Diagnose and treat irritable bowel syndrome (IBS) like master clinician, Dr. Brooks Cash of the American College of Gastroenterology. This condition frustrates clinicians and patients alike, but we’ll give you the tools to conquer IBS.
- ROME IV Criteria
- The word discomfort removed.
- Abdominal pain
- Associated with change in form or frequency of stool
- Relieved or eased with defecation
- Need at least 2 of 3.
- Usually still give diagnosis even if not formally met.
- Diagnosis of exclusion
- CBC, TSH, CRP
- Consider fecal calprotectin if inflammatory bowel disease (IBD) suspected (not Dr. Cash’s practice)
- Consider testing celiac (tissue transglutaminase [TTG] and total IgA)
- Consider colonoscopy (select cases)
- Usually test patients with diarrhea (NOT constipation)
- Be wary of patient with multiple prior workups
- Red flag symptoms: Weight loss, bleeding, family history of celiac disease, colorectal cancer, IBD
- Lifestyle modifications are initial therapy for all
- Exercise if IBS-C
- Consider dietary sensitivity
- FODMAP diet, or elimination diet
- Gluten: can cause non-celiac wheat sensitivity
- Three groups in IBS: IBS-D (diarrhea), IBS-C (constipation), IBS-M (mixed)
- IBS with diarrhea
- Treating IBS-D
- On a budget: loperamide, peppermint oil (medical food OTC), fiber (use with caution if bloating present)
- Got $$$?:
- Rifaxamin helps with bloating (good evidence). Given as a two week course.
- Eluxadoline helps with pain and fecal urgency, or urge incontinence
- Treating IBS-C
- On a budget: polyethylene glycol
- Got $$$?
- lubiprostone (titratable)
- linaclotide (more severe constipation, better laxative)
- both bring fluid into the GI tract and have good evidence
- Treating abdominal pain symptoms
- TCAs help pain at low doses ( Dr. Cash uses d
- SSRIs can exacerbate diarrhea, but helpful if anxious phenotype
- Probiotics and prebiotics: data not yet strong, but okay to continue if patient prefers
- Bile acids: soaps that irritate gut and increase motility
Dr. Cash’s Take Home Points:
- Learn and apply the ROME IV criteria
- If no alarm features, then treat empirically
Goal: Listeners will develop a standardized approach to the diagnosis and management of IBS.
By the end of this podcast listeners will:
- Implement ROME IV criteria for IBS diagnosis
- Utilize basic testing to rule out alternate etiologies for IBS symptoms
- Recall the alarm features of more serious GI conditions
- Tailor patient’s therapy based on IBS type, and patient factors (e.g. cost, comorbid conditions)
- Explain possible etiologies for IBS
Dr. Cash is on the Speakers’ Bureau for Salix, Allergan, Synergy, Takeda, and Ironwood.
02:47 Rapid fire questions
09:44 Rome IV Criteria
11:20 Diagnostic testing
15:18 Lifestyle and dietary modifications for IBS
20:18 Treat IBS on a budget
22:35 Discussion of TCAs and SSRIs for IBS
24:40 Discussion of supplements for IBS
27:23 Newer FDA approved agents for IBS-D
31:17 Small intestinal bacterial overgrowth discussed
32:40 Possible etiologies
34:54 Newer FDA agents for IBS-C
36:00 Bile acid malabsorption
40:09 Take home points
42:25 Costs discussed
Links from the show:
- On Being A Doctor by Michael A. LaCombe, MD
- ROME IV Criteria for IBS updated May 2016
- Pepper Mint Oil for IBS meta-analysis used Colpermin peppermint oil
- FODMAP diet explained by Dr. Bill Chey from University of Michigan
- FODMAP handout from Stanford
- University of Michigan website with helpful patient handouts for constipation, diarrhea, gluten free diet, etc.
- IBS review article from BMJ 2015 Saito, YA. Irritable bowel syndrome: new and emerging treatments. 2015;350:h1622å