Irritable Bowel Syndrome

Welcome to PT 635 Pathophysiology of Complex Patient Problems. This is a wiki created by and for the students in the School of Physical Therapy at Bellarmine University in Louisville KY. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!

Original Editors - Mary Page from Bellarmine University's Pathophysiology of Complex Patient Problems project.

Lead Editors - Your name will be added here if you are a lead editor on this page.  

Definition/Description

File:Ibs.jpg

 Irritable bowel syndrome (IBS) is a group of symptoms that represent the most common disorder of the GI system. IBS is a functional disorder of motility in the small and large intestine. IBS is also identified as nervous indigestion, functional dyspepsia, spastic colon, nervous colon, irritable colon, pylorospasm, spastic colitis, intestinal neuroses and laxative or cathartic colitis. Although IBS has been referred to as a type of colitis it is not an inflammatory disease of the intestinal tract ."

Prevalence

"IBS is one of the most commonly diagnosed GI disorders in the U.S. with 20% of the population affected. In Western society it accounts for 50% of sub-specialty referrals ."  "Approximately 45 million Americans have been diagnosed with IBS, and it is likely more are affected but have yet to be diagnosed ." 

"Many people have occasional signs and symptoms of irritable bowel syndrome, but you're more likely to have IBS if you: 

■Are young. IBS begins before the age of 35 for 50 percent of people.
■Are female. Overall, about twice as many women as men have the condition.
■Have a family history of IBS. Studies have shown that people who have a first-degree relative — such as a parent or sibling — with IBS are at increased risk of the condition.

Researchers are studying whether the influence of family history on IBS risk is related to genes, to shared factors in a family's environment, or both ."

Characteristics/Clinical Presentation

"GI symptoms are highly variable and can include but are not limited to nausea, vomiting, anorexia, foul breath, sour stomach, flatulence, cramps, abdominal bloating, and constipation and/or diarrhea. Some patients may report white mucus in their stool ." "Pain may be steady or intermittent, and there may be a dull, deep discomfort with sharp cramps in the morning or after eating. The typical pain pattern consists of lower left quadrant abdominal pain accompanied by constipation and diarrhea. Upper abdominal pain that extends up under the ribs can occur when the sigmoid colon in the left lower abdomen contracts and gas rises into the transverse colon. Abdominal discomfort and pain is relieved by defecation ."  

File:Clinical Features IBS2.JPG

"There is variation and overlap in symptoms for many patients and the variety of symptoms cited are commonly experienced. It is by no means an indication of a typical IBS profile since many patients experience few or all of these symptoms ."

"Complications:  Diarrhea and constipation, both signs of irritable bowel syndrome, can aggravate hemorrhoids. In addition, if you avoid certain foods, you may not get enough of the nutrients you need, leading to malnourishment. 

But the condition's impact on your overall quality of life may be the most significant complication. IBS is likely to limit your ability to:

■ Make or keep plans with friends and family. If you have IBS, the difficulty of coping with symptoms away from home may cause you to avoid social engagements.

■ Enjoy a healthy sex life. The physical discomfort of IBS may make sexual activity unappealing or even painful.
■ Reach your professional potential. People with IBS miss three times as many workdays as do people who don't have the   condition.
These effects of IBS may cause you to feel you're not living life to the fullest, leading to discouragement or even depression .

For further information visit this link for a slideshow on IBS: <a href="http://www.rxlist.com/irritable_bowel_syndrome_slideshow/article.htm">www.rxlist.com/irritable_bowel_syndrome_slideshow/article.htm</a>

Associated Co-morbidities

"Extra-GI conditions associated with IBS are numerous, such as fibromyalgia, chronic fatigue syndrome, temporomandibular joint disorder, and chronic pelvic pain <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Goodman & Fuller" />." "IBS is also often linked with psychosocial factors. In cases where symptoms are severe and unchanged by treatment, a history of mental, physical or sexual abuse may be considered."

<img src="/images/7/72/Cfs2_5.gif" _fck_mw_filename="Cfs2 5.gif" _fck_mw_location="center" _fck_mw_width="300" _fck_mw_height="300" _fck_mw_type="frame" alt="Image:Cfs2_5.gif" class="fck_mw_frame fck_mw_center" /> 

"IBS is commonly diagnosed in the early adulthood of females and there is a well documented association between IBS and dysmenorrhea. At this time it is not known whether this correlation is one of diagnostic confusion or whether dysmenorrhea and IBS have a common physiologic basis <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Goodman & Snyder" />."  

Medications

"At this time antianxiety/antidepressant drugs and anticholinergic agents are used before meals to help control symptoms. The enteric nervous system and the brain use the same chemicals and hormones. This fact may explain why low doses of antidepressants designed to affect the brain may improve certain digestive diseases. Antidepressants are thought to operate by reducing visceral hypersensitivity at the level of the visceral afferent fibers <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Goodman & Fuller" />."

"Along this same line of thought, newer drugs being used in the treatment of IBS include serotonin-modulating agents that inhibit the action of serotonin in the gut. The GI tract contains an estimated 90-95% of the body’s serotonin. Serotonin is a neurotransmitter found in the brain and gut and appears to be a common link involved in GI motility, intestinal secretion, and pain perception. Research continues to search for targeted serotonin medications that can be individualized to each patient dependent upon their presentation and symptoms <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Goodman & Fuller" />."

"Other medications include probiotic treatment with Lactobacillus and Bifidobacterium which may help to alter the microbial flora of the intestinal tract and ease the symptoms of IBS. Alternative therapy, such as peppermint oil, chamomile, rosemary, valerian, ginger, and turmeric, has antispasmodic effects and may relieve cramping <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Goodman & Fuller" />."

"Medication specifically for IBS
Two medications are currently approved for specific cases of IBS: 

■Alosetron (Lotronex). Alosetron is a nerve receptor antagonist that's designed to relax the colon and slow the movement of waste through the lower bowel. The drug was removed from the market soon after its original approval because it was linked to serious complications. The Food and Drug Administration (FDA) has since allowed alosetron to be sold again — with restrictions. The drug can be prescribed only by doctors enrolled in a special program and is intended for severe cases of diarrhea-predominant IBS in women who haven't responded to other treatments. Alosetron is not approved for use by men.

Generally, alosetron should only be used if usual therapy for IBS has failed. Additionally, it should only be prescribed by a gastroenterologist with expertise in IBS because of the potential side effects.

■Lubiprostone (Amitiza). Lubiprostone is approved for women age 18 and older who have IBS with constipation. Its effectiveness in men is not proved. Lubiprostaone is a chloride channel activator that you take twice a day. It works by increasing fluid secretion in your small intestine to help with the passage of stool. Common side effects include nausea, diarrhea and abdominal pain. More research is needed to fully understand the effectiveness and safety of lubiprostone. Currently, the drug is generally prescribed only for women with IBS and severe constipation for whom other treatments haven't been successful <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Mayo" />."

Recent Research- In a recent study by Saito et al., St. John’s Wart was tested in a randomized control trial to define it’s efficacy in the treatment of IBS. Due to the antidepressant affects of St. John’s Wart it was hypothesized St. John’s Wart may have a calming affect as other antidepressants have on IBS. However, it was found that St. John’s Wart was less effective then the placebo in a 12 week treatment of participants with an established diagnosis of IBS . 

<img src="/images/c/ce/Treatment_IBS.JPG" _fck_mw_filename="Treatment IBS.JPG" _fck_mw_location="center" _fck_mw_type="frame" alt="" class="fck_mw_frame fck_mw_center" /><span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Shan" />

Diagnostic Tests/Lab Tests/Lab Values

"Diagnosis of IBS happens one of two ways, either by “diagnosis of exclusion” or the symptom based approach ." "Diagnosis of exclusion may involve one or more tests such as an ultrasound, thyroid function test, endoscopy (rigid/flexible sigmoidoscopy, colonoscopy, barium enema) to examine the colonic lumen for other possible pathology, complete blood count and stool examination to rule out lactose intolerance and the presence of occult blood, parasites and pathogenic bacteria <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Shan" />." "The symptom based approach uses developed criteria for the diagnosis of IBS <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Goodman & Fuller" />."

"Many symptom based criteria exist, which can make it hard to decide which criteria to use. One of the most common criteria based approaches used to date by physicians is the Roma II criteria.

According to this criteria, you must have certain signs and symptoms before a doctor diagnoses irritable bowel syndrome. The most important are abdominal pain and discomfort lasting at least 12 weeks, though the weeks don't have to occur consecutively. You also need to have at least two of the following:

■A change in the frequency or consistency of your stool — for example, you may change from having one normal, formed stool every day to three or more loose stools daily, or you may have only one hard stool every three to four days
■Straining, urgency or a feeling that you can't empty your bowels completely
■Mucus in your stool
■Bloating or abdominal distension

Your doctor will likely assess how you fit these criteria, as well as whether you have any other signs or symptoms that might suggest another, more serious condition. Some red flag signs and symptoms that might prompt your doctor to do additional testing include:

■New onset after age 50
■Weight loss
■Rectal bleeding
■Fever
■Nausea or recurrent vomiting
■Abdominal pain, especially if it's not completely relieved by a bowel movement
■Diarrhea that is persistent or awakens you from sleep

If you have these red flag signs or symptoms, you'll need additional testing to further assess your condition.

If you fit the IBS criteria and don't have any red flag signs or symptoms, your doctor may suggest a course of treatment without doing additional testing. But if you don't respond to that treatment, you'll likely require more tests.

Additional tests:
Your doctor may recommend several tests, including stool studies to check for infection or malabsorption problems. Among the tests that you may undergo to rule out other causes for your symptoms are the following:

■Flexible sigmoidoscopy. This test examines the lower part of the colon (sigmoid) with a flexible, lighted tube (sigmoidoscope).
■Colonoscopy. In some cases, your doctor may perform this diagnostic test, in which a small, flexible tube is used to examine the entire length of the colon.
■Computerized tomography (CT) scan. CT scans produce cross-sectional X-ray images of internal organs. CT scans of your abdomen and pelvis may help your doctor rule out other causes of your symptoms.
■Lactose intolerance tests. Lactase is an enzyme you need to digest the sugar found in dairy products. If you don't produce this enzyme, you may have problems similar to those caused by irritable bowel syndrome, including abdominal pain, gas and diarrhea. To find out if this is the cause of your symptoms, your doctor may order a breath test or ask you to exclude milk and milk products from your diet for several weeks.
■Blood tests. Celiac disease (nontropical sprue) is sensitivity to wheat protein that also may cause signs and symptoms like those of irritable bowel syndrome. Blood tests may help rule out that disorder <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Mayo" />." 

"Symptom based (criteria based) approaches can vary widely in their administration and interpretation from one practitioner to the next and have yet to be standardized over any one health profession <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Williams" />." Research is still being done to decide the reliability and validity of different symptom based criteria as well as their ability in ruling out other pathology and ruling in IBS as the correct diagnosis.

Causes

"IBS is considered a “functional” disorder because the symptoms cannot be attributed to any identifiable abnormality of the bowel, structural or biochemical. It is thought IBS may involve three main abnormalities of gut function: altered GI motor activity, visceral hypersensitivity, and/or altered processing of information by the nervous system. IBS is characterized by abnormal intestinal contractions theorized as a result of the digestive tract’s reaction to emotions, stress, and certain chemicals in particular foods. People with IBS have an exaggerated gastrocolic reflex, the signal the stomach sends to the colon to stimulate contractions after food arrives. Some cases IBS have no signs of increased GI motility, suggesting an increased internal sensitivity.

This enhanced sensation and perception of what is happening in the digestive tract referred to as “enhanced visceral nociception.” In such cases it may be that the internal pain threshold is lowered for reasons that remain unclear. Individuals with IBS experience pain and bloating at much lower pressures than people without IBS. Serotonin, a neurotransmitter produced in the gut and located inside the enteric nerve cells, may also play a role in the disorder. The GI tract is very sensitive to changes in serotonin levels. It’s possible IBS occurs as a result of abnormalities in serotonin levels responsible for digestive function. Increased levels of serotonin in the gut result in diarrhea, while decreased levels may account for individuals who have IBS-associated constipation.

It is well documented that individuals with IBS report a greater number of symptoms compatible with a history of psychopathologic disorders, abnormal personality traits, psychologic distress, and sexual abuse. Episodes of emotional or psychologic stress, fatigue, smoking, alcohol intake, or eating (expecially a large meal with high fat content, roughage, or fruit) do not cause but rather trigger symptoms. Intolerance of lactose and other sugars may account for IBS in some people.

Scientists continue to explore the brain-gut connection to better understand IBS and other functional GI disorders. The enteric nervous system is composed of a vast network of neurons located throughout the GI tract. This neuronal network communicates directly with the brain through the spinal cord. There are as many neurons in the small intestine as in the spinal cord, and the same hormones and chemicals that transmit signals in the brain have been found in the gut, including serotonin, norepinephrine, nitric oxide, and acetylcholine. Studies investigating the effects of emotional words on the digestive tract substantiated the close interaction among mind, brain, and gut. Preliminary data demonstrate an increase in intestinal contractions and change in rectal tone during exposure to angry, sad, or anxious words. These changes of intestinal motor function may influence brain perception <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Goodman & Fuller" />."

<img src="/images/7/7b/Enteric_nervous_system.jpg" _fck_mw_filename="Enteric nervous system.jpg" _fck_mw_location="center" alt="" class="fck_mw_center" />
"Organization of the enteric component of the visceral motor system. (A) Sympathetic and parasympathetic innervation of the enteric nervous system, and the intrinsic neurons of the gut. (B) Detailed organization of nerve cell plexuses in the gut wall. The neurons of the submucus plexus (Meissner's plexus) are concerned with the secretory aspects of gut function, and the myenteric plexus (Auerbach's plexus) with the motor aspects of gut function (e.g., peristalsis) ."

<img src="/images/d/d6/Gut_brain.jpg" _fck_mw_filename="Gut brain.jpg" _fck_mw_location="center" alt="" class="fck_mw_center" />"Pyschological factors such as stress, anxiety and depression as well as psychological trauma such as verbal, physical, emotional and sexual abuse have an affect on the intestines by direct connections through the brain gut axis ."

Systemic Involvement

Gastrointestinal System

Small intestine

Large intestine

Neuromuscular System

Enteric Nervous System

Medical Management (current best evidence)

"Treatment is aimed at relieving abdominal discomfort, stabilizing bowel habits, and altering underlying causes of the syndrome. Lifestyle changes, especially dietary changes, medications, behavioral counseling, and psychotherapy have been advocated. Dietary exclusion of milk and other dairy products can be helpful for patients with lactose intolerance. Increased dietary fiber, use of bulking agents such as psyllium preparations, and avoidance of alcohol, tobacco, gas-producing foods (e.g., cauliflower, cabbage, baked beans, broccoli), and GI stimulants such as caffeine are often recommended.

Since people with IBS can have a slower intestinal transit time, resulting in constipation, maintaining regular bowel movements is an important part of them anagement of IBS. Once constipation occurs, getting rid of painful symptoms is difficult. The use of fiber supplements such as polycarbophil (FiberCon), psyllium seed (Metamucil), and increased intake of water and other fluids is advised.

A stress reduction program with a regular program of relaxation techniques and exercise in conjunction with psychotherapy and biofeedback training may be effective for some people. Behavioral therapy is focused on identifying and reducing or eliminating triggers and reducing negative self-talk. Hypnotherapy can give some control over the muscle activity of the GI tract and the gut’s sensitivity to stress and other influences <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Goodman & Fuller" />."

<img _fck_mw_template="true" _fckrealelement="1" _fckfakelement="true" src="http://www.physio-pedia.com/extensions/FCKeditor/fckeditor/editor/images/spacer.gif" class="FCK__MWTemplate">

 

Physical Therapy Management (current best evidence)

"Regular physical activity helps relieve stress and assists in bowel function, particularly in people who experience constipation.  The therapist should encourage anyone with IBS to continue with their prescribed rehabilitation intervention program during symptomatic periods.

Therapists must be alert to the person with IBS who has developed breath-holding patterns or hyperventilation in response to stress.  Teaching proper breathing is important for all daily activities, especially during exercise and relaxation techniques.

For therapists working in the field of women's health, a known correlation exisits between a history of childhood/adulthood emotional or sexual abuse and neurologic and functional (or organic) GI disorders.  The first step in effective intervention is recognizing these individuals.  Many articles are available to help the therapist incorporate this type of evaluation, including the American Physical Therapy Association Guidelines for Recognizing and Providing Care for Victims of Domestic Violence.  More must be done in this area to offer threapists guidelines and intervention management skills when sexual abuse has been part of the history <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Goodman & Fuller" />."

"A quick three question screening tool is positive for partner violence if even one question is answered "yes":

  Intro: Abuse in the home is so common today we now ask all our clients: 

• Have you been kicked, hit, pushed, choked, punched or otherwise hurt by someone in the last year?
• Do you feel unsafe in your current relationship?
• Is anyone from a previous relationship making you feel unsafe now? 

  Follow up with: Is there anything else you would like to tell me about your situation?" <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Goodman & Snyder" />

Alternative/Holistic Management (current best evidence)

  <img src="/images/2/23/Herb2.JPG" _fck_mw_filename="Herb2.JPG" _fck_mw_location="left" _fck_mw_type="frame" alt="These are just a few of the natural remedies used for IBS." class="fck_mw_frame fck_mw_left" />

<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Shan" /> "The prescription of herbal remedies is usually supplemented with advice on dietary modifications, patient reassurance and education. The holistic approach adopted by herbalists will enable the assessment of lifestyle choices and a psychological profile (for example, is there a predisposition to anxiety, depression or stress?) as well as the clinical features in diagnosis and treatment. Herbal remedies for IBS can range from the simple to the complicated; those with the following actions are indicated: antispasmodics (spasmolytics), carminatives, demulcents, astringents, nervines, stomachics, hepatics and cholagogues (these improve the general digestive efficiency) and anti-catarrhals (helps clear mucus). Additionally, if symptoms necessitate, haemostatics (styptics), anti-allergenics and anti-emetics may be considered.

Herbal teas such as chamomile (Chamaemelumnobile) can be surprisingly effective due to their relaxation and gentle antispasmodic properties. Peppermint (Mentha piperita) and fennel (Foeniculum vulgare) are both antispasmodics as well as anti-inflammatories. Herbalists often recommend combining these three herbs to make a single dose tea to soothe painful spasms and expel excess wind. Several clinical trials as well as animal studies which have shown the potential benefits of peppermint oil in IBS and other studies illustrate a clear understanding of its mode of action on the gut. However, human studies of peppermint leaf are limited and clinical trials on the actual tea are absent <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Shan" />."

Differential Diagnosis

" Inflammatory Bowel Disease:

1) Ulcerative colitis - inflammation and ulceration of the inner lining of the large intestine and rectum. 

2) Crohn's disease - inflammatory disease that most commonly attacks the terminal end of the small intestine (ileum) and the colon.  However, it can occur anywhere from the mouth to the anus.

Colorectal Cancer:

  The presentation of colorectal carcinoma is related to the location of the neoplasm within the colon and the stage of the cancer.  Early stage signs and symptoms include rectal bleeding, hemorrhoids, abdominal/back/pelvic/sacral pain, back pain radiating down the legs and changes in bowel patterns.  Advanced stage signs and symptoms include constipation progressing to obstruction, diarrhea with copious amounts of mucus, nausea, vomiting, abdominal distention, weight loss, fatigue, dyspnea, and fever <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Goodman & Snyder" />."

Case Reports 

Drossman DA, Ringel Y, Vogt BA, Leserman J, Lin W, Smith JK et al. <a href="http://conferences.thehillgroup.com/ncdd-files/5.%20Post-Conference%20Call%20Reports/Working%20Group%20%2302%20Consolidated%20-Drossman%20Case%20Profile_Alterations%20of%20Brain%20Activity%20Case%20.pdf">Alterations of brain activity associated with resolution of emotional distress and pain in a case of severe irritable bowel syndrome</a>. GASTROENTEROLOGY 2003;124:754-761.

Resources

<a href="http://www.worldgastroenterology.org/">World Gastroenterology Organization</a>

<a href="http://www.ibsgroup.org/">Irritable Bowel Syndrome Self Help and Support Group</a>

<a href="http://www.irritable-bowel-syndrome.ws/">Irriitable Bowel Syndrome Treatment</a>

<a href="http://www.aboutibs.org/">International Foundation for Functional Gastrointestinal Disorders: About IBS</a>

Recent Related Research (from <a href="http://www.ncbi.nlm.nih.gov/pubmed/">Pubmed</a>)

see tutorial on <a href="Adding PubMed Feed">Adding PubMed Feed</a>

http://eutils.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1l7lJQBQXfTNJmMnqeiR9r7Mqme5RuIyRZNkPvTdzrliJA6YU3%7Ccharset=UTF-8%7Cshort%7Cmax=10

References

see <a href="Adding References">adding references tutorial</a>.

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