| ID | 45 |
|---|---|
| Name | IRRITABLE BOWEL SYNDROME |
| Cause | |
| Signs Symptoms | |
| Diagnosis | |
| Investigations | Investigations: In I.B.S the findings of investigations are usually normal. So, it is of no value to do a lot of tests. In most young patients diagnosis can confidently be^ made on clinical presentations. But, older patients coming with abdominal pain or diarrhoea must be investigated before diagnosing as I.B.S. However, in most cases suspecting as I.B.S some routine and special investigations are done to exclude any organic disease or gynaecological involvement. Routine investigations: 1. Complete blood count & ESR 2. Serological tests (as indicated) 3. Serum albumin 4. Stool- Routine & occult blood test 5. Sigmoidoscopy Special investigations: (to be done as indicated) 1. Ba-enema or colonoscopy- to exclude colorectal cancer or inflammatory bowel disease usually in patients of age over 40 yrs. 2. Ultrasonography of abdominal & pelvic organs- to exclude any organic or gynaecological involvement. 3. Radiological investigations. 4. Test for lactose intolerence. Or, 5. Test for bile acid malabsorption. |
| Management | 1. Reassurance- in most patients where symptoms are not severe and stress-related, reassurance might be sufficient. 2. Patients with diarrhoea predominent: i. For pain & diarrhoea- an anticholinergic drug such as- hyoscyamine 0.125mg orally or sustained-release preparation 0.37mg or 0.75mg orally twice daily; or dicyclomine 10- 20mg or mebeverine hydrochloride 135mg (1 tablet) beore meals and at bedtime, may help to control symptoms. Alosetron, a 5-HT3 antagonist, alters gastrointestinal visceral sensation & colonic motility through blockade of peripheral 5-HT3-receptors, so, it is approved for the treatment of women with severe irnitable bowel syndrome with predominant diarrhoea. Alosetron 0.5-lmg twice daily reduces symptoms of pain, cramps, urgency, & diarrhoea in 50-60% of women. But, as alosetron may cause severe constipation (about 30%), or ischemic colitis (4:1000), the use of alosetron is restricted to women with severe IBS with diarrhoea, who have not responded to conventional therapies. ii. Patient should avoid lxatives, legumes and excessive dietary fibre. iii. If diarrhoea persists- Loperamide 2mg orally 3 to 4 times daily; or Codeine phosphate 30-90mg daily or colestyramine 1 sachet daily. 3. Patients with constipation predominent: i. The patient should be encouraged to have high-roughage diet, ii. If constipation persists- Osmotic laxatives such as- milk of magnesia or polyethylene glycol may increase stool frequency and improve stool consistency. Lactulose or sorbitol produces increased flatus and distention, so that these are less advisable in irritable bowel syndrome. 4. In case of acute episodes of pain and bloating- spasmolytic drugs such as, dicyclomine or hyoscyamine or mebeverine may be advised. 5. Dietary restriction, particularly the avoidance of fresh fruits and salads. Specific foods which cause or enhance irritable condition should be avoided. 6. Nonabsorbable antibiotics: Although, the use of antibiotics in irritable bowel syndrome is controversial, in case of bacterial overgrowth (if any), a nonabsorbale antibiotic- rifaximin 400mg 3 times daily for 10 days, play a role in improvement of symptoms in about 40% of patients. This inprovenent may be attributable to suppression of bacteria in either the small intestine or colon. 7. Psychotherapy may be helpful in case of anxiety & depression, if identified. Patients with predominant diarrhoea associated with psychosocial factors, may benefit from low doses of tricyclic-type antidepressants, such as amitriptyline 10-25mg or nortriptyline, desipramine, imipramine or trazodone 25mg at bedtime, may be increased gradually to 50-100mg. In patients with predominant constipation associated with psychosocial factors, drugs commonly used are sertraline 50-150mg daily or fluoxetine 20-40mg daily at morning. Improvement usually expected within 4 weeks. In chronic anxiety- an antianxiety drug e.g alprazolam 0.25mg 2 or 3 times daily may be beneficial. |
| Introduction | Irritable bowel syndrome can be defined as a functional bowel disorder characterized by a variable chronic or recurrent gastrointestinal symptoms essentially associated with abdominal pain and altered bowel habits. The symptoms can not be explained by structural or biochemical abnormalities. Usual age incidence- late teens to 40 years; women are more frequently affected than men. |
| History | |
| Etiology | Etiology2: As it is a syndrome, a single cause is unlikely. On the other hand no definite or organic cause can be evaluated. Some factors are believed to be associated with the etiology of I.B.S 1. Psychosocial factors - about 50% patients are found to be associated with this problems, such as anxiety, depression, somatisation, neurosis, panic attacks, acute psychological stress etc. 2. Altered gastrointestinal motility - some motility disorders are found but non is diagnostic. 3. Abnormal visceral perception - I.B.S may be associated with increased sensitivity to intestinal distension. 4. Luminal factors - such as following gastroenteritis, dietary intolerence e.g wheat, dairy products etc |
| Clinical Features | Clinical feature: Patient of I.B.S commonly presents with- 1. Abdominal pain referred to the left or right iliac fossa or to the hypogastrium, usually colicky or cramping, diffuse or localised and rarely severe. It is generally relieved by defaecation or with the passage of wind, and is sometimes provoked by food. Pain may be associated with constipation, the stools being hard and pellet like & accompanied by mucous, but rectal bleeding does not occur. Tenderness is common over the pelvic colon. 2. In I.B.S, diarrhoea & alternate constipation is a common phenomenon. Diarrhoea occurs characteristically in the morning; patient usually complaints of passage of frequent small volume stools & a feeling of incomplete emptying of the rectum. 3. Abdominal distension or bloating is very common. 4. Nausea, anorexia, tiredness & weakness occur. Vomiting is common. But patients don’t loss weight 5. Varying degrees of anxiety or depression is present. Patient may also have other functional complaints such as heartburn, chest pain, fatigue, urologic dysfunction, and gynaecologic problems. |
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