(Bowel syndrome, irritable bowel syndrome)
Irritable bowel syndrome (Irritable bowel syndrome, IBS) is characterized by recurrent abdominal pain or pain that is accompanied by at least two of the following symptoms: relief by defecation, change in the frequency of bowel movements or change in consistency of stool. The cause is unknown and incompletely understood pathophysiology. The diagnosis is made clinically. Treatment is symptomatic and consists of special diets and medications, including anticholinergics and substances that are effective to serotonin receptors count.
Irritable bowel syndrome (Irritable bowel syndrome, IBS) is characterized by recurrent abdominal pain or pain that is accompanied by at least two of the following symptoms: relief by defecation, change in the frequency of bowel movements or change in consistency of stool. The cause is unknown and incompletely understood pathophysiology. The diagnosis is made clinically. Treatment is symptomatic and consists of special diets and medications, including anticholinergics and substances that are effective to serotonin receptors count. Etiology The cause of Reizdarmsynsroms is unknown. In laboratory, X-ray examinations and biopsies no anatomic cause can be found. Emotional factors, diet, drugs or hormones like the appearance or worsening of gastrointestinal symptoms lead. Previously, the disease was often regarded as a purely psychosomatic. Although psychosocial factors are involved, irritable bowel syndrome is better than a combination of psychosocial and physiological factors understood. Psychosocial factors Psychological stress is often given to patients with irritable bowel syndrome, especially among those who seek medical care. Some patients have anxiety disorders, depression and somatization. Also, sleep may be present. But not always, there is a temporal correlation between stress and emotional conflicts on the one hand and the exacerbation and relapse of the symptoms on the other side. Some patients with IBS seem to have a disturbed emotional problem processing (they express emotional conflict as gastrointestinal complaints, v. A. Abdominal pain, off). Physicians treating patients with IBS, v. a. those with persistent symptoms should think of unresolved psychological conflicts, incl. the possibility of sexual or physical abuse. Psychosocial factors also influence the outcome in IBS.Physiologische factors A variety of physiological factors seem to be involved in IBS symptoms. These factors include altered motility, visceral hyperalgesia and various genetic and environmental factors. Visceral hyperalgesia refers to a hypersensitivity to the normal extent of the intraluminal strain and an increased perception of pain in normal intestinal gas volumes. This may result from the conversion of the neural pathways in the brain gut axis. Some patients (perhaps 1 of 7) have reported that their IBS symptoms occurred after an episode of acute gastroenteritis are (so-called. Postinfectious IBS). A subgroup of patients with IBS shows vegetative dysfunctions. However, one can not detect physiological disorders in many patients; and even if such disturbances exist, they do not correlate with the symptoms. Constipation can be explained by a slower intestinal transit, and diarrhea can be explained by a more rapid intestinal transit. Some patients with constipation have less intestinal contractions of high amplitude, which promote the intestinal contents by a plurality of segments. Conversely, can delay the transit to functional constipation, an excessive motor activity of the sigmoid. Postprandial abdominal pain may be an exaggerated gastrointestinal colonic reflex (the intestinal contraction is a response to a meal), the presence of intestinal contractions of high amplitude, an increased intestinal sensitivity (visceral hyperalgesia), or a combination of these factors are attributed. Fat intake can increase intestinal permeability and hypersensitivity. Ingested food, the (collectively referred to as FODMAPs) rich in fermentable oligosaccharides, disaccharides, monosaccharides and polyols, is absorbed sufficiently in the small intestine and may increase colonic motility and secretion. Hormonal fluctuations affect the bowel function in women. Rectal sensitivity is increased during menstruation, but not in the other phases of the menstrual cycle. The effects of sex hormones on the intestinal transit are subtle. The role of bacterial overgrowth in the small intestine for irritable bowel syndrome is controversial. Symptoms and complaints Irritable bowel syndrome begins in adolescence and at 20 years of age and causes irregular intervals episodes of symptoms. First appearance in later life is less common, but not rare. The symptoms often occur during sleeping patient. Often the symptoms of food, particularly fats, or triggered by stress. Patients have abdominal pain, which vary widely, but are often located in the lower abdomen, have a constant or spasmodic character and relieved by bowel movements. Moreover, the abdominal pain are in a temporal relationship with changes in stool frequency (increase in the embossed diarrhea IBS and constipation reduced in the embossed IBS) and stool consistency (i. E. Loose or lumpy and hart). Pain or discomfort associated with defecation originated probably in the intestine; Pain or discomfort associated with stress, exercise, urination or menstruation, have another cause, as a rule. Although the Stuhgewohnheiten in most patients are relatively constant, it is not uncommon for patients that constipation and diarrhea alternate. Patients may also show symptoms of abnormal stool passage (effort, urgency or feeling of incomplete evacuation), excrete mucus or complain of bloating or abdominal distension. Many patients also show symptoms of dyspepsia. Extra-intestinal symptoms (eg. As fatigue, fibromyalgia, insomnia, chronic headaches) are common. Diagnosis Clinical evaluation on the basis of the Rome criteria search for organic causes with simple laboratory tests and sigmoidoscopy or colonoscopy Further tests in patients with serious findings (rectal blood, weight loss, fever) Diagnosis IBS is based on the characteristic pattern of intestinal discomfort, the appearance and character of the pain and the exclusion of other disease processes through a detailed physical examination and routine diagnostic tests. Warnings These diagnostic tests should be intensified if the following serious results are available – either at initial presentation or at any time after diagnosis: Seniority fever weight loss Rectal bleeding vomiting Differential Diagnosis Because patients can develop with IBS organic findings, investigations of other medical conditions should also in patients be given to developing the alarm symptoms or markedly different symptoms during the course of their disease. to the common diseases that can be confused with IBS include lactose intolerance Drug-induced diarrhea postcholecystectomy syndrome misuse of laxatives Parasitic Diseases (z. B. giardiasis) Eosinophilic gastritis or enteritis Microscopic colitis bacterial overgrowth of the small intestine Celiac Disease Early inflammatory bowel disease noninflammatory Darmdivertikel but cause no symptoms, and their presence should not be regarded as conclusive. The bimodal age distribution of patients with inflammatory bowel disease makes it imperative to examine both younger and older patients. In patients> 60 years with acute symptoms of ischemic colitis should be considered. Patients with constipation without anatomical cause should respect. The presence of hypothyroidism and a hyperparathyroidism be examined. If the patient Malabsorptionssymptome shows tropical sprue, celiac disease and Whipple’s disease must be considered in the differential diagnosis. Patients who report symptoms of difficult defecation, must be thought of defecation as a cause of constipation. Among the rare causes of diarrhea include hyperthyroidism, medullary thyroid cancer or carcinoid syndrome, gastrinoma and VIPom. However, by vasoactive intestinal peptide (VIP), calcitonin or gastrin caused secretory diarrhea is typically accompanied> 1000 ml of stool daily volumes. Tips and risks noninflammatory Darmdivertikel cause any symptoms, and their presence should not be regarded as conclusive. History Special attention must be paid to the character of the pain, the bowel habits, interpersonal family relationships, as well as drug and food history. Equally important are the general emotional state of the patient, his interpretation of personal problems and his quality of life. The quality of the doctor-patient relationship is the key for the diagnostic and therapeutic success. The Rome criteria are standardized symptom-based criteria for diagnosing IBS. The Rome criteria require the presence of abdominal pain or discomfort for at least 3 days / month in the last 3 months and ? 2 of the following criteria: improvement in bowel movements start (any discomfort phase) with a change in frequency of bowel movements associated change in the consistency of stool Physical examination patients appear healthy in general. On palpation of the abdomen can detect a voltage, particularly in the left lower quadrant, at times associated with a palpable tense sigmoid. The digital rectal exam with a fecal occult blood test should be performed in all patients. In women, the pelvic exam can simultaneously the presence of tumors of the ovary, cysts or endometriosis, which can all pretend to have a IBS, ausschließen.Testverfahren The diagnosis of IBS can reasonably be done using the Rome criteria, as long as the patient no serious findings have as rectal bleeding, weight loss and fever or other findings that suggest a different etiology. Many patients with IBS are diagnosed. The following test procedures should be carried out, however: complete blood count, biochemical profile (incl. Liver function tests), ESR, stool examination for ova and parasites (in patients with predominant diarrhea), thyreoideastimulierendes hormone and calcium in patients with constipation and flexible sigmoidoscopy or colonoscopy. In the flexible fiberglass Proktosigmoidoskopie the introduction of the instrument and the air insufflation frequently trigger from intestinal cramps and pain. The mucosal and vascular patterns in irritable bowel syndrome looks usually normal. > 50-year old patient with changes in bowel habits, v. a. among those who previously did not have irritable bowel syndrome, a colonoscopy should be performed to rule out colonic polyps and tumors. In patients with chronic diarrhea, v. a. in older women, mucosal biopsy can rule out the possible existence of a microscopic colitis. Other studies (eg. As ultrasound, CT, Kolonkontrastdarstellung with barium, esophagogastroduodenoscopy, X-ray examination of the small intestine) should be carried out only in the presence of other objective signs of illness. The fecal fat amount should be determined when a concern about Steatorrhea there. A test for celiac disease and an X-ray examination of the small intestine are recommended when malabsorption is suspected. A test for carbohydrate intolerance and bacterial overgrowth in the small intestine should be considered in appropriate circumstances into consideration werden.Zusätzliche disease patients with IBS can develop additional gastrointestinal disorders in the sequence, and the clinician must not abbtun lightly their complaints. Changes in symptoms (eg. As location, type, intensity of pain, bowel habits with constipation or diarrhea) and new symptoms or complaints (eg. As nocturnal diarrhea) may signal another disease process. Other symptoms that need to be clarified are fresh blood in the stool, weight loss, severe abdominal pain and unusual abdominal tension, steatorrhea and clearly stinking stool, fever or chills, persistent vomiting, blood vomiting, symptoms that awaken the patient during sleep (such as pain or defecate) and constant aggravation of the symptoms. Patients> 40 years develop additional physical illnesses often than young patients. produce therapeutic support and understanding normal diet, avoiding foods that cause gas and diarrhea Increased intake of dietary fiber to treat constipation Drug therapy is based on the dominant symptoms. The therapy depends on the specific symptoms. An effective therapeutic relationship is important for the effective management of irritable bowel syndrome. Patients should be asked to formulate not only the symptoms but also their understanding of the symptoms and state the reasons that have led to a visit to a health care practitioner (eg. As fear of serious illness). Patients should have the disorder (eg. As normal intestinal physiology and hypersensitivity of the gut to stress and food) are clarified and one should assure them after appropriate testing that no serious or life-threatening disease is present. Suitable therapeutic targets (eg. As expectations regarding the normal course or the variability of symptoms, drug side effects, the adequate cooperation between doctor and patient) should be set up. Finally, patients can benefit by being actively involved in the treatment of their disease. If successful, this can improve the patient’s motivation to continue the treatment, foster a more positive doctor-patient relationship and mobilize coping resources themselves chronically passive patient. Psychological stress, anxiety or mood disorders must be identified, evaluated and treated. Regular physical activity is good for stress reduction and for normal bowel function, v. a. in patients with constipation. Diet Generally it can be assumed a normal diet. Meals should not be excessive and should be taken slowly and regularly. it may be beneficial for patients with a distended abdomen and increased flatulence when they avoid beans, cabbage, and other foods that digest carbohydrates. A reduced supply of sweeteners (eg., Sorbitol, mannitol, fructose), the constituents of natural and processed foods (e.g., B. apple and grape juice, banana, nuts and raisins), flatulence, bloating and diarrhea can alleviate. Patients with lactose intolerance should avoid dairy products. A low-fat diet can reduce postprandial abdominal symptoms. Fiber supplements can soften the stool and facilitate emptying. A mild intestinal contents proliferating substance can be applied (eg. B. raw bran, starting with 15 ml = 1 tablespoon, with each meal, in addition to increased fluid intake). Alternatively, psyllium can be taken with 2 glass of water. However, excessive intake of dietary fiber may have bloating and diarrhea being the reason why the dosage should be individualized. Occasionally, bloating can by switching to a synthetic fiber preparation (eg., Methyl cellulose) reduzieren.Medikamentöse therapy (See also American Gastroenterological Association’s technical review and guideline on pharmacologic management on irritable bowel syndrome.) Drug therapy is based on the dominant symptoms , Anticholinergic drugs (eg. As hyoscyamine 0.125 mg po 30-60 min before meals) can be given for its antispasmodic effect. In patients with constipation-predominant IBS (IBS-C), can be the chloride channel activator lubiprostone 8 mcg or 24 mcg p. o. twice a day and the guanylate cyclase C agonist linaclotide 145 mcg or 290 mcg p. his daily helpful o. once. Polyethylene glycol laxatives have not been well studied in IBS. But they have proved to be effective for use in chronic constipation and intestinal cleansing before colonoscopy and are therefore often used for IBS-C. In patients with diarrhöprädominatnem RDS (RDS-D) can diphenoxylate 2.5-5 mg p.o. or loperamide 2-4 mg p.o. be given before meals. The dose of loperamide should be titrated upward to reduce diarrhea, so that constipation is avoided. Rifaximin is an antibiotic that has been shown in relieving symptoms such as bloating and abdominal pain as well as the reduction of loose chairs in patients with IBS-D to be helpful. The recommended dose of rifaximin for IBS-D is 550 mg po 3 times daily for 14 days. Alosetron is a 5-hydroxytryptamine (serotonin) -3 (5HT3) – receptor antagonist that women can refractory to other drugs, help with severe IBS-D. Because alosetron has been associated with ischemic colitis, is its use in the United States under a strict prescribing program. Eluxadoline has a mixed opioid receptor activity and is indicated for the treatment of IBS-D. In many patients, tricyclic antidepressants may help alleviate the symptoms of diarrhea, abdominal pain and bloating (TZA). It is believed that these drugs reduce the pain of a reduction in the activity of afferent spinal and cortical pathways that start from the intestine. TCAs with secondary amines (eg. As nortriptyline, desipramine) are often better tolerated than tertiary amines (e.g., as amitriptyline, imipramine, doxepin), because they have less anticholinergic, sedative, anti-histamine and alpha-adrenergic side effects. Treatment should start with a very low dose of TCA (z. B. desipramine 10-25 mg once daily at bedtime) and can, if required, and compatibility be increased daily to about 100 to 150 mg once. SSRIs are sometimes used in patients with anxiety or a mood disorder, but studies have not shown significant benefits for patients with IBS and may worsen diarrhea. Preliminary data suggest that certain probiotics alleviate (z. B. Bifidobacterium infantis) IBS symptoms, particularly bloating. The beneficial effects of probiotics does not apply to all species equally, but is specific to certain strains. Certain aromatic oils (carminative) can relax smooth intestinal muscles and ease the pain that occurs in some patients by cramps. Peppermint oil is the most widely used substance in this Klasse.Psychologische therapies Cognitive behavioral therapy, psychotherapy and hypnotherapy may be helpful for some IBS patients. Important points that IBS is characterized by recurrent abdominal pain or pain accompanied by ? 2 of the following symptoms: relief through stool, change in frequency of bowel movements (diarrhea or constipation) or change in consistency of stool. The etiology is unclear, but appears to include both psychosocial and physiological factors. Dangerous diseases must be ruled out by tests, particularly in patients with serious findings and circumstances, such as increased age, fever, weight loss, rectal bleeding or vomiting are made. Among the systemic diseases that can be confused with IBS include lactose intolerance, drug-induced diarrhea, diarrhea after cholecystectomy, laxative abuse, parasitic diseases, eosinophilic gastritis or enteritis, microscopic colitis, bacterial overgrowth in the small intestine, celiac disease, early forms of inflammatory bowel diseases. Typical testing procedures are complete blood count, biochemical profile (incl. Liver function tests), ESR, stool examination for ova and parasites (in patients with predominant diarrhea), thyreoideastimulierendes hormone and calcium in patients with constipation and flexible sigmoidoscopy or colonoscopy. A supportive, understanding and therapeutic relationship is important; the dominant symptoms are treated directly with drugs.