#27 Conquer Irritable Bowel Syndrome

February 20, 2017 | By Matthew Watto, MD

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.

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Clinical Pearls:

1. ROME IV Criteria
   1. The word discomfort removed.
   2. Abdominal pain
   3. Associated with change in form or frequency of stool
   4. Relieved or eased with defecation
   5. Need at least 2 of 3.
   6. Usually still give diagnosis even if not formally met.
2. Diagnosis of exclusion
   1. CBC, TSH, CRP
   2. Consider fecal calprotectin if inflammatory bowel disease (IBD) suspected (not Dr. Cash’s practice)
   3. Consider testing celiac (tissue transglutaminase [TTG] and total IgA)
   4. Consider colonoscopy (select cases)
   5. Usually test patients with diarrhea (NOT constipation)
   6. Be wary of patient with multiple prior workups
3. Red flag symptoms: Weight loss, bleeding, family history of celiac disease, colorectal cancer, IBD
4. Lifestyle modifications are initial therapy for all
   1. Exercise if IBS-C
   2. Consider dietary sensitivity
      1. FODMAP diet, or elimination diet
      2. Gluten: can cause non-celiac wheat sensitivity
      3. fiber (use with caution if bloating present, or if IBS-D)
5. Three groups in IBS: IBS-D (diarrhea), IBS-C (constipation), IBS-M (mixed)
6. Treating IBS-D
   1. On a budget: loperamide, peppermint oil (medical food OTC)
   2. Got $$$?:
      • Rifaxamin helps with bloating (good evidence). Given as a two week course.
      • Eluxadoline helps with pain and fecal urgency, or urge incontinence
7. Treating IBS-C
   1. On a budget: polyethylene glycol, soluble fiber (e.g. psyllium)
   2. Got $$$?
      • lubiprostone (titratable)
      • linaclotide (more severe constipation, better laxative)
      • both bring fluid into the GI tract and have good evidence
8. Treating abdominal pain symptoms
   1. TCAs help pain at low doses
   2. SSRIs can exacerbate diarrhea, but helpful if anxious phenotype
9. Probiotics and prebiotics: data not yet strong, but okay to continue if patient prefers
10. Bile acids: soaps that irritate gut and increase motility

Dr. Cash’s Take Home Points:

1. Learn and apply the ROME IV criteria
2. If no alarm features, then treat empirically

Goal: Listeners will develop a standardized approach to the diagnosis and management of IBS.

Learning objectives:
By the end of this podcast listeners will:

1. Implement ROME IV criteria for IBS diagnosis
2. Utilize basic testing to rule out alternate etiologies for IBS symptoms
3. Recall the alarm features of more serious GI conditions
4. Tailor patient’s therapy based on IBS type, and patient factors (e.g. cost, comorbid conditions)
5. Explain possible etiologies for IBS

Disclosures:
Dr. Cash is on the Speakers’ Bureau for Salix, Allergan, Synergy, Takeda, and Ironwood.

Time Stamps

• 00:00 Intro
• 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
• 26:28 Antispasmodics
• 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
• 44:55 Outro

Links from the show:

1. On Being A Doctor by Michael A. LaCombe, MD
2. ROME IV Criteria for IBS updated May 2016
3. Pepper Mint Oil for IBS meta-analysis used Colpermin peppermint oil
4. FODMAP diet explained by Dr. Bill Chey from University of Michigan
5. FODMAP handout from Stanford
6. University of Michigan website with helpful patient handouts for constipation, diarrhea, gluten free diet, etc.
7. IBS review article from BMJ 2015 Saito, YA. Irritable bowel syndrome: new and emerging treatments. 2015;350:h1622å
8. Treatment of IBS-D by Wald, A in Best Pract Res Clin Gastroenterol. 2012 Oct;26(5):573-80. doi: 10.1016/j.bpg.2012.11.002.