GENERAL HEALTH WHAT IS THE NATURAL HISTORY OF IBS? People with IBS do report a change in their symptoms over time. In about 40% the symptoms improve over time but this can take some years. About 20% of patients have persisting symptoms. Interestingly, about 20% of patients report a change in their symptoms over time. For instance, some people with D-IBS develop A-IBS or vice-versa. Some of those with C-IBS will go on to develop functional constipation (i.e. the pain component of their symptoms improves but the bowel disturbance does not) or functional abdominal pain (i.e. the bowel disturbance improves but the pain does not). This is likely explained by the fact that IBS is only one member of a ‘family’of functional gastrointestinal disorders and the nature of a person’s functional disturbance can change over time. WHAT IS THE PATHOPHYSIOLOGY OF IBS? IBS results from the interaction of a number of factors and no particular abnormality is specific for this disorder. Whilst our understanding of the pathophysiology of IBS continues to evolve, it is clear that motility and visceral hypersensitivity are important in many people with IBS. Motility refers to the motor activity of the gastrointestinal tract. In C-IBS a prolonged transit time can be observed in the gut. In D-IBS an exaggerated transit time can be seen following meals, for instance. Visceral hypersensitivity refers to subjective awareness of sensation and pain related to gut function. Often these factors overlap and lead to the commonly observed symptoms of IBS, where altered motility and an increased sensitivity to pain leads to people requiring assistance in managing the resultant symptoms. There is also emerging evidence that other factors may be important, including inflammation and alterations in the gut microflora (aka microbiome). SYMPTOMATIC THERAPY FOR IBS It is a truism to say that the therapeutic relationship between doctor and patient is the cornerstone of effective therapy. This is of particular importance in the management of functional disorders such as IBS, which tend to be recurrent and where symptom management (rather than cure) is the primary goal of therapy. Often the severity of symptoms will guide the therapeutic approach. For those with mild or intermittent symptoms, education about the nature of IBS can have a powerful therapeutic effect by providing reassurance about the benign nature of the disorder. Diet based therapies (especially FODMAP TM restriction) can help up to 75% of patients improve their symptoms. Due to the restrictive nature of the low FODMAP TM diet liberalisation of the diet after a few weeks is also useful in mitigating against nutritional restriction as well as making the therapy more practicable. For moderate symptoms that fail to respond to dietary therapy alone there is significant data to support the use of pharmacological adjuncts such as tricyclic anti-depressants and selective serotonin re-uptake inhibitors (SSRIs). Indeed, very few other treatments have as much evidence to support their use in this patient population. This may be further evidence for the emerging concept of a ‘gut-brain axis’ whereby treatment of disorders of the central nervous system (CNS) and the gastrointestinal tract (GIT) can be improved by utilising treatments targeted to the other system in the axis. Psyllium based treatments can be useful in patients with C-IBS. Simple laxatives can also be effective as second line therapy in this patient group. Loperamide is often used in D-IBS and can provide symptomatic relief. There is not much evidence to support the use of currently available probiotics in patients with IBS but it is hoped that an improved understanding of the role of the microbiome in pathophysiology will lead to improved therapies. pindaramagazine.com.au Pindara Magazine 17
Pindara Private Hospital Magazine - Issue Six
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