Irritable Bowel Syndrome

Published on 31/05/2015 by admin

Filed under Obstetrics & Gynecology

Last modified 22/04/2025

Print this page

This article have been viewed 1473 times

Chapter 33 Irritable Bowel Syndrome

INTRODUCTION

Description: A syndrome of intermittent abdominal pain, constipation, and diarrhea related to hypermotility of the gut.

Prevalence: First described in 1818 and accounts for 50% of all visits to gastroenterologists; 2.4 to 3.5 million physician visits per year and an estimated 2.2 million prescriptions. Despite the prevalence of irritable bowel syndrome (IBS), only approximately 25% of those with IBS seek care, and only 1% of those with IBS are referred to specialists or become chronic health care users.

Predominant Age: Young to middle age.

Genetics: No genetic pattern, 2 : 1 female : male ratio.

ETIOLOGY AND PATHOGENESIS

Causes: Colonic wall motility is altered in these patients, with evidence suggesting altered colonic wall sensitivity. Patients with IBS have altered motor reactivity to various stimuli, including meals, psychological stress, and balloon distention of the rectosigmoid, resulting in altered transit time, which in turn results in pain, constipation, and diarrhea. Studies of patients with and without IBS have shown that there are significantly higher levels of 5-hydroxytryptamine (5-HT) in those patients with IBS, supporting a possible causal role.

Risk Factors: None known; prior infectious gastroenteritis has been postulated as a risk factor.

CLINICAL CHARACTERISTICS

Signs and Symptoms

• Intermittent abdominal pain (often worse before menses)

• Bloating and nausea

• Alternating constipation and diarrhea

Symptoms are generally worse 1 to 1½ hours after meals, with 50% of patients experiencing pain that lasts for hours or days; pain may last for weeks in up to 20% of patients. Pain is generally worse with high-fat meals, stress, depression, or menstruation and is better after bowel movements. There are three common clinical variants: (1) “spastic colitis” characterized by chronic abdominal pain and constipation; (2) intermittent diarrhea, which is usually painless; and (3) a combination of both with alternating diarrhea and constipation (see box).

MANAGEMENT AND THERAPY

Nonpharmacologic

General Measures: Because many of these patients have hysterical, depressive, and bipolar personality disorders, psychological support is important. In some studies, placebo response rates are as high as 80%.

Specific Measures: Mild sedation with phenobarbital and tranquilizers may offer some relief, although long-term success is generally poor.

Diet: Bulk agents and increased dietary fiber; reduction in alcohol, fat, caffeine, and sorbitol. Both fasting and probiotic diets have been suggested with variable results.

Activity: No restriction.

Patient Education: Diet (increased fiber) and stress management. Biofeedback and relaxation techniques may be of some help.

Drug(s) of Choice

Bulk-forming agents including Guar gum.

Emerging 5-HT₃ receptor-blocking agents, although two recently introduced agents (alosetron and tegaserod) have been withdrawn because of side effects. Melatonin has shown promise in some trials.

Contraindications: Bowel obstruction or fecal impaction, known or suspected allergy to agent or any component.

Precautions: Empiric therapy may be started during the process of evaluation but should not be continued indefinitely without the establishment of a diagnosis. Bulk-forming agents must be taken with adequate fluid intake to prevent obstruction and provide optimal effects.

FOLLOW-UP

Patient Monitoring: Normal health maintenance.

Prevention/Avoidance: High-fiber diet, stress reduction.

Possible Complications: Continued dependency on others; adverse effects of work, school, or home functions. Relapses are common.

Expected Outcome: Transient response is often good with most therapies. Long-term relapse is common.

MISCELLANEOUS

Pregnancy Considerations: No effect on pregnancy.

ICD-9-CM Codes: 564.1.

Lu WZ, Gwee KA, Moochhalla S, Ho KY. Melatonin improves bowel symptoms in female patients with irritable bowel syndrome: a double-blind placebo-controlled study. Aliment Pharmacol Ther. 2005;22:927.

Mulak A, Paradowski L. Effect of 5-HT1 agonist (sumatriptan) on anorectal function in irritable bowel syndrome patients. World J Gastroenterol. 2006;12:1591.

Bearcroft CP, Perrett D, Farthing MJG. Postprandial plasma 5-hydroxytryptamine in diarrhea predominant irritable bowel syndrome: a pilot study. Gut. 1998;42:42.

Blanchard EB, Lackner JM, Gusmano R, et al. Prediction of treatment outcome among patients with irritable bowel syndrome treated with group cognitive therapy. Behav Res Ther. 2006;44:317. Epub 2006 Jan 18

Chang L, Chey WD, Harris L, et al. Incidence of ischemic colitis and serious complications of constipation among patients using alosetron: systematic review of clinical trials and post-marketing surveillance data. Am J Gastroenterol. 2006;101:1069.

Chang L, Toner BB, Fukudo S, et al. Gender, age, society, culture, and the patient’s perspective in the functional gastrointestinal disorders. Gastroenterology. 2006;130:1435.

Degen L, Petrig C, Studer D, et al. Effect of tegaserod on gut transit in male and female subjects. Neurogastroenterol Motil. 2005;17:821.

Frissora CL, Koch KL. The role of gender and biological sex in irritable bowel syndrome. Curr Gastroenterol Rep. 2005 Aug;7(4):257.

Halvorson HA, Schlett CD, Riddle MS. Postinfectious irritable bowel syndrome—A meta-analysis. Am J Gastroenterol. 2006;101:1894.

Humphrey PPA, Bountra C, Clayton N, Kozlowski K. Review article: the therapeutic potential of 5-HT3 receptor antagonists in the treatment of irritable bowel syndrome. Aliment Pharmacol Ther. 1999;13(suppl 2):31.

Kale-Pradhan PB, Wilhelm SM. Tegaserod for constipation-predominant irritable bowel syndrome. Pharmacotherapy. 2007;27:267.

Saha L, Malhotra S, Rana S, et al. A preliminary study of melatonin in irritable bowel syndrome. J Clin Gastroenterol. 2007;41:29.

American Gastroenterological Association Patient Care Committee. American Gastroenterological Association medical position statement: Irritable bowel syndrome. Gastroenterology. 1997;112:2118.

American Gastroenterological Association. Irritable bowel syndrome: a technical review for practice guideline development. Gastroenterology. 1997;112:2120.

de Wit N, Rubin G, Jones R Irritable bowel syndrome Clin Evid 13 2005 556

Fukudo S. Sex and gender in irritable bowel syndrome. J Gastroenterol. 2006;41:608.

Gershon MD. Review article: Roles played by 5-hydroxytryptamine in the physiology of the bowel. Aliment Pharmacol Ther. 1999;13(suppl 2):15.

Hadley SK, Gaarder SM. Treatment of irritable bowel syndrome. Am Fam Physician. 2005;72:2501.

Paterson WG, Thompson WG, Vanner SJ, et al. Recommendations for the management of irritable bowel syndrome in family practice. Can Med Assoc J. 1999;161:154.

Saito YA, Camilleri M. Clinical application of pharmacogenetics in gastrointestinal diseases. Expert Opin Pharmacother. 2006;7:1857.

Spiller R. Clinical update: irritable bowel syndrome. Lancet. 2007;369(9573):1586.

Related

Netters Obstetrics and Gynecology