Geprikkeld door mijn darmen

J. Schmidt

MDL arts

Westfries Gasthuis

Casus

• Mw M. B. 26 jr; sinds 12e bij vlagen zeurende/krampende pijn onderbuik, niet gerelateerd aan menstruatie,

• Geen bewegingsdrang• Opgezette buik, veel windjes; geen duidelijk

verbd met levensmiddelen• Def: f 2a3x/wk, cons. 2a3 op Bristol schaal• Lozen van ontlasting geeft wat verlichting

Background

•

Irritable bowel syndrome (IBS) has a prevalence of 10-20% in the general population

• It is a chronic, relapsing and often life-long disorder

• The people most commonly affected are those aged 20–30 years

• It is twice as common in women as in men

IBS: How to relate COMORBIDITY

• Headache >25%• Back Pain >30%• Fatigue >40%• Myalgia >30%• Urinary Freq >20%• Dyspareunia >10%

• Fibromyalgia >30%• Chronic pelvic

pain >35%• GER >50%• Functional

dyspepsia >30%

• Consider assessment for IBS if any of these symptoms have been present for at least 6 months

Initial assessment

• Abdominal pain or discomfort• Bloating• Change in bowel habit

• Refer to secondary care if any of these indicators present

Initial assessment: ‘red flag’ indicators

Ask • Unintentional and unexplained weight loss• Rectal bleeding • A family history of bowel or ovarian cancer• Bowel habit change for > 6 weeks in person over 60 years

Assess/examine • Anaemia• Abdominal masses• Rectal masses• Inflammatory markers for inflammatory bowel disease

• Consider IBS diagnosis only if the person has abdominal pain that is relieved by defaecation or associated with altered bowel frequency or stool form, and at least two symptoms from:

Initial assessment:establishing the diagnosis

• altered stool passage• abdominal bloating, distension, tension or hardness• symptoms made worse by eating• passage of mucus

Bristol Stool Form Scale

Reproduced by kind permission of Dr K W Heaton, Reader in Medicine at the University of Bristol. 2000 Norgine Ltd.

• In people who meet the IBS diagnostic criteria, the following tests should be undertaken to exclude other diagnoses:

Diagnostic tests

• full blood count (FBC)• erythrocyte sedimentation rate (ESR) or plasma viscosity • c-reactive protein (CRP)• antibody testing for coeliac disease (endomysial antibodies [EMA] or tissue transglutaminase [TTG])

Diagnostic tests

The following tests are not necessary to confirm a diagnosis where IBS diagnostic criteria are met:

• ultrasound• rigid/flexible sigmoidoscopy• colonoscopy; barium enema/ct colonography• thyroid function test• faecal ova and parasite test• faecal occult blood test• hydrogen breath test (for lactose intolerance and bacterial overgrowth).

• People with IBS should be given information that explains the importance of self-help in effectively managing their IBS

Clinical management of IBS:dietary and lifestyle advice

• Healthcare professionals should review the fibre intake of people with IBS, adjusting (usually reducing) it while monitoring the effect on symptoms

• If symptoms persist after following lifestyle/dietary advice, consider referral to a dietitian

Clinical management of IBS:dietary and lifestyle advice

Diet• Dietary manipulation may help.• Food intolerance is common - food allergy is

rare.• Relaxation therapies may be useful adjunct

[e.g. hypnosis]

15

Diarrhoea Predominant.

• Increasing dietary fibre is sensible advice • Fibre varies, 55% of patients will get worse

with bran [tarwe zemelen].• “Medical fibre” adds to placebo effect.• Loperamide may help.

Constipation Predominant.

• Increased fibre.• Osmotic laxatives helpful [PEG]• Stimulant laxatives make symptoms

worse [bisacodyl]• Lactulose may aggravate distension and

flatulence.

Pain Predominant.

• Antispasmodics will help 66%.• Mebeverine is probably first choice.• Bloating may be helped by peppermint

oil.• Nausea may require metoclopramide.

• Advise people with IBS how to adjust their doses of laxative or antimotility agent

• Healthcare professionals should consider low-dose tricyclic antidepressants (TCAs) as second-line treatment, recommended only for their analgesic effect

Clinical management of IBS:pharmacological therapy