IBS:Constipation - louisville.edu

IBS:Cons

Richard N. Re
Professo

stipation

edinger, M.D.
or of Medicine

Functional Bowel D

z Functional bowel disorder
biopsychosocial model of
illness or disease

z Rather than having a stru
represent altered gut phys
axis that translates neuro
clinical symptoms

Disorders

rs are best understood as a
f the pathophysiology of

uctural organic basis, they
siology via the brain/gut
otransmitter function into

Functional Bowel D

z Psychosocial factors include
experiences with psychologic
capability and inadequate soc

z Physiologic alterations with g
influences impact gut motility
and altered bacterial flora cau
associated with enhanced vis
of gut function also have linka
areas that have behavioral co

Disorders

life stresses particularly early life
c stress that affect coping
cial support
genetic and environmental
y and its sensation, inflammation
using immune modulation that are
sceral sensitivity. CNS modulation
ages to emotional and cognitive
onsequences.

Rome III Functional Gastro

(Gastroenterology 2006

A. Functional esophageal disorders
A1. Functional heartburn
A2. Functional chest pain of presum
A3. Functional dysphagia
A4. Globus

B. Functional gastroduodenal disor
B1. Functional dyspepsia
B1a. Postprandial distress syndr
B1b. Epigastric pain syndrome
B2. Belching disorders
B2a. Aerophagia
B2b. Unspecified excessive belc
B3. Nausea and vomiting disorders
B3a. Chronic idiopathic nausea
B3b. Functional vomiting
B3c. Cyclic vomiting syndrome
B4. Rumination syndrome in adults

ointestinal Disorders

6;130:1377-1556)

s
med esophageal origin

rders
rome

ching
s

s

Rome III Functional Gastrointestina

C. Functional bowel disorders
C1. Irritable bowel syndrome
C2. Functional bloating
C3. Functional constipation
C4. Functional diarrhea
C5. Unspecified functional bowel disorder

D. Functional abdominal pain syndrome
E. Functional gallbladder and Sphincter of O

E1. Functional gallbladder disorder
E2. Functional biliary SO disorder
E3. Functional pancreatic SO disorder
F. Functional anorectal disorders
F1. Functional fecal incontinence
F2. Functional anorectal pain

F2a. Chronic proctalgia
F2a1. Levator ani syndrome
F2a2. Unspecified functional anorectal

F2b. Proctalgia fugax
F3. Functional defecation disorders

F3a. Dyssynergic defecation
F3b. Inadequate defecatory propulsion

al Disorders

Oddi (SO) disorders
l pain

Qualificatio

Symptom Bas

1. Coexisting disease(s) must b
i.e., no evidence of inflammat
neoplastic abnormalities

2. Symptoms from one domain m
functional bowel disorders

3. Symptoms must exist for 6 m
active for 3 months

4. Diagnostic categories do not
are seen more commonly in r
practices

5. Criteria are determined by clin
evidence

ons for
sed Criteria

be excluded
tion, anatomy, metabolic or
may overlap with various other GI

months prior to diagnosis and be
include psychosocial criteria but
referred versus primary care
nical consensus and existing

Functional Gastrointestinal Dis

Table 1.

C. Functional bowel disor
C1. Irritable bowel sy
C2. Functional bloatin
C3. Functional consti
C4. Functional diarrh
C5. Unspecified func

sorders

rders
yndrome*
ng
ipation*
hea
ctional bowel disorder

Irritable Bowel Sy

Definition:
IBS is a functional bowe

abdominal pain or disc
with defecation or a ch
and with features of di

yndrome

el disorder in which
comfort is associated
hange in bowel habit,
isordered defecation.

Epidemiology

Throughout the world, ab
adults and adolescent
consistent with IBS, an
female predominance.
and go over time, ofte
functional disorders, im
result in high health ca

bout 10%-20% of
ts have symptoms
nd most studies find a
. IBS symptoms come
en overlap with other
mpair quality of life, and
are costs.

Diagnostic criteria*

Recurrent abdominal pain or discomfo
last 3 months associated with 2

1. Improvement with defecation
2. Onset associated with a change in
3. Onset associated with a change in

*Criteria fulfilled for the last 3 months w
months prior to diagnosis.

**Discomfort means an uncomfortable
pathophysiology research and c
frequency of at least 2 days a we
subject eligibility.

* for IBS

ort** at least 3 days per month in the
or more of the following:

frequency of stool
form (appearance) of stool
with symptom onset at least 6

e sensation not described as pain. In
clinical trials, a pain/discomfort
eek during screening evaluation for

Subtyping IBS by Predom

1. IBS with constipation (IBS-C) –
loose (mushy) or watery stoo

2. IBS with diarrhea (IBS-D) – loos
25% and hard or lumpy stool

3. Mixed IBS (IBS-M) – hard or lum
(mushy) or watery stools ≥25

4. Unsubtyped IBS – insufficient a
meet criteria for IBS-C, D, or

minant Stool Pattern

– hard or lumpy stools ≥25% and
ols <25% of bowel movements.
se (mushy) or watery stools ≥

< 25% of BMs.
mpy stools ≥25% and loose
5% of bowel movements.
abnormality of stool consistency to
M.

The Bristol Stool Fo

orm Scale

Clinical Evaluatio

Diagnosis depends on caref
temporal relationships of
habit, and stool character
related to defecation is lik
whereas that associated w
urination, or menstruation
cause. Fever, gastrointes
anemia, abdominal mass,
symptoms or signs are no
accompany it.

on

ful interpretation of the
pain/discomfort, bowel
ristics. Pain/discomfort
kely to be of bowel origin,
with exercise, movement,
n usually has a different
stinal bleeding, weight loss,
, and other “alarm”
ot due to IBS, but may

Clinical Evaluatio

In women, so-called pelvic p
symptoms during menstru
other gynecologic sympto
diagnosis. Incorrect symp
hospitalization and surger
cholecystectomy, append
The recognition and evalu
in patients with “pelvic” or
reduce unnecessary surg

on

pain, worsening of IBS
uation, and dyspareunia or
oms may obscure the
ptom attribution can lead to
ry, especially
dectomy, and hysterectomy.
uation of bowel dysfunction
r abdominal pain may
gery.

Clinical Evaluatio

z Heartburn, fibromyalgia, h
genitourinary symptoms,
associated with IBS, but a
it.

z Few tests are required for
IBS symptoms and no ala
investigations may be cos

on

headache, backache,
and others are often
are not useful in diagnosing

r patients who have typical
arm features. Unnecessary
stly and even harmful.

Investigations

z Few tests are necessary for pat
and no alarm features. Tests a
duration and severity, psychoso
FH colon cancers.

z Fiberoptic sigmoidoscopy or col
z Stool Examination
z R/O celiac diseases based on c
z Assess QOL, daily Fx, personal

tients with typical IBS symptoms
are based on patients age,
ocial factors, alarm symptoms and

lonoscopy to r/o organic disease

clinical features
lity, life stresses.

Physiologic Featu

IBS is best viewed as an int
biological and psychosoci
visceral hyperalgesia, dis
interaction, abnormal cen
and hormonal events, gen
factors, postinfectious seq
disturbance are variably in
individual.

ures

teraction of important
ial factors. Altered motility,
sturbance of brain-gut
ntral processing, autonomic
netic and environmental
quels, and psychosocial
nvolved, depending on the

Psychosocial Fea

Psychological disturbance, e
patients, includes psychia
disorder, generalized anx
disorder, and posttraumat
disturbance, and dysfunct
childhood abuse is comm
events sometimes correla
exacerbation, the nature o
psychosocial factors and

atures

especially in referred
atric disorders (eg, panic
xiety disorder, mood
tic stress disorder), sleep
tional coping. A history of
mon. Although stressful life
ate with symptom
of the link between
IBS is unclear.

Treatment

Possible Drugs for a Dominant Sy

ymptom in IBS

Treatment

z Reassurance and Education

Regarding healthy lifestyles, beha
psychosocial issues.

z Establish a Therapeutic Relationshi

Develop a strong physician-patien
Be sympathetic, maintain patient c
overtest or advise harmful treatme

z Discuss diet

Avoid nutritional depletion, diarrhe

z Discuss use of Probiotics

Bifidobacterium infantis, etc

z Cognitive-Behavioral Therapy

Standard and Hypnotherapy.

avioral Rx, provide counseling for

ip

nt relationship.
contact, be understanding, don’t
ent.

eal substances (sorbitol, fructose).





Constipation

Functional vs. Secondar

ry

Functional Const

Rome III Criteria for Fu

z Two or more of the follow

z Straining during at least 25%
z Lumpy or hard stools in at l
z Sensation of incomplete ev

defecations
z Sensation of anorectal obst

25% of defecations
z Manual maneuvers to facilit

(e.g., digital evacuation, sup
z Fewer than three defecation

tipation

unctional Constipation

wing six must be present:

% of defecations
least 25% of defecations
vacuation for at least 25% of

truction/blockage for at least

tate at least 25% of defecations
pport of the pelvic floor)
ns/wk

Secondary Cause

Mechanical Obstruction
Anal stenosis
Colorectal cancer
Extrinsic compression
Rectocele or sigmoidocele
Stricture

es

Secondary Cause

Medications
Antacids
Anticholinergic agents (e.g., antipa
antispasmodics, tricyclic antidepr
Anticonvulsants (e.g., carbamazep
Antineoplastic agents (e.g., vinca d
Calcium channel blockers (e.g., ve
Diuretics (e.g., furosemide)*
5-Hydorxytryptamine, antagonists
Iron supplements*
Nonsteroidal anti-inflammatory dru
Mu-opioid agonists (e.g., fentanyl,

es

arkinsonian drugs, antipsychotics,
ressants)*
pine, phenobarbital, phenytoin)*
derivatives)
erapamil)*

(e.g., alosetron) – off market

ugs (e.g., ibuprofen)*
loperamide, morphine*