Case Report

Irritable Bowel Syndrome

Presented by : Nafeesa Shabbir

Dpt, 3rd year
Extract:
Shaista is a 32 yrs. Old woman. She has crampy Case Presentation
abdominal pain, bloating that recurs from 6 months.
She also had s.hx of appendectomy since 8 months
ago. examination shows tenderness in abdominal
muscle. GP prescribed her antidepressants and
educate her along with dietary interventions.
Objectives:
• Identify patients who are appropriately diagnosed
based on history and symptoms
• Describe the roles of the Rome-IV criteria,
colonoscopy, and other tests in the diagnosis of
irritable bowel syndrome (IBS)
• Differentiate subtypes of IBS
• Characterize medications for IBS
• Individualize treatment for IBS based on current
evidence-based guidelines

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Case:
32 year old female presents with the following symptoms
• Crampy feeling (abdominal pain), varying intensity,
intermittent
• Stress and eating exacerbate pain
• Bowel movement relieves pain
• Alternating diarrhea & constipation
• Bloated/gassy feeling
• Gastroesophageal reflux (“heart burn”)
• fatigue
Pt has had these symptoms for several days a month in the last 6
months Case
PMHx: depression, anxiety
SHx: appendectomy
Physical Examination:
Presentation
Abdomen tender to palpation in all 4 quadrants with
significant guarding
Abdomen sounds tympanic on percussion
Global fascial tightness throughout abdomen
Paraspinal changes at T9-T10
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IBS:
Is group of symptoms that represent common
disorder of lower GI tract. Referred as nervous
Definition & Etiology
indigestion, nervous colon, functional dyspepsia,
spastic colon & irritable colon but no inflammation,
so not confused with colitis or other IBD.

Etiologic Factors:
• The causes of IBS are not clear.
• gut–brain axis problems
• gut motility disorders
• pain sensitivity
• infections including
small intestinal bacterial overgrowth
• neurotransmitters
• genetic factors and food sensitivity
• triggered by an intestinal infection, or stressful
life event.
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Pathophysiology:
• Visceral Hypersensitivity:
The main mechanism inducing abdominal pain is the visceral
Pathophysiology
hypersensitivity. The primary afferent neuron which transmit
stimuli to central nervous system (CNS) through sympathetic
and parasympathetic autonomic nervous system. PNS
stimulate or inhibit the contraction of smooth muscle fibers
and the secretion of enterocytes in the gastrointestinal tract
modifying the gut motility and secretion.
• Abnormal Gut Motility and Secretory
Disorders:
Activation of 5HT3 and 5HT4 receptors enhances gastrointestinal
transit. Additionally, intrinsic afferents, utilizing 5HT3 receptors,
may be involved in a reflex circuit within the gut that increases
motility and intestinal secretions . Antagonism of the 5HT3
receptors with delays colonic transit in healthy controls and in IBS
patients with diarrhea as a predominant symptom. Gut motility and
defecation are regulated by psychical, somatic and immune stress.
• Autonomic Nervous System Dysfunction:
It is known that autonomic nervous system (ANS) regulates
visceral sensitivity and modulates and coordinates GI motility and
secretion. Main characteristic of IBS patients is the increased
activity of SANS and the decreased activity of PANS. vagal
dysfunction is associated with constipation as a predominant
symptom whereas adrenergic sympathetic dysfunction is Contoso
associated with diarrhea . Pharmaceuticals

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Signs and Symptoms:
• Abdominal pain/ discomfort
• Bloating
• Constipation
• Diarrhea

Identify Red Flags:

• HistoryAdd
Picture

 Unintentional weight loss

 Family history of cancer/ IBD
• Initial labs:
 Dec. HGB Clinical
 Inc. WBC
 Inc. ESR
Manifestations
 Inc. TSH
• Physical:
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 Rectal bleeding Pharmaceuticals

 Abnormal exam page 6

Altered Bowel Habits in IBS:
• Diarrhea:
 Frequent loose stools of small volume, with mucus.
 Generally in morning / after meal.
 May have feeling of urgency and incomplete evacuation
• Constipation:
 Severe may include bouts of diarrhea/ normal bowel function.
 Stools often hard and lumpy/ messy.
Add
Picture

 Sense of incomplete evacuation even with empty rectum.

Subtypes of IBS:
• IBS-C (predominant constipation)
Clinical
•
•
IBS-D (predominant diarrhea)
IBS-M (IBS with mixed bowel habits)
Manifestations
• People whose symptoms do not fit into any category are
considered to have IBS unclassified
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 Diagnosis of IBS

There's no test to
definitively diagnose IBS.
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• Manning Criteria(1978):
These criteria focus on pain relieved by passing stool and on
having incomplete bowel movements, mucus in the stool and
changes in stool consistency. The more symptoms you have, the
Diagnosis of IBS
greater the likelihood of IBS.
• Rome IV Criteria:
These criteria include abdominal pain and discomfort lasting on
average at least one day a week or 3 days per month in the last 3
months, associated with at least two of these factors:
• Improvement with defecation
• Onset associated with change in frequency of stool
• Onset associated with change in form of stool(appearance)
• Additional Tests:
Imaging tests can include:
• Flexible sigmoidoscopy.
• Colonoscopy.
• X-ray or CT scan.
Laboratory tests can include:
• Lactose intolerance tests.
• Breath test for bacterial overgrowth. Contoso
• Stool tests. Pharmaceuticals

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Treatment:
• Patient education Treatment Of IBS
• Dietary intervention
• Pharmacotherapy
• Psychotherapy
• Hypnotherapy
• Dpt and IBS
Pharmacologic treatment:
• Antispasmodics
• Antidepressants
• Antidiarrheal
• Benzodiazepines
• 5HT3 receptor antagonists
• 5HT4 receptor agonists
• Antibiotics
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Pharmacologic treatment
Antispasmodics
• Ex: hyoscine, cimetropium,
pinaverium (short term relief,
LT efficacy has yet to be
demonstrated).
• Can directly affect intestinal
smooth muscle relaxation, or
via
anticholinergic/antimuscarinic
properties
• They reduce colonic motor
activity and may improve
postprandial abdominal pain,
gas, bloating, and fecal
urgency.
Antidepressants
• Independent of their mood improving
effects, antidepressants have
analgesic properties, and therefore
may be beneficial in patients with
neuropathic pain
• The assumed MOA with TCA’s and
SSRI’s are facilitation of endogenous
endorphin release, blockade of NE
reuptake (leading to enhancement of
descending inhibitory pain pathways),
and blockade of the pain
neuromodulator (5-HT). TCA’s also
slow down intestinal transit time via
anticholinergic properties (helpful in
diarrhea predominant IBS)
Antibiotics
• Some patients show
improvement in sx’s of bloating,
abdominal pain or altered bowel
habits after use of antibiotics
• Rifaximin, a nonabsorbable
antibiotic, globally improved IBS
symptoms in reports of two
randomized trials
• MOA is unclear, may be due to
suppression of gas producing
bacteria in the colon
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Dpt and IBS:
• Osteopaths and IBS:
In a 2007 article in Journal of Gastroenterology &
Treatment Of IBS
Hepatology titled “Treatment of Irritable bowel
syndrome with osteopathy: Result found that 13
of 19 patients in the group receiving osteopathic
treatment had overall improvement of symptoms
in 6 months, one was free of symptoms, and the
remaining five showed slight improvement.
In the standard care group, 3/17 subjects noted
“definite” improvement, while 10 showed slight
improvement. The remaining 3 had worsened sx’s
OMT can be used!
• MFR of abdominal fascia
• OA decompression
• ANS treatments
• Treatment of diaphragms (especially thoraco-
abdominal!)

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Dpt and IBS:
• Physical Therapist and IBS:
 Regular PA helps to relieve stress & assist in bowel Rehabilitation Of IBS
function, ie with constipation. Therapist encourage
pt. with IBS to continue rehabilitation intervention
program during symptomatic period.
 Teaching breathing ex’s for all daily activities and
during exercise &relaxing techniques.
 American Physical Therapy Association gives
Guidelines for recognizing and providing care for
victim of domestic violence
How Can Physical Therapy Help with
Constipation?
•Gentle manual therapies and release techniques to
restricted muscles and fascia of pelvic areas
•Visceral mobilization techniques to help the abdominal
organs
• pelvic floor muscles train so relax and open fully during
a bowel movement and not contracted
•Teach breathing techniques and other stretching exercises
that stimulates the parasympathetic NS

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Dpt and IBS:
• ILU massage:
•Apply very light cream to your abdomen region first. With Rehabilitation Of IBS
your fingertips, lightly stroke in a clockwise direction as
shown starting from the lower right pelvis upwards then
across to the left side, then down to the lower left pelvis.
Add small circular motions. Repeat for 1-3 minutes or until
you hear a “gurgling” of your stomach.
•How Can Physical Therapy Help with Abdominal
Distension?
•Distension on the other hand, refers to the physical
expansion of the abdomen. While abdominal distension
may occur with IBS , it may be caused by a condition
called “abdomino-phrenic dyssynergia”.
• the bloating sensation sends the wrong signal to the
brain. As a result, the reflex that controls the diaphragm
mistakenly sends a signal to press the stomach down when
eating instead of the signal to move the diaphragm up to
allow the stomach to expand when eating.
•A physical therapist can use breathing techniques

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• An individualized approach to managing
patients with IBS-D begins with
reassurance, explanation, and a positive
diagnosis that includes limited testing to Summary
rule out disorders that may mimic IBS-D (eg,
IBD or celiac disease).
• Treatment options should be considered in
the context of symptoms, possible etiologic
factors, and benefits vs risks. Treatment
typically begins with dietary modifications,
increased exercise, and stress reduction.
• A probiotic could be considered, particularly
for bloating, and a TCA for pain. Diarrhea
might be ameliorated with loperamide or a
bile acid sequestrant. For persistent and/or
more severe symptoms, rifaximin,
eluxadoline, or alosetron could be
considered, with the specific choice guided
by patient-specific factors.

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Thank You
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