#74: IBS: More than a Gut Feeling

December 7, 2022 | By Justin Berk

Summary

Do you get irritated when people say that someone’s abdominal pain is “just from anxiety”? What IS a FODMAP, anyways? Join our guest Hannibal Person who is trained in both psychiatry and pediatric gastroenterology as he describes his approach to diagnosing, explaining, and treating irritable bowel syndrome.

Credits

• Producer, Writer, Infographic: Angela Y. Zhang MD
• Showrunner: Sam Masur MD
• Cover Art: Chris Chiu MD
• Hosts:  Justin Berk MD, Angela Y. Zhang MD
• Editor:Justin Berk MD; Clair Morgan of nodderly.com
• Guest: Hannibal Person MD

Irritable Bowel Syndrome (IBS) Pearls

1. Try not to frame IBS as an exclusion of diagnosis and a “functional” (vs. “organic”) syndrome – instead, move towards viewing it as a disorder of gut-brain interaction.
2. If there are alarm symptoms, do further workup for other disorders. If there aren’t any, try to avoid over-diagnosing and over-workup.
3. Effective treatment for patients involves partnerships, rapport building, and shared goal-setting. 

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Irritable Bowel Syndrome Notes 

Note: Most research in IBS is in adults, please apply accordingly in clinical practice. Studies have been cited accordingly and pediatric data was cited when available. More research needs to be done for IBS in general, and especially for our pediatric patients. 

Pathophysiology

Old framework: Organic vs. functional as “diagnosis of exclusion”. This divide promotes stigma, and also overlooks the fact that these “functional disorders” have pathophysiologic underpinnings. Instead, call them “disorders of gut-brain interaction” (DGBIs).

The pathophysiology of IBS is complex and not fully understood, but involves visceral hypersensitivity to normal gut stretch and peristalsis (fMRI studies showing uptick of pain networks/emotional regulations); microbiome changes; sub-clinical inflammatory processes (study on injecting food allergen into colonic lining resulting on co-localization of mast cells).

Clinical History

Officially, the criteria for diagnosing IBS are the Rome IV criteria, outlined below:

• Recurrent abdominal pain on average at least 1 day/week in the last 3 months, associated with two or more of the following criteria (fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis):
• Related to defecation
• Associated with a change in frequency of stool
• Associated with a change in form (appearance) of stool

The stool pattern can be mainly constipation, mainly diarrhea, or mixed/alternating – a patient can also have normal bowel movements in between.

However, while the official criteria are useful for standardizing research populations, they may lead to under-diagnosis and delay in treatment in clinical practice. Recognizing this, the Rome Foundation released modified clinical guidelines for use in practice.

In short, while the qualitative features of the Rome IV criteria must be met:

• Symptoms must be bothersome enough to seek care, or affect quality of life or daily activity (can use the IBS-QOL questionnaire)
• Can be less frequent than Rome IV, as long as the symptoms are bothersome enough.
• The 6-month duration is not required; the modified guidelines suggest a duration of 8 weeks, unless “the clinician needs to make an earlier diagnosis and is satisfied that the medical evaluation excludes other disease”.

Expert pearl: Be aware of language barriers if using an interpreter. Some symptoms, like “bloating”, may not interpret well across languages and/or cultures, so symptoms may be missed.

Expert opinion: Like in all conditions, there exists significant racial inequities in the diagnosis and treatment of IBS. 

What else, besides bowel habits, should you screen for?

• Screen for ACEs/trauma history, as these are risk factors
• Screen for comorbid pain conditions, like fibromyalgia, pelvic pain, chronic headache – these may help you come up with treatment modalities that cross organ systems

Labs and Further Workup

Alarm Symptoms

IBS is not a diagnosis of exclusion – one could make the diagnosis with a history and physical exam. However, any of the following alarm symptoms should trigger a further workup for other GI conditions:

• Weight loss and/or failure to gain weight
• Failure to meet pubertal milestones
• Isolated/consistent pain process, e.g. colicky RUQ pain after eating
• Blood in emesis or stool
• Refractory vomiting
• Waking up at night due to pain
• Nocturnal stooling
• Extra-intestinal manifestations, e.g. joint pain, rashes, mouth sores, fevers

Currently, the ACG strongly recommends testing for Celiac in patients you suspect of having IBS. However, little evidence exists for pediatrics and our expert guest tends to not test in the absence of alarm symptoms and family history. 

Expert practice: If your patient is having chronic diarrhea, even without alarm symptoms it would be reasonable to get a stool calprotectin, infectious studies, malabsorption if losing weight, and H. Pylori antigen if pertinent family or travel/residential history. 

Expert opinion: For those with significant family histories of celiac, IBD, and other GI disorders, some basic workup can go a long way to reassure families. However, not all negative testing will provide similar reassurance.

Fun fact: A small, proof-of-concept study found that a device that records bowel sounds was accurate in predicting IBS. 

Management & Treatment

General Goals of Treatment

• IBS can significantly impact QOL, especially for adolescents. In broad strokes, it’s helpful to understand a patient’s priority and goals for treatment (also of any concurrent pain conditions).
• Focus on early victories to build a therapeutic relationship.
• If your patient is seeing other specialists or providers for concurrent pain conditions, be sure to communicate your treatment plan.

Explaining IBS to Patient & Family

There are many, non-stigmatizing ways to explain the diagnosis and management of IBS to your patient and their family. Although there isn’t a one-size-fits-all model, our expert guest had some wise advice:

• Contrary to former models, try not to overemphasize anxiety, which can create a pattern of blaming a child for their illness. Start by talking about the gut and the microbiome. 
• It’s the gut that makes them anxious, not the anxiety making their gut not work.
• Analogies are helpful in this situation.
  • Imagining “butterflies in your stomach” – mental anticipation of something can create a physical sensation in your body
  • Imagine putting on a heavy coat and walking outside. Ask your patient to imagine the feeling of the zipper, the lining, the weight. Ask them how it would feel by the time they got to their destination- chances are, they probably forgot they were even wearing it. A healthy gut should similarly quiet down, but the gut-brain axis is dysregulated.

Diet

• In general, moving away from an ultra-processed diet and known triggers is a good idea.
• Some data about a modified Mediterranean diet (some data about treating depression in adults)
• Yogurt/probiotic foods with mixed evidence
• The low-FODMAP Diet has mixed pediatric data
  • Some studies showing efficacy (one from the UK and one from Iran that also looked at dietary counseling, though keep in mind that the customary diet may differ in Iran)
  • It’s useful to have a robust team, including dieticians, and making sure counseling around FODMAPs doesn’t lead to under-nutrition, and is responsibly done.
  • How restrictive is too restrictive? Be mindful of your patient’s behavior around food – for instance, if they already have avoidant or restrictive food behaviors, you may want to just counsel on cutting out high FODMAP foods instead of adhering to a strict diet. 
  • Can do strict elimination diet for 4-6 weeks (include a dietitian if you do this!).
  • MONASH University app is helpful for remembering which foods are high FODMAP. However, it’s not geared towards children so remember to balance growing nutritional needs.

Pharmacology

Expert practice: Start low, go slow. Before deciding to treat symptoms, elucidate stool pattern and rate of “switching” between constipation and diarrhea if applicable. This is helpful for directing treatment and prevents you from flipping the patient into the other bothersome stool pattern. A poop diary isn’t a bad idea either!

Expert pearl: A lot of kids with IBS are labeled as having “functional constipation”. But if you are effectively managing constipation and they still have pain, it’s time to put IBS on your differential. 

Abdominal Pain

• Probiotic (lactobacillus) has some initial studies on efficacy
• Anti-spasmodics (cyproheptadine, dicyclomine, hyocyamine) are good for occasional episodic use, but not good long-term evidence in children and can lead to anticholinergic side effects.

Diarrhea

• Rifamixin
• Loperamide (first rule out infectious or inflammatory situations as to not cause toxic megacolon)

Constipation

• Osmotic laxatives (Miralax, which has been shown to be superior to lactulose or magnesium), though these have not been shown to treat the pain associated with IBS-C.
• Stimulant laxatives
• Newer agents have mixed evidence in children, with marked adverse effects (e.g. linaclotide)

Neuromodulators

• Duloxetine has been studied in small trials and shown efficacy. 
  • Of note, duloxetine is FDA-approved for patients 13-17 years old with fibromyalgia.
• Our expert guest prefers SNRIs over SSRIs, as the latter is typically effective in those with a predominant mood disorder as opposed to predominantly IBS. TCAs can be an option but have more side effects for pediatric patients. He may also use antipsychotics or an atypical antidepressant like mirtazapine to help with sleep issues. However, it would be wise to collaborate with a psychiatrist at this point.

Behavioral and Integrative Therapies

Mind-Body Therapy

• Diaphragmatic breathing: CT studies (of adults) have shown that some patients with sense of increased gas did not have radiographic evidence of increased bowel gas, but instead was more related to uncoordinated diaphragm/abdominal muscle movement. Therefore, to treat this “sense” of fullness, use diaphragmatic breathing.
• Guided imagery: shown to be effective in a pediatric study
• Refer to this UpToDate table with concrete examples of instructions a patient might receive.

Psychotherapy

• CBT and clinical hypnotherapy have the most evidence behind them
• Major limitation: finding a gut-directed psychotherapy provider

Acupuncture/Acupressure

• A randomized control trial showed efficacy for these methods.

Devices

IB STIM is an FDA-approved device for patients 11-18 years old that uses electrical signals to stimulate cranial nerves for pain reduction.

Goal

Listeners will learn a framework for the pathophysiology, diagnosis, and management of irritable bowel syndrome for optimal outpatient treatment.

Learning objectives

After listening to this episode listeners will…  

1. Distinguish the framework of disorders of gut-brain interaction as opposed to a functional framework.
2. Recognize when a diagnosis of IBS is important, and when workup for an alternate diagnosis is required.
3. Feel comfortable educating patients and families on the pathophysiology of IBS.
4. Describe the utility of pharmacotherapy and adjunct therapies for IBS.
5. Be able to elucidate successful components of a therapeutic provider-patient relationship and how it is important for the treatment of IBS.

Disclosures

Dr. Person reports no relevant financial disclosures. The Cribsiders report no relevant financial disclosures. 

Citation

Zhang AY, Person H, Masur S, Chiu C, Berk J. “#74 IBS: More Than A Gut Feeling”. The Cribsiders Pediatric Podcast. https:/www.thecribsiders.com/74/  12/6/22