An Overview of the Management of Inflammatory Bowel Disease (IBD) and Irritable Bowel Syndrome (IBS) Sue Surgenor October 6 th 2015

Transcription

1 An Overview of the Management of Inflammatory Bowel Disease (IBD) and Irritable Bowel Syndrome (IBS) Sue Surgenor October 6 th 2015

2 Background Teasing out the differential Reviewing treatment options Personalised care Ongoing support I think I m inflamed!!!

3 Background Management of IBS represents a large burden to both primary and secondary care centres 1 90% of those with IBS have seen a primary or secondary care physician 19% had been provided with a diagnosis on the first visit but 56% required 1-5 further visits to their clinician before a diagnosis could be made 1 Hungin APS, et al. Aliment Pharmacol Ther 2003; 17:

4 Background In a year, patients with IBS spend on average: days seeing a doctor or nurse v 5.2 days for non-sufferers 5.5 days off work sick v 3.1 days for non-sufferers 3.9 days in bed v 2.7 days for non-sufferers 10.2 days where work activities have to be cut short v 4.8 days for non-sufferers Hungin APS, et al. Aliment Pharmacol Ther 2003; 17:

5 Background About 280,000 people in the UK have IBD, approximately 400 patients per 100,000 population. The cost of IBD to the NHS has been estimated at about 720 million per annum, based on the prevalence and an average cost of 3,000 per year per patient. There is no cure. Cause is likely to be multi-factorial, a combination of genetic predisposition and environmental triggers. These are lifelong conditions Men and women are diagnosed in equal numbers

6 Diarrhoea Diarrhoea may be defined as the abnormal passage of three or more loose or liquid stools per day for more than four weeks A clinical definition of diarrhoea based on symptom reporting alone will lead to an overlap with functional bowel disorders such as irritable bowel syndrome

7 Differential Infective colitis Pseudomembranous colitis Acute self-limiting colitis Diverticulitis Ischaemic colitis Collagenous colitis Acute inflammatory bowel disease Irritable Bowel Syndrome

8 History and Examination Establish the likelihood that symptoms are organic (as opposed to functional) Distinguish malabsorptive from colonic/inflammatory forms of diarrhoea Assess for specific causes of diarrhoea

9 Resolving the differential History - patient age? - risk factors (e.g. preceding antibiotics) - time course - PH / FH of bowel disease - colour of diarrhoea - stress?? Examination - masses, arterial bruits - sigmoidoscopy and biopsy AXR - mucosal oedema, dilatation, proximal loading Stool culture, C. Diff assay, Faecal Calprotectin estimation

10 RED FLAGS! Red flag symptoms which are not typical of IBS: Pain that awakens/interferes with sleep Diarrhoea that awakens/interferes with sleep Blood in the stool (visible or occult) Weight loss Fever Abnormal physical examination Anaemia Elevated CA125

11 Examination Fever Extra-intestinal manifestations (Mouth ulcers, iritis, episcleritis, erythema nodosum, pyoderma, arthropathy) Ankylosing spondylitis +/- vomiting +/- dehydration

12 Symptoms of Irritable bowel Syndrome Nausea Crampy abdominal pain An alteration in bowel habit (diarrhoea, constipation or alternating diarrhoea and constipation) Bloating of the abdomen Rumbling noises and excessive passage of wind Urgency Proctalgia Fugax Passage of mucus with the stool

13 Impact of Irritable Bowel Syndrome Reduced sleep Decreased sexual functioning Poorer mental as well as physical health Problems with diet Problems with employment Problems with travel

14 What Causes Irritable Bowel Syndrome?

15 Leads to: A Abdominal PAIN B BLOATING C Change in bowel habit

16 NICE Guidelines Abdominal Pain/discomfort relieved by defeacation or associated with altered stool, frequency 1. Rome III diagnostic criteria for functional gastrointestinal disorders. 2. NICE clinical guideline 61, 2015; (accessed April 2015). 3. Spiller R, et al. Gut 2007; 56:

17 Classification of Irritable Bowel Syndrome Irritable bowel syndrome can be subtyped according to the predominant stool form: 1 IBS-A: Irritable Bowel Syndrome with alternating symptoms of diarrhoea and constipation IBS-C: Irritable Bowel Syndrome with constipation as primary bowel dysfunction IBS-D: Irritable Bowel Syndrome with diarrhoea as the primary bowel dysfunction Longstreth GF, et al. Gastroenterology 2006; 130:

18 Nice Guidelines (2015) RECOMMENDATION In people who meet the IBS diagnostic criteria, the following tests should be undertaken to exclude other diagnoses: Full blood count (FBC) Erythrocyte sedimentation rate (ESR) C-reactive protein (CRP) Antibody testing for coeliac disease (endomysial antibodies [EMA] or tissue transglutaminase [TTG]).

19 RECOMMENDATION Nice Guidelines (2015) The following tests are NOT necessary to confirm diagnosis in people who meet the IBS diagnostic criteria: Ultrasound Rigid/flexible sigmoidoscopy Colonoscopy; barium enema Thyroid function test Faecal ova and parasite test Faecal occult blood Hydrogen breath test (for lactose intolerance and bacterial overgrowth).

20 What Treatment is Available? IBS is a heterogenous disorder Aim of management - symptom control So no cure as such for IBS! Conventional treatments include Pharmacological Dietary modification Relaxation therapy Acupuncture No longer recommended Gut Directed Hypnosis/ CBT (NICE 2008)

21 Advice to give We are not going to cure IBS but manage symptoms Reassure that it is a benign condition Diet: Eat regularly! Limit tea and coffee Reduce processed foods Reduce insoluble fibre, increase soluble fibre Low wheat diet FODMAP diet Low Lactose diet

22 Pharmacological management should be tailored to subtype Aim of current treatments is symptomatic relief of the most troublesome symptom, rather than cure 1,2 Different subtypes require different management strategies: 1-3 IBS with constipation (IBS-C) IBS with diarrhoea (IBS-D) IBS-alternating (IBS-A) 1. Hulisz D. J Manag Care Pharm 2004; 10: Spiller R, et al. Gut 2007; 56: NICE clinical guideline 61, 2015; (accessed March 2015).

23 Other Management Loperamide should be the first choice of antimotility agent for diarrhoea in people with IBS. [NICE 2008] Increases anal sphincter tone, reduces colonic propulsion and secretion Reduce sorbitol and artificial sweetener use Titrate dose to clinical response Peppermint Oil for relief of abdominal colic and bloating Trial of Probiotics for one month

24 Low FODMAP Diet If a person s IBS symptoms persist while following general lifestyle and dietary advice, offer advice on further dietary management. Such advice should include : single food avoidance and exclusion diets (for example, a low FODMAP [fermentable oligosaccharides, disaccharides, monosaccharides and polyols] diet) only to be given by a healthcare professional with expertise in dietary management. [NICE 2015]

25 Hypnosis - The Gut Directed Approach Hand warmth on abdomen Image of a normal gut Imagined rehearsal Post hypnotic suggestions

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27 Take home Messages Make a positive diagnosis of IBS Reassess for red flags at review Nocturnal diarrhoea is uncommon in functional disease

28 Conclusions IBS is a chronic, functional, relapsing, and often lifelong gastrointestinal disorder that is estimated to affect 10-20% of the UK population 1 IBS has a greater impact on quality of life than diabetes and renal failure 2 IBS is a multifactorial disease which is generally characterised by abdominal pain, bloating and change in bowel habit 1 IBS can be sub-classified (subtyped) according to the predominant stool form: IBS-C, IBS-D, IBS-A 1. NICE clinical guideline 61, Irritable bowel syndrome in adults: diagnosis and management of irritable bowel syndrome in primary care. (accessed March 2015). 2. Gralnek IM, Hays RD, Kilbourne A, Naliboff B, Mayer EA. The impact of irritable bowel syndrome on health-related quality of life. Gastroenterology 2002; 119:

29 The Spectrum of IBD Chronic inflammatory disorders of the bowel aetiology unknown Major subtypes Ulcerative colitis Crohn s disease [Microscopic colitis] UC & CD one disease or two?

30 Ulcerative Colitis Rectal bleeding with mucus, urgency And bowel frequency (stools can be solid) Persistent watery diarrhoea Rectal bleeding starting after stopping smoking Commonest age of presentationyoung adult Crohn s Disease Diarrhoea Abdominal pain Weight loss Systemic disturbance (fever malaise) Above symptoms with perianal disease EXAMINATION & INVESTIGATIONS Abdominal palpation Platelet count ^ Stool Culture - Neg Anal examination FBC HB ۷ WBC ^ ALP, ALT, Bilirubin ^ Digital rectal examination ESR ^ CRP ^ If Hepatic Involvement Albumin ۷

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32 Ulcerative Colitis

33 Crohn s Disease

34 The rationale behind the management of IBD is to: Improve the patients symptoms Achieve and maintain remission Improve the patient s quality of life Help the mucosal healing process

35 Management of IBD: Types of therapy - Overview The mainstays of IBD therapy are aminosalicylates 5-ASA and corticosteroids Improved understanding of the causes of IBD is leading to the identification of new therapeutic targets Most clinicians use a stepped approach to therapy

36 Management of IBD: Types of therapy - Overview Treatment varies according to: Type of IBD Activity of IBD Location and extent of IBD Patient s preference

37 Management of IBD: Types of therapy - Aminosalicylates Aminosalicylates (5-ASA) are used for: Treatment of mild to moderate active UC Maintenance of remission of UC Maintenance of remission of Crohn s ileocolitis Type of formulation depends on location/extent of disease and patient preference Long term use of 5-ASA may reduce risk of colorectal cancer by 81% (Eaden J et al 2000)

38 Management of IBD: Types of therapy - Corticosteroids Potent anti-inflammatory agents that act through the inhibition of several inflammatory pathways Mainly used for moderate to severe IBD Potentially serious side effects mean that they should be carefully considered

39 Management of IBD: Types of therapy - Thiopurines Thiopurines modulate the immune response by inducing T cell apoptosis They are unlicensed for the treatment of IBD but have an important steroid sparing role in: Unresponsive or chronically active CD Resistant or frequently relapsing IBD Postoperative prophylaxis of complex IBD

40 Management of IBD: Types of therapy - Biologics Infliximab and Adalimumab are anti TNF therapies that have potent ant-inflammatory effects They are licensed for: Severe active Crohn s disease in patients with an inadequate response to or intolerant of corticosteroids/conventional immunosuppressants Refractory fistulating Crohn s disease Acute ulcerative colitis

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42 Healing of Crohn s Colitis

43 Management of IBD: Nutrition Nutritional support is appropriate for: Paediatric growth failure in small bowel Crohn s disease as a disease modifying therapy Malnourished patients as an adjunctive therapy Intestinal partial obstruction Postoperative complications

44 Management of IBD: Surgery in UC The main indication for surgery is severe,unresponsive UC Subtotal colectomy or proctocolectomy with ileostomy or ileoanal anastomisis is usual Ileoanal anastamosis leaves an ileal pouch to act as a resevoir, avoiding ileostomy

45 Management of IBD: Surgery Crohn s Disease Surgery should be avoided if possible as CD is potentially pan-enteric and can recur It should be confined to: Symptomatic, radiologically defined CD unresponsive to medical therapy CD with complications Growth failure in children Resections should be conservative and limited to macroscopic disease

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48 Management of IBD: Summary Patients should be actively involved in the management of their IBD Management of IBD depends on the type, activity, location and extent of the disease Aminosalicylates are used for mild to moderate IBD, and maintaining remission Corticosteroids are used for moderate to severe IBD but should not be used for the long term Thiopurines are a useful steroid sparing therapy

49 Management of IBD: Summary Biologics should be reserved for unresponsive CD and rescue therapy in ulcerative colitis Side effects of all treatments should be discussed with the patient Formulation and route of delivery should be tailored to disease location Surgery can be effective for severe, unresponsive and complicated IBD

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