4/18/18 Irritable Bowel Syndrome (IBS) Dr. Andy Liu, MD PGY-4, Division of Gastroenterology Cumming School of Medicine, University of Calgary April 17, 2018 Financial disclosure Thank You to Our Name: Dr. Andy Liu, MD Speaker ✓ Sponsors! Financial compensation – Ignite Nutrition • Their dona+ons to this event helped make it happen • $5 of each +cket sold being donated to the Canadian Diges+ve Health Founda+on 1
4/18/18 Disclaimers IBS • Presentation for information purposes only • Abdominal pain with changes in bowel movements • All treatments should be used under supervision of MD or RD • 15% of Canadian population • Off-label use of medications will be discussed • Second most common cause of absenteeism • Economic impact of $6.5 billion Prognosis Causes • • Functional disorder Chronic • • Visceral hypersensitivity No long -term serious consequences • • Abnormal gut motility Not curable, but manageable • • Gut microbiome YOU are in control! 2
4/18/18 Visceral hypersensitivity Diagnosis • NOT “in your head” 60 = IBS patients have IBS lower pain thresholds • NOT a diagnosis of exclusion % Reporting pain 40 • Symptoms-based with limited evaluation 20 Normal • Strict clinical criteria: Rome IV (2017) 0 0 60 100 140 180 Rectosigmoid balloon volume (mL) Whitehead WE et al. Dig Dis Sci. 1980;25:404-13. Rome IV Subtypes Abdominal pain: • Constipation-predominant Average one day per week in the past three months • Diarrhea-predominant With • Mixed constipation and diarrhea Two of the following three features: 1. Pain related to BM 2. Change in frequency of BM 3. Change in appearance of BM Simren M et al. Curr Gastroenterol Rep. 2017;19:15. 3
4/18/18 Treatment Red flags Non-pharmacologic: Pharmacologic: • Bleeding • • Drugs Exercise • Greasy stools • • Exciting (and expensive) new Dietary changes drugs • Nocturnal symptoms • Probiotics • Weight loss • Anti -spasmodics Exercise Low FODMAP diet 30-60 minutes moderate-high intensity exercise 3-5 times per week “Fermentable oligo-, di-, mono-saccharides and polyols” • Poorly absorbed sugars 38 patients: Patients in exercise group had: Exercise • Fermented to produce gas • Trend towards clinical 12 weeks 75 improvement patients • Abdominal pain and bloating (recall “visceral hypersensitivity”!) 37 patients: • Significantly less worsening Sedentary of IBS symptoms Johannesson E et al. Am J Gastroenterol. 2011;106(5):915. 4
4/18/18 Low FODMAP diet Caveats • CAREFUL: low FODMAPs ≠ healthy diet! “Fermentable oligo-, di-, mono-saccharides and polyols” 21 days low 21 days low • MUST be done under RD supervision FODMAP FODMAP Patients on low 30 IBS FODMAPs diet had: patients Or Or and Significantly less 8 21 days 21 days bloating, pain, healthy normal diet normal diet and passage of controls wind Do a Do a survey survey Halmos et al. Gastroenterol. 2014;146(1):67-75 There’s an app for that Probiotics • CAREFUL: un-regulated industry Monash University - $10.99 • Small effect only – match the probiotic with the symptom • Choose evidence based probiotics & measure outcome • Align ( Bifidobacterium infantis 35624) - $30/month • TuZen ( Lactobacillus plantarum 299v) - $45/month • Visbiome (combination) - $90/month 5
4/18/18 Anti-spasmodics Treatment Non-pharmacologic: Pharmacologic: • Reduce colonic motor activity • • Drugs Exercise • Relax smooth muscles of the gut • • Exciting (and expensive) new Dietary changes • Most require prescription drugs • Probiotics • A natural option: peppermint oil • Watch for acid reflux! • IBGard (unique delivery mechanism) - $60/month • Anti -spasmodics Drugs: IBS-C Drugs: IBS-D 1. Laxatives: how do I choose? 1. Imodium (loperamide) 2 mg before meals • RestoraLAX (PEG 3350) 17 g once or twice daily - $1/dose • $1/dose • Milk of magnesia, lactulose • Safe • Dulcolax, Senokot • Titratable • Enemas, colonoscopy prep 2. Olestyr (cholestyramine) 4 g daily 2. Constella (linaclotide) 290 mcg daily • Especially if gallbladder removed • Also pain-modulating • Titratable 3. Viberzi (eluxadoline) 100 mg twice daily 6
4/18/18 IBS tips IBS tips 1. Eat smaller, regular meals 6. Wear looser clothing 2. Low FODMAP diet 7. Reduce stress 3. Stay hydrated 8. Exercise 4. Decrease caffeine 9. Work with your MD and RD 5. Don’t eat late at night 10.See your doctor if any red flag symptoms arise Raman M et al. The Complete Health and Diet Guide. 2011. Robert Rose Inc. Toronto. Raman M et al. The Complete Health and Diet Guide. 2011. Robert Rose Inc. Toronto. Thank you! Andy.Liu@ahs.ca 7
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