900 are always there are certain behavior and psychological factors associated with it 34 00:02:51.500 --> 00:02:56.900 but let me more than 50% patient has no psychological disorder 35 00:02:56.900 --> 00:03:01.900 associated with it. There may be psychological factor but it is seen 36 00:03:01.900 --> 00:03:07.000 in almost less than 50% of the patient. These are depression, anxiety, 37 00:03:07.400 --> 00:03:13.500 somatization or neurosis are very common with this disorder. So 38 00:03:15.100 --> 00:03:19.700 thing is that that whenever there is psychological stress or any psychiatric 39 00:03:19.700 --> 00:03:25.100 disease or even simple lifestyle changes little bit of stress unfortunately 40 00:03:25.100 --> 00:03:30.400 that is very common with females. Secret the same hormone 41 00:03:30.800 --> 00:03:35.900 same acetylcholine same serotonin which controls your intestine movement. So 42 00:03:35.900 --> 00:03:40.900 GI intestinal motility is affected and due to this motility 43 00:03:40.900 --> 00:03:47.000 problem patients are having various symptoms. Second 44 00:03:48.000 --> 00:03:53.100 you will see this patient are very anxious and they will be 45 00:03:53.100 --> 00:03:57.300 visiting doctors with very smaller complaint a typical type A personality as 46 00:03:57.300 --> 00:04:02.500 we say patient will be agitated patient will be anxious patient nature 47 00:04:02.500 --> 00:04:07.800 will be angry nature. So all these causes a hormonal imbalance 48 00:04:07.800 --> 00:04:12.400 in the body and which can cause the symptoms of irritable bowel 49 00:04:12.400 --> 00:04:17.800 syndrome. Basically it is a definite pathophysiology IBS is a serotonergic 50 00:04:17.800 --> 00:04:23.500 disorder increase serotonin is particularly observed in irritable 51 00:04:23.500 --> 00:04:28.500 bowel syndrome associated with diarrhea and this same serotonin is decrease in 52 00:04:28.500 --> 00:04:33.400 irritable bowel syndrome associated with constipation. It is the hormonal imbalance which 53 00:04:33.400 --> 00:04:38.800 causes this symptoms. That is why 5HT3 receptor antagonists are effective 54 00:04:38.900 --> 00:04:44.800 in IBS-D that is IBS diarrhea while 5HT4 agonist improve 55 00:04:44.800 --> 00:04:48.900 bowel function in irritable bowel syndrome with associated with constipation. So we 56 00:04:48.900 --> 00:04:52.300 have to see this irritable bowel bowel syndrome with a separate various 57 00:04:52.300 --> 00:04:57.200 subtypes either it is irritable bowel syndrome with diarrhea, irritable bowel syndrome 58 00:04:57.200 --> 00:05:02.400 with constipation, irritable bowel syndrome with predominant abdominal pain or 59 00:05:02.500 --> 00:05:08.400 irritable bowel syndrome with both constipation and diarrhea. So IBS 60 00:05:08.500 --> 00:05:12.500 actually represented state of very low grade inflammation that's why it's not 61 00:05:12.500 --> 00:05:17.600 picked up in any imaging studies or endoscopies. It causes 62 00:05:17.600 --> 00:05:23.000 immune activation which is not detected by test. If we do biopsy 63 00:05:23.000 --> 00:05:27.400 sometimes rarely we may find increased number of mucosal mast cells. So 64 00:05:27.800 --> 00:05:31.400 again this is the same kind of a pathophysiology which we see 65 00:05:31.400 --> 00:05:36.400 an allergic disorder common cold exact. So which and these mast cells 66 00:05:36.500 --> 00:05:41.800 sensitize enteric neurons by releasing histamine and tryptase. So basically 67 00:05:41.900 --> 00:05:47.100 again it's an intestinal hormonal imbalance. That is why some 68 00:05:47.100 --> 00:05:50.200 patients respond to keto defense also which is a actually a mast 69 00:05:50.200 --> 00:05:55.300 cell stabilizer. Immune activation may be associated with altered CNS 70 00:05:55.300 --> 00:06:00.300 processing of visceral pain signal. That is why this patient develop 71 00:06:01.000 --> 00:06:06.800 sometimes present with intense abdominal pain without any obvious cause. So 72 00:06:08.000 --> 00:06:12.700 particularly female patient and that is why we sometimes label female patient 73 00:06:12.800 --> 00:06:17.800 is a their faking symptoms or what we call 74 00:06:17.800 --> 00:06:22.800 is that they have a depression, anxiety or malingering or psychotic 75 00:06:22.800 --> 00:06:28.900 patient but actually they are suffering from this functional bowel disorder. Sometime 76 00:06:28.900 --> 00:06:33.000 it is triggered by salmonella campylobacter but there is no specific correlation 77 00:06:33.000 --> 00:06:38.100 is seen. There are also also associated with intestinal luminal 78 00:06:38.100 --> 00:06:43.300 factor. So whenever there is an alteration in intestinal microbiota 79 00:06:43.900 --> 00:06:49.400 or bacteria normal bacteria present in intestine. It 80 00:06:49.400 --> 00:06:54.200 can present as the symptoms of irritable bowel syndrome. That is why 81 00:06:58.100 --> 00:07:04.600 specific antibiotic which we rifaximin which is specifically effective in against 82 00:07:04.600 --> 00:07:08.900 the gut bacteria is sometimes effective in this irritable bowel syndrome patient. 83 00:07:09.500 --> 00:07:15.000 Rarely this patient may present with symptoms of subacute intestinal obstruction without 84 00:07:15.000 --> 00:07:20.500 any specific cause. They 85 00:07:20.800 --> 00:07:24.700 may be having some chemical food intolerance but there is no definite 86 00:07:24.700 --> 00:07:29.700 association proven mild intolerant 87 00:07:29.700 --> 00:07:33.900 to lactose, fructose, sorbitol but what we are we have seen that 88 00:07:34.000 --> 00:07:38.800 whenever this patient present we sometimes the physician we blindly tell them 89 00:07:39.000 --> 00:07:44.200 to stop milk, stop roti or stop gluten containing 90 00:07:44.200 --> 00:07:49.400 diet which is actually not an ideal management. 91 00:07:50.200 --> 00:07:54.000 it is the patient who need to understand which food is causing 92 00:07:54.000 --> 00:07:56.900 me the problem and according to change the diet you have it. 93 00:07:57.800 --> 00:08:04.600 Sometimes yes the patient have lactose intolerance sometimes they have gluten or 94 00:08:04.700 --> 00:08:08.800 despite that you will not find an obvious either histological or chemical 95 00:08:09.400 --> 00:08:17.200 or another diagnostic feature of gluten sensitivity or celiac disease. Rarely 96 00:08:17.200 --> 00:08:22.200 patients are intolerant to salicylate and benzoate present in certain food. 97 00:08:22.500 --> 00:08:25.900 Now as we see there are various subtypes sometimes it is predominant 98 00:08:25.900 --> 00:08:31.000 constipation sometimes it predominantly diarrhea. Of 99 00:08:31.000 --> 00:08:36.800 course the reason for constipation is the decrease orocecal transit time reduced 100 00:08:36.800 --> 00:08:41.100 number of high amplitude of propagated colonic contraction waves. So irritable bowel 101 00:08:41.100 --> 00:08:46.200 syndrome is just about defect in intestinal motility but 102 00:08:46.700 --> 00:08:51.700 you will again you will not find any consistent evidence of abnormal 103 00:08:51.700 --> 00:08:56.500 motility. So actually all kind of diagnostic tests are done that is 104 00:08:56.500 --> 00:09:01.100 actually to exclude other disease. no test is specific for irritable bowel 105 00:09:01.100 --> 00:09:07.100 syndrome. It is diagnosed based in symptom. Then another subtype 106 00:09:07.100 --> 00:09:12.400 of irritable bowel syndrome is IBS-D or irritable bowel syndrome predominantly 107 00:09:12.400 --> 00:09:17.500 diarrhea. So one is decreased motility here you 108 00:09:17.500 --> 00:09:22.400 will see the jejunal contraction increases. That is why intestinal transit increases 109 00:09:22.700 --> 00:09:26.600 and that is why it causes diarrhea. Again colonic contraction will also 110 00:09:26.600 --> 00:09:33.300 increase. So typical 111 00:09:33.300 --> 00:09:38.300 clinical features are recurrent abdominal pain. You have 112 00:09:38.300 --> 00:09:42.500 to ask the patient of last six months or one year history 113 00:09:42.500 --> 00:09:46.000 patient will report that there are some bad period in between there 114 00:09:46.000 --> 00:09:51.200 will be a good period and most commonly the typical thing patient 115 00:09:51.200 --> 00:09:56.800 will tell that I am feeling relieved after passing stool. and 116 00:09:56.800 --> 00:10:01.900 as the day progresses my bloating is worse. Sometime patient complaining 117 00:10:01.900 --> 00:10:07.000 of mucus discharge but bleeding is not associated with irritable bowel 118 00:10:07.000 --> 00:10:10.000 syndrome. If there is a rectal bleeding you have to rule out 119 00:10:10.000 --> 00:10:15.300 other causes. Patient will not present with weight loss to any 120 00:10:15.300 --> 00:10:20.800 diagnosed dilemma about cancers or something. All physical examination 121 00:10:21.600 --> 00:10:26.700 would be normal. Abdominal tenderness also very rarely seen. So 122 00:10:26.700 --> 00:10:31.100 how to diagnose? Now there is a specific criteria. This is that 123 00:10:31.100 --> 00:10:35.000 is known as the Rome IV criteria. If these are things present 124 00:10:35.000 --> 00:10:40.000 generally no tests are required in otherwise normal physical examination your 125 00:10:40.000 --> 00:10:44.500 most patient will be having irritable bowel syndrome. So what is the 126 00:10:44.500 --> 00:10:49.800 criteria? Recurrent abdominal pain with onset of at least six months prior 127 00:10:49.800 --> 00:10:53.500 to diagnosis. It is never an acute pain patient will give history 128 00:10:53.500 --> 00:10:58.900 of vaccine and waning of pain. Associated with two of the following 129 00:10:58.900 --> 00:11:03.300 things should be present at least one day per week in last 130 00:11:03.300 --> 00:11:08.400 three months. Pain has to should be related to defecation. 131 00:11:09.300 --> 00:11:13.900 It should be related to change in frequency or change in consistency. 132 00:11:16.000 --> 00:11:21.400 In children if children's are also 133 00:11:21.400 --> 00:11:26.100 have this IBS very commonly. In children abdominal pain at least four 134 00:11:26.100 --> 00:11:30.200 days per month for at least two months before the diagnosis with 135 00:11:30.900 --> 00:11:34.300 one of the more following these are similar to earlier thing but 136 00:11:34.800 --> 00:11:39.200 which is related to defecation associated with change in frequency of stool 137 00:11:39.500 --> 00:11:44.600 and associated with change in appearance of stool. So 138 00:11:46.100 --> 00:11:49.800 typical features is patient will be having colicky abdominal pain patient will 139 00:11:49.800 --> 00:11:54.100 present with either constipation or diarrhea. There will be patient reported abdominal 140 00:11:54.100 --> 00:11:58.800 distension. On clinical examination you will not find that much of distension 141 00:11:58.800 --> 00:12:03.900 sometimes mucus passes and patient will always be feeling that my defecation 142 00:12:03.900 --> 00:12:07.900 is incomplete and I am not satisfied. that's a typical word patient 143 00:12:07.900 --> 00:12:13.200 use. So again 144 00:12:14.000 --> 00:12:18.400 supporting the diagnostic feature symptoms should be more than six months and 145 00:12:18.400 --> 00:12:22.500 you will see that patient will be consulting other doctors for non-GI 146 00:12:22.500 --> 00:12:27.800 problem like headache. That's a very common myth that my gas causes 147 00:12:27.800 --> 00:12:31.500 my headache but actually it is the headache associated with this IBS 148 00:12:32.300 --> 00:12:37.100 symptoms and no gas can cause headache. Patient will be having rheumatologist 149 00:12:37.100 --> 00:12:42.300 consultant sometimes with fibromyalgia, myalgia they must have visited 150 00:12:42.400 --> 00:12:48.600 orthopedic they must have visited psychiatric with their anxiety problem. And 151 00:12:48.600 --> 00:12:53.700 all would be medically unexplained. And if you 152 00:12:53.700 --> 00:12:59.400 ask patient that if any change in lifestyle decrease sleep stress 153 00:12:59.700 --> 00:13:05.200 whether it worsens symptoms or not patient will typically give supporting 154 00:13:05.200 --> 00:13:10.300 history regarding this. So when to investigate? 155 00:13:11.600 --> 00:13:16.600 When so basically when we doubt that apart from IBS 156 00:13:16.600 --> 00:13:20.800 the patient might have malignancies at that time it is better to 157 00:13:20.800 --> 00:13:24.500 investigate that is generally more than 50 years male you will not 158 00:13:24.500 --> 00:13:29.900 find rarely find an elderly male with 159 00:13:30.300 --> 00:13:35.800 typically abdominal pain and bloating other associated with constipation. 160 00:13:35.800 --> 00:13:40.600 They present with constipation that's the functional constipation is altogether different syndrome 161 00:13:40.800 --> 00:13:46.000 but typically fulfilling Rome IV criteria you will not find. So whenever 162 00:13:46.000 --> 00:13:51.200 there's elderly male patient present with weight loss symptoms in night. 163 00:13:51.500 --> 00:13:56.000 In IBS nocturnal symptoms are not that common. Patient is a family 164 00:13:56.000 --> 00:14:01.000 history of colonic cancer anemia or rectal bleeding. So basically classical 165 00:14:01.000 --> 00:14:06.400 indication of endoscopy or colonoscopy would apply here otherwise generally your 166 00:14:06.400 --> 00:14:13.000 all kind of endoscopy and colonoscopy will come inconclusive. So 167 00:14:13.000 --> 00:14:18.400 all examination is negative. Full blood count ESR 168 00:14:18.400 --> 00:14:23.600 fecal calprotectin to rule out inflammatory bowel disease or sometimes sigmoidoscopy patient 169 00:14:23.600 --> 00:14:26.800 present with all kind of a report but all the report would 170 00:14:26.800 --> 00:14:31.600 be normal. Colonoscopy are generally indicated with worrying symptoms that we are 171 00:14:31.600 --> 00:14:37.200 already mentioned. So sometimes it is not 172 00:14:37.200 --> 00:14:42.500 that common in Indian setting but IBS with diarrhea can have other 173 00:14:42.800 --> 00:14:48.100 malabsorption syndrome like celiac disease or microscopic colitis, lactose intolerance. So 174 00:14:48.100 --> 00:14:52.900 if there is an associated feature with this diagnosis like thyrotoxicosis then 175 00:14:52.900 --> 00:14:56.300 they should be ruled out otherwise most of the IBS should be 176 00:14:56.300 --> 00:15:00.500 diagnosed on OPD basis with 5 to 10 minutes of history taking 177 00:15:00.500 --> 00:15:03.700 and if it fulfills Rome IV criteria you have to consider it 178 00:15:03.900 --> 00:15:09.400 as an IBS or irritable bowel syndrome. Now management is all 179 00:15:09.400 --> 00:15:14.700 vague management. There are no proven therapy but some treatment help and 180 00:15:14.700 --> 00:15:18.800 some treatment help and it is proven in RCTs. Of course there 181 00:15:18.800 --> 00:15:23.200 is a how you counsel the patient how you make them understand 182 00:15:23.200 --> 00:15:27.200 this syndrome rather than blaming them that that they are faking the 183 00:15:27.200 --> 00:15:31.200 symptom make them understand this symptom that it is going to recur. 184 00:15:31.400 --> 00:15:34.400 You will have some kind of good period some bad period that 185 00:15:34.400 --> 00:15:38.500 helps a lot. If patient is having typical food allergy if their 186 00:15:38.500 --> 00:15:42.600 symptoms are version with wheat or milk at that time you can 187 00:15:42.600 --> 00:15:47.600 ask to reduce them otherwise there are no specific role of reducing 188 00:15:47.600 --> 00:15:52.800 them. Emitriptylin now emitriptylin 10 to 25 mg 189 00:15:52.800 --> 00:15:57.600 of at night is a it helps in many patient because again 190 00:15:57.600 --> 00:16:02.600 it's a 5HT it acts as a selective serotonin reuptake inhibitor. 191 00:16:02.600 --> 00:16:07.100 So again it's a serotonin mechanism which helps that is why amitriptyline 192 00:16:07.100 --> 00:16:11.000 have here amitriptyline of you are not giving a the antidepressant or 193 00:16:11.000 --> 00:16:16.000 anti-anxiety drug. Just remember that. Particularly in 194 00:16:16.000 --> 00:16:22.400 IBS-C lubiprostone sometimes effective with constipation is very bad. Again 195 00:16:22.800 --> 00:16:27.800 rifaximin which is intraluminal antibiotic helps in many of the patients. 196 00:16:28.000 --> 00:16:33.800 Your standard prescription should be one amitriptyline one rifaximin. Particularly 197 00:16:33.800 --> 00:16:37.800 rifaximin is helpful in a irritable bowel syndrome with diarrhea. If it 198 00:16:37.800 --> 00:16:43.100 is constipation lubiprostone helps. In rare cases when all this medical 199 00:16:43.100 --> 00:16:48.300 treatment also fails there are some role of cognitive behavioral 200 00:16:48.300 --> 00:16:53.400 therapy or psychiatric consultation but generally if they are very less effective 201 00:16:53.400 --> 00:16:58.700 in Indian patients. And patient you have to make the patient understand 202 00:16:58.700 --> 00:17:03.400 that they have a relaxing and remitting disease. So to sum up 203 00:17:03.600 --> 00:17:07.500 it is whenever a patient with irritable bowel syndrome comes to you 204 00:17:08.200 --> 00:17:12.600 first step is take proper history diagnostic IBS based on history make 205 00:17:12.600 --> 00:17:17.700 them understand that disease. Still if patient 206 00:17:17.700 --> 00:17:22.700 disease some persist and with pain is significant then you have 207 00:17:22.700 --> 00:17:28.100 to give a spasmolytic drug. Amitriptyline, probiotics, dietary 208 00:17:28.100 --> 00:17:33.300 changes all this helps in pain and bloating. Constipation initially 209 00:17:33.300 --> 00:17:38.700 try with simple medication like isabgol or lactulose or loose. If 210 00:17:38.700 --> 00:17:44.900 that doesn't help you can try the lubiprostone. If 211 00:17:44.900 --> 00:17:49.900 diarrhea again simple here you have to ask them 212 00:17:49.900 --> 00:17:54.800 to avoid too much of fiber because it's in actually in constipation 213 00:17:54.800 --> 00:17:58.000 patient we ask them to take fiber. In diarrhea you have to 214 00:17:58.400 --> 00:18:03.000 avoid the fiber. Rarely anti-diarrheal treatment can be given but at most 215 00:18:03.000 --> 00:18:07.400 the time try to avoid it. Again amitriptyline and rifaximin for two 216 00:18:07.400 --> 00:18:13.200 weeks this medication helps in IBS diarrhea also. So 217 00:18:13.200 --> 00:18:17.100 use this medication as a first-line therapy. If it doesn't fail then 218 00:18:17.100 --> 00:18:22.200 you can use the various treatment available. With that 219 00:18:22.200 --> 00:18:25.600 I will finish. Thank you very much. My aim was to keep 220 00:18:25.600 --> 00:18:29.600 this talk brief. So we just have an idea of IBS how 221 00:18:29.600 --> 00:18:34.300 to deal with those patients and specific treatment available and the message 222 00:18:34.300 --> 00:18:38.100 is that we should not consider this patient as a faking or 223 00:18:38.100 --> 00:18:40.300 psychiatric patient. Thank you very much.