Irritable Bowel

Syndrome

Lecture Objectives:
➢ Understand the hypothesis explaining the pathophysiology of IBS.
➢ Common sign and symptoms.
➢ Rome III criteria of diagnosis.
➢ Introduction to management of IBS.
Mind Map
Irritable bowel syndrome (IBS):
Is a gastrointestinal disorder characterized by chronic abdominal pain and altered bowel
habits in the​​
absence​ of any organic cause.​
( when we investigate we will find nothing)

➢ It is the most commonly diagnosed gastrointestinal condition.​ (70%)

➢ The pathophysiology of IBS remains​ ​
uncertain.​
(it is different among people)
➢ It is viewed as a disorder resulting from an interaction among a number of factors.
(multifactorial)

Pathophysiology:
1.GASTROINTESTINAL MOTILITY:
Motor abnormalities of the GI tract are detectable in some patients with IBS.
Abnormalities observed include:
1. Increased frequency and irregularity of luminal contractions.
2. Prolonged transit time in constipation-predominant IBS.

2.VISCERAL HYPERSENSITIVITY:
➢ Visceral hypersensitivity ​(increased sensation in response to stimuli)​is a frequent
finding in IBS patients.
➢ Perception in the gastrointestinal (GI) tract results from stimulation of various
receptors in the gut wall.
➢ These receptors transmit signals via​ ⇒​ afferent neural pathways to​ ⇒​ the dorsal horn
of the spinal cord and​⇒​ultimately to the brain
Examples are as shown below:

Distention: Bloating :

Various studies have shown that in patients About half of patients with IBS (mainly
with IBS, awareness and pain caused by those with constipation) have a measurable
balloon distention in the intestine are increase in abdominal girth associated with
experienced at ​
lower balloon volumes bloating (​
sensation of abdominal fullness​
)
compared with controls

unclear ​
**It is​ whether heightened sensitivity of the intestines to normal sensations is
mediated by the local GI nervous system, by central modulation from the brain, or by some
combination of the two.
3.INTESTINAL INFLAMMATION

➢ Increased numbers of ​ lymphocytes​ have been reported in the colon and small
intestine in patients with IBS .
➢ increase in lymphocyte infiltration in the myenteric plexus in nine patients and​ ​
neuron
degeneration​ ​
in six patients .
➢ These cells release mediators​ (nitric oxide, histamine and proteases)​capable of ​
⇒
stimulating the enteric nervous system​ ⇒​
​ abnormal motor and visceral responses
within the intestine

4.ALTERATION IN FECAL MICROFLORA

1. Change ​ in gut microbiota:​​
(normal flora)
Emerging data suggest that the fecal microbiota in individuals with IBS differ from healthy
controls and varies with the predominant symptom
2. Bacterial​ Overgrowth
(either probiotics: taking the bacteria itself and eating them prebiotics: taking food that
promotes the growth of bacteria)

5.POSTINFECTIOUS
after being infected by a microbe, they will develop IBS

6.FOOD SENSITIVITY
The notion of food allergy in irritable bowel syndrome (IBS) is not new. However, recent
evidence suggests significant reduction in IBS symptom severity in patients on elimination
diets, provided that dietary elimination is based on foods against which the individual had
raised IgG antibodies

7.PSYCHOSOCIAL DYSFUNCTION
Psychosocial factors may ​
influence​
the expression of IBS.
 Clinical features
1. younger patients and women are more likely to be diagnosed with IBS.
2. (2:1) female predominance in North America.
3. In china male are more common to have IBS

Signs and Symptoms

1. Chronic abdominal Pain
2. Altered bowel habits
3. Diarrhea
4. Constipation
5. Others (Gastroesophageal reflux, dyspepsia, early satiety, nausea and noncardiac
chest pain)

Subtypes of IBS

1-IBS with 2-IBS with diarrhea 3-Mixed IBS 4-Un-subtypes IBS

constipation:
The easiest type
to treat

Hard or Lumpy ≥
25% <5% ≥
25 %
percentage in bowl Insufficient
movement abnormality of
stool consistency
<25%. ≥
25% ≥
25% to meet the other
Loose or Watery subtypes.
percentage in bowl
movement
Diagnostic approach
1-​Diagnostic criteria (Rome III criteria) :
Recurrent abdominal pain or discomfort​ at least 3 days per month in the last 3 months
associated with 2 or more of the following:
I. Improvement ​ with defecation.
II. Onset associated with a change​ in frequency​ ​
of stool.
III. Onset associated with a change​ in form​​
(appearance) of stool.
2-Patients are identified as having a symptom complex compatible with IBS based upon the
Rome III criteria.
3- Routine laboratory studies (complete blood count, chemistries) are normal in IBS.
4- NO red flag symptoms: ( ​Rectal bleeding​,​
​ ​
Nocturnal or progressive abdominal pain​
,
Weight loss​ )​
W​eight loss, ​
A​
bdominal pain, ​
R​
ectal bleeding
Mnemonic: (WAR), if present you need to investigate..

( NOTE: Red flag symptoms predict malignancies )

(iBS does not start in old age, usually in young age if patient is 40 then this isn't IBS. lower or upper bleeding isn't IBS, IBS
does not cause bleeding, IBS won't cause significant weight loss and won't wake them up from sleep)

Management
➢ IBS is a chronic condition with no known cure.
➢ The focus of treatment should be on relief of symptoms and in addressing the
patient's concerns.
1. Therapeutic relationship
2. Patient education
3. Dietary ​
modification
4. Psychosocial therapies
​
5. Medications: Antidepressant medication (the​ ​
SSRI​
is the best)
Mast cells and pro­inflammatory cytokines
Mast cells Proinflammatory cytokines

What are they..? Effector cells of the immune system. Proteins that are mediators
of immune responses.

1.An​increased number​ ​
of mast cells E​
levated ​
levels of plasma
has been demonstrated in the proinflammatory
terminal ileum, jejunum, and colon of interleukins have been
IBS patients. observed in patients with
IBS.
The role in IBS..?
2.Studies have demonstrated a In addition, peripheral blood
correlation between abdominal pain mononuclear cells of IBS
in IBS and the presence of ​activated patients produce higher
amounts of​ tumor necrosis
mast cells in proximity to colonic
factor​
than healthy control.
nerves.

_____________________________
____________
 MCQs
1) Irritable bowel syndrome is most common in elderly males.
a) True.
b) False.
2) Once other disease conditions have been ruled out, a person can be considered for the
diagnosis of irritable bowel syndrome if the symptoms were present for the last-?
a) One week.
b) Two week.
c) One month.
d) Three months.
3) The abdominal pain in patients with irritable bowel syndrome worsens after bowel
movement (defecation).
a) True.
b) False.
4) Foods that could worsen symptoms of irritable bowel syndrome include-?
a) High fat food.
b) Excessive caffeine or alcohol.
c) Milk product.
d) All of them.
5) People with irritable bowel syndrome may suffer either from?
a) Constipation.
b) Diarrhea .
c) Both.
d) Nether.
6) IBS associated with ..?
a) Improvement with defecation .
b) Change in frequency of stool .
c) Change in form of stool .
d) All of them.

1)B 2)D 3)B 4)D 5)C 6)D

 SAQs
A 34-year-old mother of 3 presents to her family physician with a 3-week history of
abdominal cramping pain in both lower quadrants. She has been having frequent small, soft
stools accompanied by some mucus but no blood. Her symptoms are improved with bowel
movement or passage of flatus. She has had these symptoms almost monthly since she was in
college, but they have been worse recently. Past history is negative except for 3 normal
pregnancies. Family history is negative for colon cancer. A sister has similar symptoms but
has not seen a physician. Personal/social history reveals that she is an accountant working
long hours. Her firm is about to merge with another, and she fears her job situation is
tenuous. Review of systems is otherwise negative. She has not lost any weight or had any
other constitutional symptoms. On physical examination, the only finding is some mild
tenderness in the RLQ. No mass is felt

What is your diagnosis ?

Irritable bowel syndrome (IBS)

What is the most important factor affecting her symptoms?

Psychosocial factor
______________________________________________________________________________

A 40-year-old housewife complains of recurrent constipation. She has had problems since her
20s, but they are worse now. The constipation is accompanied by abdominal bloating and
abdominal pain, and the discomfort is only better when she has a bowel movement. On her
gynaecologist's advice, she has tried more fibre in her diet, including fresh fruits and leafy
vegetables, but that has only made the bloating worse. Her past history includes a
cholecystectomy and a hysterectomy. Physical examination is entirely normal. Rectal
examination reveals normal consistency stool. Stool samples test negative for occult blood.

What is the most likely pathogenesis of this case ?

Abnormal gastrointestinal motility

What is your goal management?

To relieve her symptoms either by :
Therapeutic relationship Patient education Dietary modification Psychosocial therapies
Done By:
➔AbdulRahman AlArfaj
➔Saleh AlBanyan
➔Abdullah AlSahli
➔Abdulaziz AlSaud
➔Rawa AlOhali
➔Reema AlRasheed
➔Ameera Bin Za’eer
➔Rasha Bassas

Never Forget to:

Contact us at:
[email protected]