wilhelm IBS + gas

which gender and age is IBS most prevalent in

women, 30-50yrs

t/f: patients with IBS have more GI motility both post consumption and at baseline

true

t/f: patients without IBS report more pain than pts with IBS as rectal distention increases

false. pts WITH IBS report more

IBS is a multifactorial disease with pain resulting from which types of abnormalities

- psychosocial

- motility

- sensory

- CNS processing

(ex: stress can cause chronic inflammation and pain seen in IBS)

rome IV criteria for IBS dx

1. recurrent abdominal pain at least 1 DAY PER WEEK in LAST 3 MONTHS with 2 of the following: related to defecation, change in times you poop, change in appearance of poop

2. symptoms started 6 MONTHS before dx

3. other GI diseases are excluded, with NO ALARM symptoms

what are the "alarm symptoms" that exclude an IBS diagnosis based on the rome iv criteria

ABCD WAP-> alarm sx that exclude IBS dx

1. Age= over 50

2. Bleed in GI

3. Colon cancer family hx

4. Diarrhea= fasting, nocturnal, large

5. weight loss, unexplained

6. anemia

7. pain= persistent or progressive

bristol stool chart

Medical aid to classify stool

types 1/2: constipation

types 3/4: ideal

types 5-7: diarrhea

what are the 3 IBS subtypes and which bristol stool types dominate

1. IBS-C= constipation, types 1 and 2 (over 25%)

2. IBS-D= diarrhea, types 6 and 7 (over 25%)

3. IBS-M= mixed bowel habits

diarrhea is classified as >____ stools per day

more than 3 per day

constipation is classified as

less than 3 stools per week

t/f: clinical presence of IBS may be abdominal pain, diarrhea, mucus passage, and GI bleeding

false. all of them except for GI bleeding- remember thats an alarm sx!!

non-pharm diet modifications for IBS tx

1. SOLUBLE fiber: psyllium, polycarbophil

[wheat bran is insoluble and can cause gas,distention,pain]

2. eliminate gluten (see if gets better)

3. reduce FODMAPS

what are FODMAPS

Fermentable

Oligosaccharides (wheat,beans)

Disaccharides (lactose/dairy)

Monosaccharides (fruits, corn syrup)

And

Polyols (processed, sorbitol, mannitol)

-> these are carbs not digested in GI, stay and ferment

what are the 2 ways that FODMAP ingestion can be modified in IBS

1. eliminate everything and gradually add back

or

2. eliminate one at a time

what are non-pharm tx for IBS, other than diet

1. stress relief= breathing techniques, relaxation

2. physical activity

3. psychosocial/ cognitive behavioral/ hypno

treatment for IBS-constipation (summary)

1. guanylyl cyclase c agonists: linaclotide and plecanatide

2. chloride channel activators: lubiprostone [women, bid, food]

3. sodium/H exchanger 3 inhibitor: tenapanor

4. fiber: psyllium and polycarbophil [avoid wheat/insoluble]

5. osmotic laxative: PEG (no effect on pain)

6. 5HT4 partial agonist: tegaserod [NOT AVAILABLE]

linaclotide

class/moa:

use:

guanylate cyclase C agonist

for IBS-C

plecanatide

class/moa:

use:

guanylate cyclase C agonist

for IBS-C

lubiprostone

class/moa:

use:

chloride channel activator

for IBS-C in WOMEN

BID with food

tenapanor

class/moa:

use:

sodium/hydrogen exchanger 3 inhibitor (NHE3 inhibitor)

for IBS-C

increases electrolytes and fluid in GI tract

which fibers would you recommend for IBS-C

psyllium or polycarbophil [NOT INSOLUBLES/ WHEAT BRAN]

titrate slowly

what osmotic laxative would you recommend for IBS-C

PEG-> increases stool frequency but does not help with pain

tegaserod

5ht4 partial agonist for IBS-C

NO LONGER AVAILABLE

what CAM supplement would you recommend for IBS-C?

moa?

limitations?

cascara sagrada=> stimulates colonic motility, increases propulsions

limitations: might cause pain and diarrhea, leading to fluid/electrolyte disorders

cascara sagrada

moa:

CI:

for IBS-C; stimulates colonic motility, increases propulsions

CI: intestinal obstruction, stenosis, atony, inflammation in colon

treatment for IBS-diarrhea (summary)

1. opioid agonists: loperamide

2. probiotics (balance microbiome)

3. antibiotics: rifaximin (balance microbiome)

4. opioid agonist/antagonist: eluxadoline

5. bile acid sequestrants: cholestyramine and colestipol

6. 5-HT3 antagonists: alosetron [BLACK BOX stop if constipated]

loperamide

opioid agonist

for IBS-D

does not treat pain

t/f: both probiotics and antibiotics (rifaximin) are recommended for IBS-D to balance the microbiome

true

eluxadoline moa

both an opioid agonist and antagonist that works to

1. decrease pain

2. control GI motility

cholestyramine

bile acid sequestrant

for IBS-D, bile acids increase in IBS-D which can worsen diarrhea so this is used as a control and usually combined w other drugs

colestipol

bile acid sequestrant

for IBS-D, bile acids increase in IBS-D which can worsen diarrhea so this is used as a control and usually combined w other drugs

alosetron

Serotonin 5-HT3 receptor antagonists

for IBS-D in WOMEN

BLACK BOX: stop if constipated

alosetron moa

5-HT3 receptor antagonist used for IBS-D, stops peristalsis, secretion, and sensation

what black box warning is seen with alosetron

stop immediately if constipation or ischemic colitis occurs

eluxadoline (Viberzi) contraindications

alcoholism

biliary duct obstruction

pancreatitis

severe hepatic impairment

chronic/severe constipation

t/f:eluxadoline is a strong cyp3a4 inhibitor

true

which 2 bacterial strains are most effective in IBS-D

lactobacillus and bifidobacterium

probiotics moa

-Replenish normal flora which suppresses growth of diarrhea-causing bacteria

-anti-inflammatory

- reduce visceral afferent hypersensitivity, help restore mucosa

small intestinal bacterial overgrowth (SIBO)

abnormally large numbers of bacteria present in the small intestine's proximal half

->increased gas and distention early on

in a study that compares low dose, medium dose, and high dose probiotics, which one did the worst and why?

high dose did the worst bc it never even dissolved. low and med were same

treatments for abdominal pain in IBS (summary)

1. TCAs= amitriptyline, nortriptyline, imipramine

2. SSRIs= paroxetine, sertraline, citalopram

3. smooth muscle antispasmodics= dicyclomine, hyoscyamine, peppermint oil EC

what type of IBS are TCAs used for

IBS-D

they target both pain and diarrhea

give low doses

which medication can be given for IBS pain and comorbid depression

SSRIs= paroxetine, sertraline, citalopram

(also have some promotility action)

which medications can be given for both pain and diarrhea in IBS

smooth muscle antispasmodics (dicyclomine, hyoscyamine, peppermint oil EC capsules) and TCAs (-triptylines)

TCAs

moa

when do pts benefit

reduce visceral nerve sensitivity, help w pain

efficacy w LOWER doses

pts without depression benefit in 2-4 weeks

TCAs adverse effect

anticholinergic ADEs, increase appetite, nausea, heartburn

high dose: cardiac arrhythmias, reduces seizure threshold

when are SSRIs given in IBS

pts with depression. they might also have a reduction in IBS symtpoms

-> but it is NOT generally recommended if theres no depression

peppermint oil

MOA

ADRs

moa: antispasmodic, interferes w calcium movement. reduces foaming, bloating, and gas formation

ADRs: renal failure, nephritis, increased bile production!, reduces LES pressure== may worsen reflux

which pts should avoid peppermint oil EC capsules for IBS pain tx

cholelithiasis (bc this increases bile) and GERD (bc this reduces LES pressure and worsens reflux)

oligosaccharides

diet sources:

cause of gas:

legumes/veggies

absence of alpha-galactosidase

disaccharides

diet sources:

cause of gas:

lactose: milk, ice cream, yogurt

low lactase activity

monosaccharides

diet sources:

cause of gas:

fruit, honey, veggies, soft drinks

slow intestinal transport

complex carbs

diet sources:

cause of gas:

fruit, flour, veggies, refrigerated wheat products

naturally resistant to amylase

fiber

diet sources:

cause of gas:

whole grains, veggies, fruits

absence of alpha-glucosidase

summarize tx options for gas

1. diet: omet offending foods

2. OTC: simethicone, activated charcoal, gripe water, probiotics

3. enzyme deficiency: supplements, lactase (dairy), galactosidase (beans, legumes)

when should alpha-galactosidase supplements be avoided

-diabetes-> may increase absorption of carbs and increase blood sugar

-children

simethicone

MOA:

CIs:

foaming agent, joins gas bubbles in STOMACH so its more easily belched away (no effect on intestinal gas)

DO NOT USE MORE THAN 2 WEEKS

CIs: avoid combo products w electrolytes in kidney disease!

how long can simethicone be used for

no more than 2 weeks

activated charcoal

MOA:

CIs:

reduce INTESTINAL gas (compare to simethicone which works on stomach)

CIs: do not use if decreased bowel sounds, GI obstruction, electrolyte imbalance

how can gas be treated in pediatrics? what should be avoided?

1. simethicone drops= preferred

2. lactase= children >2

3. gripe water (fennel and ginger):>2 weeks old

AVOID:

alpha-galactosidase= NOT for infants and children