IRRITABLE BOWEL SYNDROME

INTRODUCTION Irritable bowel syndrome is a disorder characterized most commonly by cramping,abdominal pain, bloating, constipation,and diarrhea. IBS causes a great deal of discomfort and distress, but it does not per-manently harm the intestines and does notlead to a serious disease, such as cancer.Most people can control their symptoms with diet, stress management, and pre-scribed medications. For some people,however, IBS can be disabling. They may be unable to work, attend social events,or even travel short distances Irritable bowel syndrome DEFINITION (IBS) is an intestinal disorder that causes abdominal pain or discomfort, cramping or bloating, and diarrhea or constipation. Irritable bowel syndrome is a long-term but manageable condition irritable bowel syndrome is defined as a chronic, relapsing functional disorder of the gut characterised by: abdominal pain abdominal distension abnormality in bowel habit

INCIDENCE It is estimated that between 10% and 15% of the population of North America, or approximately 45 million people, have irritable bowel syndrome, yet only about 30% of them will consult a doctor about their symptoms. IBS tends to be more common in: Half of the people who have IBS develop symptoms before age 35, and 40% develop symptoms between the ages of 35 and 50. In women, IBS is 2 to 3 times more common than in men.

CAUSES IBS is a disorder of GI motility. Its exact cause remains unknown, although there is a familial link It is not caused by nerves or poor diet. Both stress and intolerance for some foods, however, can precipitate attacks. Other triggers include some types of abdominal surgery, acute illness that has disrupted bowel function , prolonged use of antibiotics, exposure to toxins, and emotional trauma. Ingestion of caffeine, alcohol, and other gastric stimulants Lactose intolerance seem to play roles for many individuals.

. SUB TYPES IBS with constipation (hard/lumpy stools predominant) IBS with diarrhea (loose/watery stools predominant) Mixed IBS (neither predominates) Unsubtyped IBS (insufficient stool abnormality to meet the above subtypes

CLINICAL MANIFESTATIONS Gastrointestinal Symptoms o Abdominal discomfort o Bloating, Distension o Change in bowel habit o Abnormal stool passage o Change in stool form Urinary Symptoms o Frequency o Urgency o Nocturia Gynaecological symptoms o Dysmenorrhoea o Dyspareunia o Premenstrual Tension Non-specific symptoms o Back Pain o Headaches o Bad breath o Poor Sleep

o Fatigue DIAGNOSTIC CRITERIA ROME II Criteria (1999) In the preceding 12 months there should be at least 12 weeks (consecutive) of abdominal discomfort or pain that has two of three of the following features: Relieved with defecation Onset associated with a change in frequency of stool Onset associated with a change in form of stool The following symptoms cumulatively support the diagnosis of IBS: Abnormal stool frequency (abnormal may be defined as >three/day and <three /week Abnormal stool form Abnormal stool passage (straining urgency or feeling of incomplete evacuation Passage of mucous Bloating or feeling abdominal distension

OTHER TEST Flexiblesigmoidoscopyor colonoscopy Barium enema Complete blood count serologic tests serum albumin, stool for guaiac(occult blood), abdominal x-ray erythrocyte sedimentation rate abdominal ultrasound endoscopy hydrogen breath testing rectal biopsy lactose intolerance test DIFFERENTIAL DIAGNOSIS Inflammatory bowel disease. Cancer. Diverticulosis. Endometriosis.

COMPLICATIONS

This disorder is associated with: o Psychological distress o Sexual dysfunction o Interference with work and sleep o Decreased quality of life Unnecessary surgery due to misdiagnosis appendectomy, or partial colectomy

(such

as

cholecystectomy,

MANAGEMENT MEDICAL MANAGEMENT Dietary modification: Patient may have food allergies, should exclude gas-producing foods, coffee, fatty foods, carbohydrates (sx may be related to impaired absorption of carbohydrates: FODMAPs enter distal small bowel and colon when they are fermented, leading to sx and increased intestinal permeability, although there have been few studies to demonstrate this); Increase fiber intake (say most studies, although keep in mind that might be an issue for diarrhea-predominant IBS Patient-physician relationship is important! Physical activity: in a randomized trial, this was examined - Physical activity comprised of 20-6- min of moderate to vigorous activity 3-5x/w showed improvement in severity of IBS compared with control group Psychosocial therapies: behavioral treatments for those who associate sx with stressors the goal being to reduce anxiety, among other things Hypnosis. Hypnosis can help some people relax, which may relieve abdominal pain. Relaxation or meditation. Relaxation training and meditation may be helpful in reducing generalized muscle tension and abdominal pain. Biofeedback. Biofeedback training may help relieve pain from intestinal spasms. It also may help improve bowel movement control in people who have severe diarrhea. Treatment is focused on relieving symptoms. Treating the patient's most predominant symptoms determines the most successful therapy. Stress relieving measures,yoga,acupuncture Stress relief excercises Antispasmodic and peppermint oil

PAIN AS APREDOMINANT SYMPTOM o Anticholinergic drugs: dicyclomine (Bentyl) or hyoscyamine (Levsin) taken before meals; should be used only for limited periods such as during a flare-up o Combination agents: phenobarbital, hycosamine, atropine, and scopolamine (Donnatal) or chlordiazepoxide and clidinium bromide (Librax) are second-line agents

Nonopioid agents: acetaminophen, tramadol (Ultram), gabapentin (Neurontin), carbamazepine (Tegratol), and anti-inflammatory agents o Tricyclic antidepressants: desipramine (Norpramin), doxepin (Sinequan), and amitriptyline (Elavil) CONSTIPATION AS APREDOMINANT SYMPTOM: o Fiber: psyllium, ispaghula husk, polycarbophil o Osmotic laxatives: lactulose, sorbitol o 5-HT4 agonist: tegaserod (Zelnorm) mimics the action of serotonin in the gut and treats global symptoms DIARRHEAAS APREDOMINANT SYMPTOM o Cloperamide (Imodium)reduces stool consistency and improves stool consistency o Cholestyramine (Questran)binds bile salts o 5-HT3 agonist: alosetron (Lotronex)first neuroenteric modulator to treat severe cases in which standard therapy has failed Eliminate irritating dietary substances, such as caffeine, fatty foods, fructose, or lactose, that may cause such symptoms as spasms, cramps, bloating, and/or diarrhea. A regular exercise routine can improve gastric emptying and relieve constipation and stress.
o

NURSING ASSESSMENT

Assess patient for contributing factors that may affect symptoms: diet, emotions, professional and personal relationships, patient's fears and concerns, and precipitating events, such as financial stress or problems at work or home. Record specific symptoms that patient is experiencing in order to determine best treatment options. Explore pain characteristics: frequency, duration, location, timing, and intensity.

NURSING DIAGNOSIS Chronic Pain related to functional disorder

Assess and evaluate abdominal pain using a pain scale. Review pain medications for proper usage and possibility of adverse effectsdrowsiness and dry mouth with anticholinergics, combination agents, and tricyclic antidepressants; bloating, abdominal pain, gas, diarrhea, or constipation with others. Constipation or Diarrhea related to change in bowel motility

Monitor amount, consistency, and frequency of stool. Encourage exercise and adequate fluid/fiber intake to promote bowel motility for constipation.

Encourage adequate fluid intake to prevent fluid volume deficit and electrolyte imbalance for diarrhea. Ineffective Coping related to anxiety, stress, and depression

Validate patient's complaints and express interest in diagnosis. Follow-up and reassess patient's complaints and status of treatment goals. Refer patient for pain management, psychological counseling, or behavior management therapy if indicated.

PATIENT EDUCATION AND HEALTH MAINTENANCE

Educate patient on the diagnosis and the natural course of IBS. Instruct patient about all prescribed medications, including purpose, dosage, and adverse effects. Encourage patient to participate in stress-reducing activities, such as exercise, relaxation techniques, and music therapy. Encourage participation in counseling sessions to deal with anxiety and depression. Suggest ways for patient to learn coping skills and stress management.

CONCLUSION IBS is a common functional gastrointestinal (GI) disorder, which accounts for up to 20% of gastroenterology referrals in the UK and approximately 4 million physician office visits in the USA annually . The etiology of IBS is complex and poorly understood. It may be viewed as a multi-factorial disorder where dysregulation of the so-called braingut axis, alongside abnormal function in the enteric, autonomic and/or central nervous systems, causes symptoms. BIBLIOGRAPHY Linton. Introduction to medical surgical nursing. 4 th edition. St. Louis Missouri, Elsevier; 2007 Platt D, Moss M. Adult medical Surgical Nursing. RN, LLC Publishers; 2000 Lewis. Medical Surgical Nursing. 1st Ed. Elsevier; 2011. Linde Williams. Understanding medical Surgical Nursing 2nd edition. FA Davis company, Philadelphia, 2003. Brunner and Suddarths.; Text book of medical Surgical Nursing. 11 th Ed, India, Wolters Kluwer Publishing; 2008 Ignatavicius DD, Workman ML. Medical Surgical Nursing 5th Ed, St Louid, Saunders. 2006. Black MJ, Hawks HI. Medical surgical Nursing 7 th ED. India. 2005.

JOURNAL REFERENCES

Jones J, Boorman J, Cann P, Forbes A, Gornborone J, et al. (2000) British Society of Gastroenterology guidelines for the management of the irritable bowel syndrome. GUT 47: 119. Williams JG, Roberts SE, Ali MF, Cheung WY, Cohen DR, et al. (2007) Gastroenterology services in the UK. The burden of disease, and the organisation and delivery of services for gastrointestinal and liver disorders: a review of the evidence. GUT 56: 1113. Sandler RS (1990) Epidemiology of irritable bowel syndrome in the United States. Gastroenterology99: 40915. Azpiroz F, Bouin M, Camilleri M, Mayer EA, Poitras P, et al. (2007) Mechanisms of hypersensitivity in IBS and functional disorders. Neurogastroenterol Motill 19: 6288.