​Kembara Xtra - Medicine - Irritable Bowel Syndrome

​Kembara Xtra - Medicine - Irritable Bowel Syndrome 
A gastrointestinal problem (GI disorder) without an organic cause is defined by persistent and recurrent abdominal pain, discomfort, bloating, distension, and changes in bowel habits.
 May be classified as having a predominance of diarrhea (IBSD), constipation (IBS-C), mixed (IBS-M), or unknown (IBS-U); symptoms may fluctuate.
Synonym(s): agitated colon; spastic colon

Epidemiology 

In the United States, Irritable Bowel Syndrome (IBS) accounts for 30–50% of visits to gastroenterologists and 2 million primary care visits yearly, with a cost range of $1.5–$10 billion.
Rate: -2 per 1,000 people per year
Prevalence

Globally, a pooled estimate of 4% using the Rome IV criterion or 9% using the Rome III criteria
 Age distribution: 20 to 39 years
If over 50, take other diagnosis into account.
In the US, females outnumber men 3:1.
 More prevalent in areas with poor socioeconomic status

Pathophysiology and Etiology 

Unknown cause; increased sensitivity to visceral stimuli and disorders of intestinal motility are related. Environmental or luminal triggers are both possible.
The involvement of food sensitivity, microbiome dysbiosis, genetic, and psychological reasons including early childhood stress are being studied. Roughly 10% of infected enteritis patients develop PI-IBS (post-infectious).
IBS patients have higher mast cell density and activity, which has been shown on biopsy from the terminal ileum, jejunum, and colon and may be related to visceral hypersensitivity. Currently, research is being done to determine the role of low-grade mucosal and neuroinflammation in the dysregulation of the "brain-gut" axis.
Genetics
Unknown. IBS runs in some families; relatives of IBS sufferers are 2-3 times more likely to get the condition.

Risk factors include female sex (1.67 odds ratio).
Somatic variables include GI illness, pain syndromes, obesity, antibiotic use, and stomach surgery. Psychological aspects include stress, abuse history, anxiety, depression, or somatization.
 Social determinants: family history and childhood socioeconomic status
Child Safety Considerations
Mother and fetus are not at risk.


Accompanying Conditions 

 Additional gastrointestinal (GI) functional disorders, such as heartburn, dyspepsia, gastroesophageal reflux disease, nausea, diarrhea, incontinence, pelvic floor dyssynergia, and constipation; chronic illnesses, such as migraines, fibromyalgia, chronic pelvic pain, temporomandibular joint dysfunction, chronic fatigue syndrome, sleep disorders, and overactive bladder
. Psychiatric diseases, including posttraumatic stress disorder, significant depression, anxiety, and somatoform disorders

Rome IV criteria: abdominal discomfort that has occurred for an average of more than one day per week during the previous three months, with an onset that occurred more than six months prior to diagnosis.
- Pain relief or aggravation after defecating
- Changes in bowel frequency and form (appearance). According to the Rome IV classification, there are four bowel patterns:
- IBS-D: diarrhea predominates, with >25% diarrhea and 25% constipation in Bristol stool types 6 or 7.
- In people with IBS-C, constipation predominates, with >25% experiencing Bristol stool types 1 or 2 and 25% experiencing diarrhea.
- IBS-M: mixed bowel patterns, including >25% diarrhea and >25% constipation
IBS-U: unclassified-symptoms: Rome IV criteria are met but there are no subtypes
 Patient has no red flags or warning signs:
- Age above 50, no history of colon cancer screening, and the presence of symptoms
- A recent change in bowel habits - A melana or hematochezia, which is a sign of overt GI bleeding
- Nighttime pain or bowel movement
- Unintentional weight loss of more than 10% in three months
- A palpable abdominal mass or lymphadenopathy - A positive fecal occult blood test - A family history of colorectal cancer, inflammatory bowel disease, or celiac disease - A positive blood test for iron deficiency anemia - A fever associated with gastrointestinal symptoms

Clinical evaluation 

 Comprehensive exam to rule out other explanations, including a digital rectal exam; vital signs and exam are normally unremarkable Peritoneal symptoms, ascites, enlarging lymph nodes, jaundice, and organomegaly are not present.

Differential diagnoses include: Crohn's disease and ulcerative colitis; endocrine disorders such as hyper/hypothyroidism, Addison's disease, and diabetes mellitus; lactose intolerance and fructose malabsorption; infections such as Giardia lamblia, Entamoeba histolytica, Salmonella, Campylobacter, Yersinia, and Clostridium difficile; celia
 Somatization; sadness Small bowel bacterial overgrowth Pancreatic insufficiency
Radiation injury to the colon or small bowel; villous adenoma; endocrine cancers (gastrinoma or carcinoid);


Laboratory Results 
Use a proactive diagnostic approach as opposed to an exclusive diagnosis.
Only acquire baseline labs (CBC, basic metabolic profile, stool O&P, fecal leukocytes, Giardia antigen, and Clostridium difficile toxin) with a usual history and no warning signals (anemia or weight loss), then start treatment.
IBS-D and IBS-M, but not IBS-C, have higher plasma levels of anti-cytolethal distending toxin B (anti-CdtB) and anti-vinculin antibodies (2).
Initial examinations (lab, imaging)
Eliminate any pathology that is unique to the patient's symptoms:
Diarrhea-predominant patients should have thyroid-stimulating hormone (TSH), CRP, CBC, IgA tissue transglutaminase (to rule out celiac disease), fecal calprotectin or fecal lactoferrin, and stool examination for parasites and eggs.
TSH, electrolytes, and calcium (hyperparathyroidism) are the most common causes of constipation.
 LFTs, lipase, or amylase for abdominal pain
Lab tests like fecal calprotectin (40 g/g) are thought to be sufficient to effectively rule out IBD in the absence of warning signs. As an alternative, CRP (0.5 mg/dL) and fecal lactoferrin (7 g/g) might be employed.
Consider conducting a hydrogen breath test to rule out bacterial overgrowth.
Consider additional testing with imaging (ultrasound or CT), endoscopy, video capsule endoscopy, or sitz marker studies for patients who do not react to treatment. In IBS, these will typically be unimpressive.

Tests in the Future & Special Considerations
Consider using a lactulose breath test to check for IBS-related small intestine bacterial overgrowth.
 If a patient has severe diarrhea, is female, older than 60 years old, or is at high risk for microscopic colitis, a colonoscopy should be considered.
Other/Diagnostic Procedures
To rule out microscopic colitis or inflammatory bowel disease, sigmoidoscopy/colonoscopy may be utilized.
If you have IBS-C, an abdominal radiograph may be used to determine how severe the stool burden is.
In patients with severe constipation that is resistant to dietary change and osmotic laxative medication, physiologic tests (anorectal manometry and balloon expulsion) can be used to rule out dyssynergic defecation.

Caution 
Check for colorectal cancer in all people over 45 (or those who exhibit warning symptoms or red flags).


Management 
Goals: To reduce symptoms and enhance quality of life.
Therapy should target a particular IBS subtype.
Lifestyle adjustment
- 3 to 5 times a week of exercise reduces severity.
- A food journal to identify triggers

Medication 
Supplementing with soluble fiber (psyllium) makes the feces more voluminous, yet it rarely relieves tummy pain.
For all IBS varieties:
- Antispasmodics such dicyclomine 20 to 40 mg PO BID and hyoscyamine 0.125 to 0.250 mg PO/SL q4h PRN.
Dry mouth, wooziness, and blurred eyesight are side effects.
- TCAs using the lowest dose possible. IBS has a multimodal method of action. Dry mouth, sleeplessness, flushing, and palpitations are typical side effects. The number of patients (NNT) is 4.5. The NNH scale spans from 9 to 18.
- Probiotics like Streptococcus, Bifidobacterium, and LactobacillusIBS-D with a prominent diarrhea
- Lopiridol To lessen bowel movements and improve stool consistency, use 4 to 8 mg daily divided into 1 to 3 doses as necessary. may additionally make use of atropine and diphenoxylate (4)[B]
- Bile acid sequestrants, such as cholestyramine, colestipol, and colesevelam, in individuals who may be suffering from bile acid malabsorption.
Bloating, discomfort, and stool consistency have all been proven to improve with the use of rifaximin (2-week course). With a NNH of 8,971, the safety profile is favorable.
Alosetron (Lotronex; 0.5 to 1.0 mg PO BID) is a 5-HT3 antagonist that slows intestinal transit and is recommended for women with severe symptoms. In a limited number of patients, however, it has been linked to ischemic colitis, constipation, and mortality.- Other than pain, ondansetron was proven to lessen the severity of symptoms.
- Eluxadoline (75 to 100 mg BID) acts as both an agonist and an antagonist at opioid receptors. Nausea, constipation, stomach pain, sphincter of Oddi spasms, and pancreatitis are examples of side effects. Patients with a history of cholecystectomy, pancreatitis, alcohol usage, or alcoholism should not take this medication.
IBS-C with major constipation may benefit from laxatives like polyethylene glycol, but not pain.
Neomycin is an antibiotic. Lubiprostone is a prostaglandin E1 analog with a high affinity for type 2 chloride channels, which enhances intestinal secretion and peristalsis (8 mg BID with meals). NNT of 12.5, negative symptoms consist of diarrhea and nausea (5) [A].
- Linaclotide (290 g qd) is a guanylate cyclase 2C agonist that has been shown to improve bowel function and decrease abdominal pain and overall severity in adults only; NNT of 6; plecanatide (3 mg qd) is approved for patients with constipation-predominant IBS; it acts by increasing intestinal transit and fluid content and is comparable to linaclotide; NNT of 9; tenapanor
Colonic motility is increased with Tegaserod, a serotonin 5-HT4 receptor agonist licensed by the FDA. lowers stomach ache as well. only suitable for ladies above 65.
Patients with more than one cardiovascular risk factor, a history of intestinal obstruction, gallbladder illness, sphincter of Oddi dysfunction, abdominal adhesions, or a history of ischemic colitis should not take this medicine.



Referral 
The management of affective or personality problems may be aided by a referral to behavioral health services.
 Referral to gastroenterology for situations that are challenging to control
ADVANCED THERAPIES
The usage of probiotics may lessen the discomfort and flatulence associated with IBS. Probiotics with multiple strains typically work better in improving symptoms than those with only one.
As it has antispasmodic, anti-inflammatory, and serotonin 5-HT3 receptor antagonist properties that might help slow motility and possibly lessen visceral hypersensitivity while having few side effects, peppermint oil is utilized as a first-line therapy for IBS-D in Europe.


Patient Follow-Up Monitoring

A validated tool to evaluate the severity of IBS symptoms and track therapy response is the IBS Severity Scoring System. This comprises the degree to which IBS is affecting quality of life, the intensity of the pain and distension, the regularity of bowel movements, and the contentment with bowel habits.


Low-FODMAP eating is recommended.
Consider starting with a 2-week lactose-free diet to rule out lactose intolerance and gradually increasing fiber to prevent excessive intestinal gas production.
In spite of negative results from tests for celiac disease, some people find relief from symptoms on a gluten-free diet by avoiding large meals, fatty foods, and caffeine.

Education of Patients

IBS is a chronic disorder with no elevated risk of malignancy; it is not a psychological illness.


IBS is an illness that lowers quality of life but does not increase death, according to the prognosis.
Recurrences are frequent
Evidence suggests that in some patients, "symptom shifting" does place, when functional bowel symptoms resolve and are then followed by the emergence of functional symptoms in a different system.