O S I A I N

C
N T P T O

DR. M.S. SHAMOL

FCPS (MEDICINE)
DR.shamol / intern / IBS & CONS 1
Define IBS Irritable bowel syndrome (IBS) is a functional bowel disorder in which
abdominal pain is associated with defecation or a change in bowel habit
ROME III Recurrent associated with Improvement with defecation
Criteria abdominal pain or two or more of Onset associated with a change in
For IBS discomfort the following frequency of stool
at least 3 Onset associated with a change in
days/month form (appearance) of stool
in the last 3 months
IBS is the diagnosis of exclusion Abdomonial TB
Before diagnosis of IBS Please exclude malabsorption
these DD Thyrotoxicosis
parasitic infection/ helminthiasis/ Giardiasis
IBD
coeliac disease
Malignancy
Pancreatic insufficiency/chronic pancreatitis

DR.shamol / intern / IBS & CONS 2

Red flag sign Age > 50 yrs; male gender
Any patient with chronic diarrhea history <6 months
( if these feature then DX other than anorexia; weight loss, Anaemia
) Nocturnal symptoms : waking at night with pain/diarrhea
mouth ulcers
PR bleeding
Family history of colon cancer
Fever
abnormal CRP, ESR, Hb, coeliac serology
CLINICAL Altered stool alternate episodes of diarrhea and constipation
FEATURES Bowel form May be diarrhea predominate IBS-D / constipation predominate IBS-C
habit Constipated Pellety stools with abdominal pain Or
proctalgia
Diarrhoea Frequent defecation but Produce low-volume
stools
or
bowel frequency
Colicky abdominal pain
Abdominal distension /abdominal bloating
Rectal mucus
Feeling of incomplete defecation/ evacuation
worsening of symptoms after food
Some no No nocturnal symptoms
NO rectal bleeding
No fever
No Anemia
No lose weight and DR.shamol / intern / IBS & CONS 3
No rise of ESR/CRP
Investigation in patient 1st line CBC—↓HB ,↑ESR-- red flag sign
of IBS CRP---↑ red flag sign
AIM :is to exclude other RBS
diseases S.creatinine
Hepatic function –SGPT
TSH/Thyroid function
USG--
Second line Colonoscopy –must do if red flag sign
Third line

DR.shamol / intern / IBS & CONS 4

Drug used in IBS
For abdominal Mebeverine HCl Tab Rostil/Mave / Iriban ½ +0+ ½ or 1 +0+1
pain 135mg
Anti-spasmotic Cap. Rostil SR/Mave SR / 1 +0+1
Iriban SR 200
Alverine citrate Tab. Alve 60 mg 1 +0+1
Peppermint oil Cap. Colmint / liqumint 1 +0+1
Trimebutine Maleate Tab .tritin/trimotil 100mg 1 +0+1 ot 1 +1+1
Anti-biotic Rifaximin Tab Rifagut / hepaximin /rifamax 200 1+1+1---14 days
(600mg /daily) Tab Rifagut / hepaximin /rifamax 550 0+0+1—14 days
Secnidazole Tab.Secnid DS / Secnizole DS 0+0+2—one day
Ornidazol Tab.Robic / ornil 50O mg 1 +0+1—3days
metronidazole Tab Amodis /filmet 400mg 1+1+1 for3 to 5days
Ciprofloxacin Tab. Ciprocin/Neofloxacin 500 mg 1 +0+1 –5 days
,Nitazoxanide Tab. Zox 500 mg 1 +0+1 –3 days
Anti- Amitriptyline Triptin 10 mg 0+0+1
depressant imipramine Tab. Pramin/ Tofranil25 mg 0+0+1
Duloxetine Tab.Duloxen / cap. Diliner DR 3Omg /60mg 0+0+1
Nortriptylin Tab.Nortin / Norzin 10 mg 0+0+1
Anti- Loperamide 2–8 mg daily Cap.Imotil 2mg 2 tab stat and one tab after
diarrhoeal Maxium 16 mg /daily each loose motion
drugs Colestyramine Quastran sachet 1 sachet daily
1 sachet daily
Probiotics Enterogernia 1+0+1---14 days
DR.shamol / intern / IBS & CONS 5
RX of IBS
Explanation and symptoms are not due to a serious underlying disease/ malignancy
reassurance It is a chronic but benign disease and symptoms is usually recurrent
she should have a normal life span
Treatment is successful in 50% cases
aim to make symptoms less intrusive
Dietary modification healthy diet
Diet should be avoided fiber ,legumes, and cabbage
lactose, fructose
wheat, starch
Caffeine
Any deit worsen symptoms
Milk and milk product
Drug Anti biotic and probiotic
Anti-spasmodic & anti-diarrhea
Anti-depressant

DR.shamol / intern / IBS & CONS 6

Rx of IBS Moderate to severe
Explanation and reassurance—see above Anti –depressant any one of the following
Dietary modification—see above Tab.Nortriptylin (Nortin / Norzin ) 10 mg ( first choice )
1.Anti-biotic : 0+0+1
Tab.Rifaximin200 (Rifagut / hepaximin /rifamax) Tab. Amitriptyline 10 mg (Triptin)
1+1+1---14 days 0+0+1
Or Tab. Imipramine25 mg (Pramin/ Tofranil)
Tab.Rifaximin 550 (Rifagut / hepaximin /rifamax) 0+0+1
0+0+1—14 days Tab.Duloxetine(Duloxen /cap. Diliner DR) 3Omg
Plus anyone of the following 0+0+1
Tab. Secnidazole (Secnid DS / Secnizole DS) Any one of the PPI
0+0+2—one day Tab/Cap. Esomeprazole 20/ 40mg(Maxpro / esonix )
Tab.Ornidazol 50O mg (Robic / ornil) 1+0+1 ½ hr before meal
1 +0+1—3days Cap .Omeprazole 20/ 40 mg (Seclo /losectil/ Xeldrin)
2.Probiotics 1+0+1 ½ hr before meal
Tab. Enterogernia Tab.Pantoprazole 20/ 40mg(Pantonix,pantobex)
1+0+1---14 days 1+0+1 ½ hr before meal
For abdominal pain any one of the following Tab. Rabiprazole 20 mg (Paricel / finix)
Tab. Mebeverine (Rostil/Mave / Iriban) 135mg 1+0+1 after meal
½ +0+ ½ or 1 +0+1--(first choice )
Cap. Mebeverine (Rostil SR/Mave SR / Iriban SR) 200
1 +0+1
Tab.Alverine citrate (Alve ) 60 mg
1 +0+1
Cap. Peppermint oil (Colmint / liqumint
1 +0+1
Tab .Trimebutine Maleate (tritin/trimotil) 100mg
DR.shamol / intern / IBS & CONS 7
1 +0+1 or 1 +1+1
Mild
Explanation and reassurance—see above
Dietary modification—see above
anyone of the following
Tab. Secnidazole (Secnid DS / Secnizole DS)
0+0+2—one day
Tab.Ornidazol 50O mg (Robic / ornil)
1 +0+1—3days
For abdominal pain any one of the following
Tab. Mebeverine (Rostil/Mave / Iriban) 135mg
½ +0+ ½ or 1 +0+1
Cap. Mebeverine (Rostil SR/Mave SR /Iriban SR) 200
1 +0+1
Anti –depressant any one of the following
Tab.Nortriptylin (Nortin / Norzin ) 10 mg
0+0+1
Tab. Amitriptyline 10 mg (Triptin)
0+0+1
Any one of the PPI
 Tab/Cap. Esomeprazole 20/ 40mg(Maxpro / esonix )
1+0+1 ½ hr before meal
 Cap .Omeprazole 20/40 mg (Seclo /losectil/ Xeldrin)
1+0+1 ½ hr before mealDR.shamol / intern / IBS & CONS 8
Approach to patient with
Symptoms Acute /chronic/recurrent / recent onset Sign Aanemia –Malignancy
History watery / mucus / undigested food Angular stomatitis, glossitis -
steatorrhoea/ mal-absorption mal-absorption
Oral ulcer— IBD
melena /blood per rectum Temperature --TB
relation with food Liver –
pain less /pain full Spleen - TB
appetite N /↓ Ascites –malabsorption/ TB
improved on fasting Lymphnode—TB /lymphoma
Tenesmus Clubbing—IBD
systemic feature Leuconychia ----malabsorbtion
(fever /anorexia/ Weight loss/ Night sweat) Koilonychia
Noctural symptoms Joint pain --IBD
Drug laxative Erythema nodosum--IBD
Disease –DM /thryrotoxicosis Oedema
Age
Alteration with constipation or not

DR.shamol / intern / IBS & CONS 9

DR.shamol / intern / IBS & CONS 10
Patient with water diarrhea Patient bloody diarrhea
Diet : normal Diet : normal
Plenty of fluid and ORS Plenty of fluid and ORS
Tab. Ciprofloxacin ( Ciprocin/Neofloxacin) 500 mg Tab. Ciprofloxacin ( Ciprocin/Neofloxacin) 500 mg

1 +0+1 –7 days 1 +0+1 –7 days

OR If pain
Tab.Azithromycin(Zimax)500 mg Any one of the PPI
2 tab stat Cap .Omeprazole 20/ 40 mg (Seclo /losectil/ Xeldrin)
If pain 1+0+1 ½ hr before meal
Any one of the PPI Tab/Cap. Esomeprazole 20/ 40mg(Maxpro / esonix )
Cap .Omeprazole 20/ 40 mg (Seclo /losectil/ Xeldrin) 1+0+1 ½ hr before meal
1+0+1 ½ hr before meal Tab.Pantoprazole 20/ 40mg(Pantonix,pantobex)
Tab/Cap. Esomeprazole 20/ 40mg(Maxpro / esonix ) 1+0+1 ½ hr before meal
1+0+1 ½ hr before meal Plus
Tab.Pantoprazole 20/ 40mg(Pantonix,pantobex) Tab . trimonium (algin )
1+0+1 ½ hr before meal 1+1+1 for3 to 5days
Plus
Tab . trimonium (algin )
1+1+1 for3 to 5days

DR.shamol / intern / IBS & CONS 11

Patient with dysentery Gastroenteritis / cant differentiate diarrhea or
dysentery
Diet normal Diet normal
Plenty of fluid and ORS Plenty of fluid and ORS
Tab. Metronidazole(Amodis /filmet) 400mg Tab. Ciprofloxacin ( Ciprocin/Neofloxacin) 500 mg
1+1+1 for3 to 5days
OR 1 +0+1 –7 days
Tab. Nitazoxanide(Zox)500 mg PLUS
1 +0+1 –3 days Tab. Metronidazole(Amodis /filmet) 400mg
If pain 1+1+1 for3 to 5days
Any one of the PPI OR
Cap .Omeprazole 20/ 40 mg (Seclo /losectil/ Xeldrin) Tab. Nitazoxanide(Zox)500 mg
1+0+1 ½ hr before meal 1 +0+1 –3 days
Tab/Cap. Esomeprazole 20/ 40mg(Maxpro / esonix ) If pain
1+0+1 ½ hr before meal Any one of the PPI
Tab.Pantoprazole 20/ 40mg(Pantonix,pantobex) Cap .Omeprazole 20/ 40 mg (Seclo /losectil/ Xeldrin)
1+0+1 ½ hr before meal 1+0+1 ½ hr before meal
Plus Tab/Cap. Esomeprazole 20/ 40mg(Maxpro / esonix )
Tab . trimonium (algin ) 1+0+1 ½ hr before meal
1+1+1 for3 to 5days Tab.Pantoprazole 20/ 40mg(Pantonix,pantobex)
1+0+1 ½ hr before meal
Plus
Tab . trimonium (algin )
1+1+1 for3 to 5days

DR.shamol / intern / IBS & CONS 12

Anti-biotic associated diarrhea If vomiting add
Stop the offending drug Give any one of following
Give Ondansetron (emistat ) 8mg
Tab. Metronidazole(Amodis /filmet) 400mg 1+0+1
1+1+1 for3 to 5days Palonosetron 0.5mg (paloset /paloxi)
OR 0+0+1
Tab. Nitazoxanide(Zox)500 mg Emestop 40 mg
1 +0+1 –3 days 0+0+1
If not respond Choice of fluid in vomiting –normal saline
Give vancomycin In diarrhea –cholera saline / Hartman hartsol
Don’t give domperidone if patient have diarrhea

DR.shamol / intern / IBS & CONS 13

Constipation is infrequent passage of hard stools ( less than 3 bowel actions/wk)
defined as with a sense of incomplete evacuation
Any one of the less often than the person’s normal habit
following Passed with difficulty, strainingeither perianal pain or abdominal discomfort
ROME--III
Constipation: the S Straining for ≥25% of BMS
presence of ≥2 A Sensation of anorectal obstruction or blockage for ≥25% of BMS
symptoms during L Lumpy or hard stools in ≥25% of BMS
bowel movements LESS than 3 BMS per week
(BMS): I Sensation of incomplete evacuations for ≥25% BMS
M Manual manoeuvres to facilitate evacuation at least 25% of BMS
Chronicity constipation for the last 90 days, with onset ≥6 months ago
If u deal with N Neurological causes –stroke ,MS , Parkinson
constipation please I Immobility
exclude these causes irritable bowel syndrome
NICDH C colonic carcinoma
Hypercalcaemia
D Diabetes mellitus
Dietary
Drugs
H Hypothyroidism

DR.shamol / intern / IBS & CONS 14

Constipation
Gastrointestinal disorders Non-gastrointestinal disorders NEDO
S-- Structural colonic carcinoma N—neurolgical M— Multiple sclerosis
Diverticular diseas MCPS C— Cerebrovascular accidents
P— Parkinsonism
S—Spinal cord
A-- Anorectal Crohn’s, E— Diabetes mellitus
disease fissures, endocrine/Metabolic Hypercalcaemia
haemorrhoids Hypothyroidism
Pregnancy
M-- Motility Slow-transit constipation Drugs Opiates
Irritable bowel syndrome Anticholinergics
Drugs Calcium antagonists
Chronic intestinal pseudo- Iron supplements
obstruction Aluminium-containing
O-- ` O— Others Any serious illness with
Obstructed immobility, especially in the
defecation elderly, Depression
D—Dietary Lack of fibre and/or fluid
intake

DR.shamol / intern / IBS & CONS 15

Red flag sign A age >40yrs
abdominal pain
anaemia
B- Bleeding per rectum
C-Change recent change in bowel habit
D- D-decrease weight / weight loss
Approach to patient with constipation
History Age of the patient (older age Sign Anaemia ---B12 + iron
malignancy )
Recent onset or chronic Oral ulcer –chrons
Abdominal pain , weight loss BMI
Bleeding PR , Fever , weight loss and night
sweating
Fever ,weight loss night sweat Thyroid face and goiter
Dietary HO Temperature raised
Endocrine disease DM /hypothyroid Abdominal lump
Drug history Per rectal examination --
Presence of neurological disorder Rectal masses, faecal
impaction, prolapse
Constipation is alternate with diarrhea Feature of hypothyroidism
Prolong immobilization and bed ridden Neurological exam of lower
limb
DR.shamol / intern / IBS & CONS 16
Investigation for constipation
Investigation Not needed increased fluid intake,
unless not respond to dietary fire supplementation,
exercise and
the judicious use of laxatives
Presence of red flag sign
1st line CBC &ESR Anaemia & high ESR /CRP –red flag sign
RBS
S.Creatinin
s.calcium
TSH
Digital rectal examination, proctoscopy
2nd line Colonoscopy biopsy of If suspected colorectal malignancy.
abnormal mucosa or if red flag sign present
Sigmoidoscopy & biopsy of
abnormal mucosa
3rd line Intestinal marker studies Usually Not done
anorectal manometry
electrophysiological studies
magnetic resonance
proctography

DR.shamol / intern / IBS & CONS 17

Mild to moderate Severe case
Patient education: Patient education:
Aim to dependency on laxatives and to increase Dietary fiber
fluid and fiber intake Fiber containing food and vegetables
Dietary fiber Fluid at least 3 liter /day
Fiber containing food and vegetables Avoid red meat
Fluid at least 3 liter /day Drug :
Avoid red meat Tab .Lubiprostone(Lubistone/Lubilax) 8µmg
Laxative (any one of the following group ) 1+0+1
1.Bulking agents—first choice Laxative (any one of the following group )
Psyllium (Fibogel / Fiberlax) (rich patient ) 1.Bulking agents—first choice
1 to 2 TSF in ½ glass water BD Psyllium (Fibogel / Fiberlax) (rich patient )
Ispaghula husk(Laxadil /ispergul 3.5 gm sachet )(poor ) 1 to 2 TSF in ½ glass water BD
1 sachet in ½ glass water BD Ispaghula husk(Laxadil /ispergul 3.5 gm sachet )(poor )
2.Osmotic laxatives—second choice 1 sachet in ½ glass water BD
Syp Lactulose(D-lac/Osmolax /Avolac) 2.Osmotic laxatives—second choice
3 TSF at night Syp Lactulose(D-lac/Osmolax /Avolac)
Macrogol (Movicol )sachet 3 TSF at night
1 sachet at night Macrogol (Movicol )sachet
Magnesium salts (Milk of magnesia) 1 sachet at night
2 TSF at night ( poor patient ) Magnesium salts (Milk of magnesia)
3. Stimulant laxatives ( poor patient ) –third choice 2 TSF at night ( poor patient )
Bisacodyl (Tab. Duralax) 3. Stimulant laxatives ( poor patient ) –third choice
0+0+2 Bisacodyl (Tab. Duralax)
Senna(tab.Laxena) 0+0+2
0+0+2 Senna(tab.Laxena)
If bowel not passed in last 2 or 3 days to evacuate impacted 0+0+2
stool Pl give If bowel not passed in last 2 or 3 days to evacuate impacted
Glycerol suppositories (Glysup-adult ) stool Pl give
4 to 5 stick at time Glycerol suppositories (Glysup-adult )
Then use any of the above laxative DR.shamol / intern / IBS
4 to & CONS
5 stick at time 18
Then use any of the above laxative
Poor patient
Patient education: If patient not passed 3 to 4 days and
Aim to dependency on laxatives and to increase abdomen distended
fluid and fiber intake Give enema
Dietary fiber Fleet enema or enema simplex
Fiber containing food and vegetables Then any of laxative
Fluid at least 3 liter /day Food containing fibers
Avoid red meat Fruits Vegetables
Laxative (any one of the following group ) Apple (with skin) Beans,
1.Bulking agents—first choice Banana Broccoli
Ispaghula husk(Laxadil /ispergul 3.5 gm sachet )) Dates Cabbage
1 sachet in ½ glass water BD Pineapple Carrots
2.Osmotic laxatives—second choice Pear (with skin) Potato (with skin)
Magnesium salts (Milk of magnesia) Grape Nuts
2 TSF at night ( poor patient )
3. Stimulant laxatives–third choice
Bisacodyl (Tab. Duralax)
0+0+2
Senna(tab.Laxena)
0+0+2
DR.shamol / intern / IBS & CONS 19
DR.shamol / intern / IBS & CONS 20