DEPARTMENT OF PSYCHIATRY

CIMS BILASPUR

Irritable Bowel Syndrome

Guided by-
Dr. S.K. Naik (Professor & HOD)
Dr. G.S. Singh (Associate professor) Presented By
Dr. Rakesh Kumar Jangde (Assistant professor) Dr Shashi Shekhar Singh( Intern)

Dr. Rahul Rajeev (senior resident).

Irritable Bowel Syndrome
Definition

Irritable bowel syndrome (IBS) is a

functional bowel disorder characterised by
abdominal pain or discomfort and altered
bowel habits in the absence of detectable
structural abnormalities.

No clear diagnostic markers exist for IBS;

thus the diagnosis of the disorder is based
on clinical presentation.
 Diagnostic criteria of IBS
Rome IV Criteria (2016)
Recurrent abdominal pain, on average, at least 1 day per week in the last 3 months, associated with
≥2 of the following criteria.

1. Related to defecation

2. Associated with a change in frequency of stool

3. Associated with a change in form (appearance) of stool

 Clinical Features

• Abdominal Pain

• Upper GI symptoms like • Gas and Flatulence

dyspepsia, heartburn,
nausea, and vomiting

• Altered Bowel habit

 Abdominal Pain

According to the current IBS diagnostic criteria, abdominal pain is a prerequisite clinical feature
of IBS.

Abdominal pain in IBS is

• Highly variable in intensity and location.
• It is frequently episodic and crampy (It may be superimposed
on a background of constant ache)
• Pain is often exacerbated by eating or emotional stress

• Improved by passage of flatus or stools.

• Female patients with IBS commonly report worsening

symptoms during the premenstrual and menstrual phases.
 Altered Bowel habits
• Alteration in bowel habits is the most consistent clinical feature in IBS.

• The most common pattern is constipation alternating with diarrhea.

• At first, constipation may be episodic, but eventually it becomes continuous and increasingly
intractable to treatment with laxatives.
• Stools are usually hard with narrowed caliber (reflecting excessive dehydration caused by pro- longed
colonic retention and spasm)
• Patients also experience a sense of incomplete evacuation, thus leading to repeated attempts at
defecation in a short time span.
• Patients whose predominant symptom is constipation may have weeks or months of constipation
interrupted with brief periods of diarrhea.
• Diarrhea resulting from IBS usually consists of small volumes of loose stools. Most patients
have stool volumes of <200 mL.
• Diarrhea may be aggravated by emotional stress or eating.

• Stool may be accompanied by passage of large amounts of mucus.

• Bleeding is not a feature of IBS (unless haemorrhoids are present).

• Malabsorption or weight loss does not occur in IBS.

 Bowel Patterns in IBS
Bowel pattern subtypes are highly unstable in IBS patients
Pathophysiology of IBS
 GI Motor Abnormalities

• Colonic motor abnormalities are more prominent under stimulated conditions in IBS.

• IBS patients may exhibit increased rectosigmoid motor activity for up to 3 h after eating.

Visceral Hypersensitivity

• As with studies of motor activity, IBS patients frequently exhibit exaggerated sensory responses
to visceral stimulation
• The frequency of perceptions of food intolerance is at least two fold more common than in the
general population.
 The mechanisms responsible for visceral hypersensitivity. It has been proposed that
these exaggerated responses may be due to :

Development of
Endogenous (cortical long- term
Increased end-organ and brainstem) hyperalgesia due
sensitivity with modulation of caudad to development of
recruitment of nociceptive neuroplasticity
“silent” nociceptors transmission
resulting in
permanent or
Spinal hyperexcitability semipermanent
with activation of nitric changes in neural
oxide and possibly other responses to
neurotransmitters recurrent visceral
stimulation.
Central Neural Dysregulation
 IBS patients also show
preferential activation of the
prefrontal lobe

contains a vigilance network

within the brain that increases
alertness.

It represent a form of cerebral

dysfunction

Leading to the increased

perception of visceral pain.
 Abnormal Psychological Features

• Abnormal psychiatric features are recorded in up to 80% of IBS patients.

• Psychological factors influence pain thresholds in IBS patients, as stress alters sensory
thresholds. However no single psychiatric diagnosis predominates.
 Post infectious IBS

• IBS may be induced by GI infection.

• The microbes involved in the initial infection are Campylobacter, Salmonella, and Shigella.
• Risk factors for developing post-infectious IBS include:
1. Prolonged duration of initial illness
2. Toxicity of infecting bacterial strain
3. Smoking
4. Mucosal markers of inflammation
5. Gender Female
6. Depression
7. Hypochondriasis
8. Treatment with antibiotics associated with increased risk
 Immune Activation and Mucosal Inflammation

• Peripheral blood mononuclear cells (PBMCs) from IBS patients show abnormal release of pro-
inflammatory cytokines such as IL6, IL1β, and TNF
• These abnormalities may contribute to abnormal epithelial secretion and visceral
hypersensitivity.
• Psychological stress and anxiety can increase the release of pro inflammatory cytokine, and this
in turn may alter intestinal permeability.
 Altered Gut Flora
• IBS patients had decreased proportions of the genera Bifidobacterium and Lactobacillus and increased
ratios of Firmicutes:Bacteroidetes.
• It has been speculated that these changes may be related to stress and diet.
 Abnormal Serotonin Pathways

• The serotonin (5-HT)-containing enterochromaffin cells in the colon are increased in a subset of
IBS-D patients compared to healthy individuals
• Postprandial plasma 5-HT levels were significantly higher in this group of patients compared to
healthy controls.
• Tryptophan hydroxylase 1 (TPH1) is the rate-limiting enzyme in enterochromaffin cell 5-HT
biosynthesis, functional TPH1 polymorphism has been shown to be associated with IBS habit
subtypes.
• Serotonin plays an important role in the regulation of GI motility and visceral perception, the
increased release of serotonin may contribute to the postprandial symptoms of these patients and
provides a rationale for the use of serotonin antagonists in the treatment of this disorder.
 APPROACH TO THE PATIENT
• IBS is a disorder for which no pathognomonic abnormalities have been identified, its diagnosis
relies on recognition of positive clinical features and elimination of other organic diseases.
• Symptom based criteria have been developed for the purpose of differentiating patients with IBS
from those with organic diseases including Rome I, Rome II, Rome III, and Rome IV(published
in 2016)
• As defined earlier Rome IV criteria for the diagnosis of IBS were published in 2016 and defined
IBS on the basis of abdominal pain and altered bowel habits.
• Because the major symptoms of IBS is abdominal pain, abdominal bloating, and alteration in
bowel habits. These are common complaints of many GI organic disorders,
Differential diagnoses :

1) When abdominal pain is major complaint :

• If Pain due to IBS that occurs in the epigastric or periumbilical area must be differentiated from
biliary tract disease, peptic ulcer disorders, intestinal ischemia, and carcinoma of the stomach
and pancreas.
• If Pain occurs mainly in the lower abdomen, the possibility of diverticular disease of the colon,
inflammatory bowel disease (including ulcerative colitis and Crohn’s disease), and carcinoma of
the colon
• Postprandial pain accompanied by bloating, nausea, and vomiting suggests gastroparesis or
partial intestinal obstruction. Intestinal infestation with Giardia lamblia or other parasites may
cause similar symptoms.
2) When diarrhea is major complaint:

• There is possibility of lactase deficiency, laxative abuse, malabsorption, celiac sprue,

hyperthyroidism, inflammatory bowel disease, and infectious diarrhea.

3) When Constipation is major complaint:

• Constipation may be a side effect of many different drugs, such as Anticholinergic,
antihypertensive, and antidepressant medications
• Endocrinopathies such as hypothyroidism and hypoparathyroidism must also be considered in
the differential diagnosis of constipation
• Acute intermittent porphyria and lead poisoning may present in a fashion similar to IBS, with
painful constipation as the major complaint.
 Investigations Done to rule out DD’s :

• Complete blood count

• Sigmoidoscopic examination
• Stool specimens should be examined for ova and parasites in those who have diarrhea.
• In patients with persistent diarrhea not responding to simple anti- diarrheal agents, a sigmoid colon biopsy
should be performed to rule out microscopic colitis.
• In those age >40 years, an air-contrast barium enema or colonoscopy should also be performed.
• If the main symptoms are diarrhea and increased gas, the possibility of lactase deficiency should be ruled
out with a hydrogen breath test or with evaluation after a 3-week lactose-free diet.
• Laboratory features that argue against IBS include evidence of :

• Anemia,

• Elevated sedimentation rate,

• Presence of leukocytes or blood in stool,

• Stool volume >200–300 mL/d.

TREATMENT
 1) Patient Counseling and Dietary Alterations

• Avoid obvious food precipitants are important first steps in patient counseling and dietary
change
• Excessive fructose and artificial sweeteners, such as sorbitol or mannitol, may cause diarrhea,
bloating, cramping, or flatulence.
• A diet low in fermentable oligosaccha- rides, disaccharides, monosaccharides, and polyols
(FODMAPs) has been shown to be helpful in IBS patients
 2) Stool-Bulking Agents
• High-fiber diets

• Bulking agents

• MOA:

1. Water-holding action of fibers may contribute to increased stool bulk because of the ability of
fiber to increase fecal output of bacteria.

2. In diarrhea-prone patients, whole-colonic transit is faster than average; however, dietary fiber
can delay transit

3. Hydrophilic properties, stool-bulking agents bind water and thus prevent both excessive
hydration and dehydration of stool.
 3) Antispasmodics

• Anticholinergic drugs may provide temporary relief for symptoms such as painful
cramps related to intestinal spasm
• Anticholinergics contain natural belladonna alkaloids, which may cause xerostomia,
urinary hesitancy and retention, blurred vision, and drowsiness.
• Synthetic anticholinergics such as Dicyclomine that have less effect on mucous
membrane secretions and produce fewer undesirable side effects.
 4) Antidiarrheal Agents
• Peripherally acting opiate-based agents are the initial therapy of choice for IBS-D.
• When diarrhea is severe, especially in the painless diarrhea variant of IBS, small doses of
loperamide, 2–4 mg every 4–6 h up to a maximum of 12 g/d, can be prescribed.
• These agents are less addictive than paregoric, codeine, or tincture of opium.
• Intestines do not become tolerant of the antidiarrheal effect of opiates, and increasing doses are not
required to maintain antidiarrheal potency.
• These agents are most useful if taken before anticipated stressful events that are known to cause
diarrhea.
• Side effect :- High dose of loperamide may cause cramping because of increases in segmenting
colonic contractions.
5) Antidepressant Drugs
1) In IBS-D Patients :

Tricyclic antidepressant

Imipramine

Slows down Jejunal migrating

motor complex transit Alter visceral afferent
propagation neural function.

Delays orocecal and whole gut

transit

indicative of a motor inhibitory effect.

 Desipramine

showed improvement
in

stool frequency diarrhea pain depression

When stratified according to the predominant

symptoms

Improvements were observed in IBS-D

patients,
2) In IBS-C patients Selective serotonin reuptake
inhibitor (SSRI)

Paroxetine

Accelerates orocecal transit

Therefore improves symptoms

in IBS-C patients.
 6) Antiflatulence Therapy

• Bloating decreases if associated gut syndrome such as IBS or constipation is improved.

• Avoiding flatogenic foods

• Exercising

• Losing excess weight

• Low FODMAP diet effective in reduce gas and bloating

• Pancreatic enzymes reduce bloating, gas, and fullness during and after high-calorie, high-fat
meal ingestion.
 7) Modulation of Gut Flora
• Altered colonic flora (gut dysbiosis) may contribute to the pathogenesis of IBS, this has led to
great interest in using antibiotics, prebiotics, and probiotics to treat IBS
• Prebiotics, probiotics, and low FODMAP diet may be used to modulate gut flora and treat IBS
• Prebiotics - These are nondigestible food ingredients that stimulate growth and activity of
bacteria in the GI tract.
• Probiotics These are defined as live microorganisms that when administered in adequate
amounts confer a health benefit on the host.
• IBS patients found significant relief of pain and bloating with the use of Bifidobacterium breve,
B.longum, and Lactobacillus acidophilus species
• there was no change in stool frequency or consistency.

• Low FODMAP Diet

• A diet rich in FODMAP (fermentable oligo- saccharides, disaccharides, monosaccharides, and

polyols) often triggers symptoms in IBS patients.
Pathogenesis of FODMAP-related symptoms
• FODMAPs are poorly absorbed by the small intestine and fermented by bacteria in the colon to
produce gas and osmotically active carbohydrates
• FODMAPs may serve as nutrient for the colonic bacteria and promote the growth of gram
negative commensal bacteria which may induce epithelial damage and subclinical mucosa
inflammation.
• Fructose and fructans induce IBS symptoms in a dose-dependent manner.

• Low FODMAP diet reduces IBS symptoms.

• A randomized controlled trial showed a 4-week low FODMAP diet improved symptoms in 68%
of IBS patients compared with 23% on a habitual diet.
 8) Serotonin Receptor Agonist and Antagonists

• Serotonin acting on 5-HT3 receptors enhances the sensitivity of afferent neurons projecting from
the gut.
• 5-HT3 receptor antagonist such as alosetron reduces perception of painful visceral stimulation
in IBS.
• Also induces rectal relaxation, increases rectal compliance, and delays colonic transit.
Thank you