Diagnosis and Treatment of IBS in the IBD Patient …vid.imedex.com/pdf/5477/macdermott.pdfCase 2: Crohn’s Disease and IBS Presentation: • 27 y/o F S/P severe Crohn’s disease

Diagnosis and Treatment Diagnosis and Treatment of IBS in the IBD Patientof IBS in the IBD PatientDiagnosis and Treatment Diagnosis and Treatment of IBS in the IBD Patientof IBS in the IBD Patient

Richard MacDermott MDRichard MacDermott MDRichard MacDermott MDRichard MacDermott MD

Case 1: IBS Diagnosed and Treated as IBDCase 1: IBS Diagnosed and Treated as IBD

Presentation:Presentation:•• 21 y/o F: Diarrhea, abd pain, nausea21 y/o F: Diarrhea, abd pain, nausea•• Crohn’s dx age 19, while at college Crohn’s dx age 19, while at college •• Intermittently on Prednisone for 2 yearsIntermittently on Prednisone for 2 yearsy yy yEvaluation:Evaluation:•• Blood work, EGD, Colonoscopy, Abd CT negBlood work, EGD, Colonoscopy, Abd CT neg•• Hx stress, anxiety, depressionHx stress, anxiety, depressionHx stress, anxiety, depressionHx stress, anxiety, depressionTreatment:Treatment:•• Pt treated for IBS. Steroids discontinuedPt treated for IBS. Steroids discontinued

IBS Versus IBDIBS Versus IBD

Hi tHi t W i ht l GI Bl diW i ht l GI Bl di•• History:History: Weight loss; GI BleedingWeight loss; GI Bleeding•• Exam:Exam: Fever; Mass; MalnutritionFever; Mass; Malnutrition•• Labs:Labs: Elevated WBC, Sedimentation Rate, Elevated WBC, Sedimentation Rate,

CC R ti P t i Pl t l t C t A iR ti P t i Pl t l t C t A iCC--Reactive Protein, Platelet Count; Anemia; Reactive Protein, Platelet Count; Anemia; Electrolyte Abnormalities; Low AlbuminElectrolyte Abnormalities; Low Albumin

•• Procedures:Procedures: Abnormal findings on Abnormal findings on Colonoscopy; Upper Endoscopy; CT Scan;Colonoscopy; Upper Endoscopy; CT Scan;Colonoscopy; Upper Endoscopy; CT Scan; Colonoscopy; Upper Endoscopy; CT Scan; SBFT; Capsule EndoscopySBFT; Capsule Endoscopy

Case 2: Crohn’s Disease and IBSCase 2: Crohn’s Disease and IBSPresentation:Presentation:Presentation:Presentation:•• 27 y/o F S/P severe Crohn’s disease of colon. 27 y/o F S/P severe Crohn’s disease of colon.

Perirectal and RectoPerirectal and Recto--vaginal fistulae vaginal fistulae •• Excellent response to Remicade for 3 yearsExcellent response to Remicade for 3 yearsp yp y•• Two episodes severe diarrhea, abd pain, nauseaTwo episodes severe diarrhea, abd pain, nauseaHistory:History:•• Pt had gone to NYC for Yankees game: hot Pt had gone to NYC for Yankees game: hot

d b d l i l NYCd b d l i l NYCdogs, beer and multiple NYC restaurantsdogs, beer and multiple NYC restaurants•• Week later: family spaghetti sauce that took Week later: family spaghetti sauce that took

three days to make three days to make

IBS in Chronic IBDIBS in Chronic IBD

•• IBS may occur in 33IBS may occur in 33 40% of chronic IBD pts40% of chronic IBD pts•• IBS may occur in 33 IBS may occur in 33 --40% of chronic IBD pts40% of chronic IBD pts•• May contribute to high placebo response ratesMay contribute to high placebo response rates•• Similar symptoms: diarrhea, abd painSimilar symptoms: diarrhea, abd pain

IBD i fl ti IBSIBD i fl ti IBS•• IBD inflammation may worsen IBSIBD inflammation may worsen IBS•• IBS symptoms too often treated with IBD medsIBS symptoms too often treated with IBD meds•• Differentiate IBS from IBD by history: gas and Differentiate IBS from IBD by history: gas and

bloating; cramping abd pain; heartburn;bloating; cramping abd pain; heartburn;bloating; cramping abd pain; heartburn; bloating; cramping abd pain; heartburn; symptoms worsened by foods and beveragessymptoms worsened by foods and beverages

•• Procedures and labs helpful if normalProcedures and labs helpful if normal

IBS in Chronic IBD: IBS in Chronic IBD: Treatment of DiarrheaTreatment of Diarrhea

•• Use Daily:Use Daily:Lomotil in divided dosesLomotil in divided dosesImodium in divided dosesImodium in divided dosesFiberFiberTricyclic antidepressants (low dose) Tricyclic antidepressants (low dose) y p ( )y p ( )

IBS in Chronic IBD: Treatment IBS in Chronic IBD: Treatment of Abdominal Pain/Crampingof Abdominal Pain/Crampingp gp g

•• Use Daily in Divided Doses:Use Daily in Divided Doses:B lB lBentylBentylLevsinLevsinDonnatolDonnatolLibraxLibrax

IBS in Chronic IBD: IBS in Chronic IBD: Treatment of ConstipationTreatment of Constipation

•• Use Daily:Use Daily:FiberFiberColaceColace

•• Use as Needed or Daily:Use as Needed or Daily:MiralaxMiralaxLactuloseLactulose

IBS in Chronic IBD: IBS in Chronic IBD: Medication Side EffectsMedication Side Effects

•• Major side effect of meds for diarrhea: Major side effect of meds for diarrhea: ConstipationConstipationM j id ff t f d f ti tiM j id ff t f d f ti ti•• Major side effect of meds for constipation: Major side effect of meds for constipation: DiarrheaDiarrhea

•• Each patient needs to learn to adjust the Each patient needs to learn to adjust the d d f f IBS dd d f f IBS ddose and frequency of IBS meds dose and frequency of IBS meds

IBS in Chronic IBD: Treatment of IBS in Chronic IBD: Treatment of Stress/Anxiety/DepressionStress/Anxiety/Depression

•• Cognitive TherapyCognitive Therapy•• BiofeedbackBiofeedback•• Stress RelaxationStress Relaxation•• AntidepressantsAntidepressants•• AnxiolyticsAnxiolyticsyy•• Psychiatric evaluationPsychiatric evaluation

IBS in Chronic IBD: Use of Tricyclic IBS in Chronic IBD: Use of Tricyclic and SSRI Antidepressantsand SSRI Antidepressants

TricyclicTricyclic SSRISSRI

IndicationsIndications DepressionDepression DepressionDepressionChronic Pain AnxietyChronic Pain Anxiety

TricyclicTricyclic SSRISSRI

IndicationsIndications DepressionDepression DepressionDepressionChronic Pain AnxietyChronic Pain AnxietyChronic Pain AnxietyChronic Pain Anxiety

Chronic PainChronic Pain

Side EffectsSide Effects

Chronic Pain AnxietyChronic Pain AnxietyChronic PainChronic Pain

Side EffectsSide EffectsConstipationConstipationDry MouthDry Mouth

DiarrheaDiarrheaInsomnia Insomnia Dry Mouth Dry Mouth

SedationSedation Agitation Agitation HeadacheHeadache

Narcotics Narcotics Pain ReliefPain ReliefNarcotics Narcotics

Pain ReliefPain ReliefDelayed Delayed TransitTransitDelayed Delayed TransitTransit

IBS in Chronic IBD: Avoid Narcotics IBS in Chronic IBD: Avoid Narcotics

Pain & Narcotics: Pain & Narcotics: Narcotic DependenceNarcotic Dependence

Pain & Narcotics: Pain & Narcotics: Narcotic DependenceNarcotic Dependence

Pain ReliefPain ReliefPain ReliefPain Relief TransitTransitTransitTransit

IleusIleusIleusIleusNarcoticsNarcoticsNarcoticsNarcoticsNarcotic DependenceNarcotic DependenceNarcotic DependenceNarcotic Dependence

DistensionDistensionDistensionDistensionIncreased Increased IIntestinalntestinal

SSpasm / pasm / PPainainIncreased Increased IIntestinalntestinal

SSpasm / pasm / PPainainpppp

Nausea /Nausea /VomitingVomitingNausea /Nausea /VomitingVomitingNarcotic

WithdrawalNarcotic

Withdrawal

IBS in Chronic IBD: Problems With IBS in Chronic IBD: Problems With Our Current Treatment ApproachOur Current Treatment Approach

•• Current approach: medications used to allow Current approach: medications used to allow patients to eat and drink what they want patients to eat and drink what they want

•• Patients already on multiple medicationsPatients already on multiple medications•• Common: instead of diet and weight loss Common: instead of diet and weight loss

1. Statins for high cholesterol 1. Statins for high cholesterol 2. Oral hypoglycemics for type 2 diabetes2. Oral hypoglycemics for type 2 diabetes3 A i i f i3 A i i f i3. Antihypertensives for hypertension3. Antihypertensives for hypertension

•• Medications for IBS often ineffective against Medications for IBS often ineffective against food and beverage stimulation of GI tractfood and beverage stimulation of GI tract

Food and Beverage Stimulation Food and Beverage Stimulation of Normal GI Tractof Normal GI Tract

•• Gastric motility Gastric motility •• Acid secretionAcid secretion•• Gallbladder contractionGallbladder contraction•• Pancreatic enzyme secretionPancreatic enzyme secretion•• Small bowel motilitySmall bowel motilityyy•• GastroGastro--colic reflexcolic reflex

2000200020002000

MealMeal--Stimulated Sigmoid Motility in Stimulated Sigmoid Motility in IBSIBS20002000

15001500

10001000

20002000

15001500

10001000SigmoidSigmoid

MealMealMealMeal

500500500500

MotilityMotilityIndexIndex IBSIBSIBSIBS

NormalNormalNormalNormal

1001001001000000

0000 50505050 130130130130

MinutesMinutesMinutesMinutesRogers J, Gut; 1989Rogers J, Gut; 1989Rogers J, Gut; 1989Rogers J, Gut; 1989

Effects of Food on Serotonin in IBS Effects of Food on Serotonin in IBS 1400

800

1000

1200

1400

Plasma Plasma Plasma Plasma

IBS PatientsIBS PatientsNormal PatientsNormal PatientsIBS PatientsIBS PatientsNormal PatientsNormal Patients

200

400

600SerotoninSerotoninSerotoninSerotonin

011 22 33 44 55 66 77 88 99 1010 1111

Bearcroft, Gut; 1993Bearcroft, Gut; 1993Bearcroft, Gut; 1993Bearcroft, Gut; 1993 Normal PatientsNormal Patients IBS PatientsIBS Patients

IBS in Chronic IBD: IBS in Chronic IBD: Visceral Hypersensitivity To FoodVisceral Hypersensitivity To Food

Serotonin Serotonin ReleaseRelease

Serotonin Serotonin ReleaseRelease Spinal AfferentSpinal AfferentSpinal AfferentSpinal Afferent Normal GI Normal GI

MotilityMotilityNormal GI Normal GI

MotilityMotility

Food in Normals Food in Normals

Increased Increased Serotonin Serotonin ReleaseRelease

Increased Increased Serotonin Serotonin ReleaseRelease

Spinal AfferentSpinal AfferentSpinal AfferentSpinal Afferent Increased GI Increased GI MotilityMotility

Increased GI Increased GI MotilityMotility

Food in chronic IBD patients with IBSFood in chronic IBD patients with IBS

ReleaseReleaseReleaseRelease

Inflammatory Inflammatory MediatorsMediators

Inflammatory Inflammatory MediatorsMediators

Increased Increased SensitizationSensitizationIncreased Increased SensitizationSensitization

IBS in Chronic IBD: Foods and IBS in Chronic IBD: Foods and Beverages that Cause DiarrheaBeverages that Cause Diarrhea

•• Caffeinated Beverages, SodasCaffeinated Beverages, Sodas•• Milk Products, Ice Cream, Cheese, ChocolateMilk Products, Ice Cream, Cheese, Chocolate•• AlcoholAlcohol•• Dietetic Beverages, Foods, Gum, CandyDietetic Beverages, Foods, Gum, Candy•• Spices, Sauces, Red MeatsSpices, Sauces, Red Meats•• Gravies, Soups, Spaghetti SauceGravies, Soups, Spaghetti Sauce•• Fruits, Fruit JuicesFruits, Fruit Juices

IBS in Chronic IBD: Foods and IBS in Chronic IBD: Foods and Beverages that Cause Gas and BloatingBeverages that Cause Gas and Bloating

Delayed Fermentation ProcessDelayed Fermentation Process•• Milk Products, Cheese, Ice Cream, Yogurt, Milk Products, Cheese, Ice Cream, Yogurt,

Chocolate, Cake, Cookies.Chocolate, Cake, Cookies.C oco e, C e, Coo esC oco e, C e, Coo es•• Salad Dressings, Mayonnaise.Salad Dressings, Mayonnaise.•• Beans, Cabbage, Raw VegetablesBeans, Cabbage, Raw Vegetables•• Bagels, Sourdough Bread, Multigrain Bread.Bagels, Sourdough Bread, Multigrain Bread.Bagels, Sourdough Bread, Multigrain Bread.Bagels, Sourdough Bread, Multigrain Bread.•• Fast Foods, Pizza, Fried Foods.Fast Foods, Pizza, Fried Foods.•• Carbonated BeveragesCarbonated Beverages

IBS in Chronic IBD: Food and Beverage IBS in Chronic IBD: Food and Beverage Intolerance, Avoidance DietIntolerance, Avoidance Diet

•• Food and Beverage intolerances vary: Different Food and Beverage intolerances vary: Different for each person.for each person.

•• Food intolerances:Food intolerances: Not food allergiesNot food allergiesFood intolerances: Food intolerances: Not food allergiesNot food allergies..•• Amount dependent and cumulative.Amount dependent and cumulative.•• Additive within and between meals. Additive within and between meals. •• Symptoms can occur within 15 minutes or canSymptoms can occur within 15 minutes or can•• Symptoms can occur within 15 minutes or can Symptoms can occur within 15 minutes or can

be delayed for 6 to 48 hours.be delayed for 6 to 48 hours.

Food and Beverage Intolerances in IBS Food and Beverage Intolerances in IBS in Chronic IBD: Taking the Historyin Chronic IBD: Taking the History

P iP iPatient statementsPatient statements•• “After I eat I have pain and diarrhea”“After I eat I have pain and diarrhea”•• ““All foods go right through”All foods go right through”Questions to AskQuestions to Ask•• What foods/beverages do you avoid?What foods/beverages do you avoid?•• Trouble eating out?Trouble eating out?•• Recent dietary change?Recent dietary change?Most helpful approach: “What do you eat forMost helpful approach: “What do you eat forMost helpful approach: “What do you eat for Most helpful approach: “What do you eat for

breakfast, lunch, dinner, and snacks? What do breakfast, lunch, dinner, and snacks? What do you drink during the day?”you drink during the day?”

Problematic Foods in Recent PatientsProblematic Foods in Recent Patients

•• Crystal Light; Diet Sodas; Snapple Iced TeaCrystal Light; Diet Sodas; Snapple Iced Tea•• Milk, Cheese, Ice Cream, ChocolateMilk, Cheese, Ice Cream, Chocolate•• Bagels; Donuts Bagels; Donuts •• Cookies; PretzelsCookies; Pretzels•• Diet: Fruits; Vegetables; Granola Bars; Fiber Diet: Fruits; Vegetables; Granola Bars; Fiber •• Barbecue Sauce; Chicken Wings; PizzaBarbecue Sauce; Chicken Wings; Pizza

Input From Spouse Often Very Helpful !!Input From Spouse Often Very Helpful !!

IBS in Chronic IBD: SubstitutionIBS in Chronic IBD: Substitution

•• Milk Products: Milk Products: Soy and Rice Products; No LactaidSoy and Rice Products; No Lactaid•• Caffeine, Fruit Juice, Alcohol, Sodas, Diet Sodas: Caffeine, Fruit Juice, Alcohol, Sodas, Diet Sodas: WaterWater•• Bagels/Donuts: Bagels/Donuts: English Muffins; White BreadsEnglish Muffins; White Breads•• Salad Dressings: Salad Dressings: Oil and VinegarOil and Vinegar•• Red Meats: Red Meats: Plain Fish, Chicken, TurkeyPlain Fish, Chicken, Turkey•• Fresh Fruits, Vegetables: Fresh Fruits, Vegetables: Cooked, CannedCooked, Canned•• Sauces Gravies Spices Fast Foods Fried FoodsSauces Gravies Spices Fast Foods Fried FoodsSauces, Gravies, Spices, Fast Foods, Fried Foods, Sauces, Gravies, Spices, Fast Foods, Fried Foods,

Condiments: Condiments: Avoid CompletelyAvoid Completely

Advice on Foods and Beverages in IBSAdvice on Foods and Beverages in IBS

•• What you eat and drink is influenced by your What you eat and drink is influenced by your taste buds, which make your brain happy.taste buds, which make your brain happy.

•• Stomach, and intestine do not have taste buds Stomach, and intestine do not have taste buds ,,•• Tongue and brain happy; GI tract suffers Tongue and brain happy; GI tract suffers •• No damage is done; does not make IBD worse No damage is done; does not make IBD worse •• Goal is to avoid treatment of IBS with IBDGoal is to avoid treatment of IBS with IBDGoal is to avoid treatment of IBS with IBD Goal is to avoid treatment of IBS with IBD

medicationsmedications

PsychiatryPsychiatry

IBS in Chronic IBD: TreatmentIBS in Chronic IBD: Treatment OverviewOverview

PsychiatryPsychiatryPain ManagementPain Management

Cognitive Therapy/ Cognitive Therapy/ Stress Reduction/ Stress Reduction/ BiofeedbackBiofeedback

Antidiarrheals /Anxiolytics /Antidiarrheals /Anxiolytics /Antidepressants/Fiber/Antidepressants/Fiber/Miralax/LactuloseMiralax/Lactulose

Education / ReassuranceEducation / ReassuranceDietary ModificationDietary Modification