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$fS$o[۫YZ6 Rlkqy-XɴvB5%1J4<[eBF+qVǂf-]ѵgHF2 JdjTI9T<֋t,XGg=ZubFTo3s=ɯD>xgG{m7fbd{d]NprG߆SMn4亘W3]ns?Ν<7+i)>k#$@ jwrKg3!VܥHv.mo@9${W?kY\\ZݱbsA=xS׼Kmxk{X5Fz)NrM{ŵZăP` Y-U63~ԍRá]'Pۺ]%^mPp4E$0Kqj3+cO%⶟crl5&"X_v3OS[!xͳ0ŰT~u"8oIHB5qp>Q^+Mȫ3/,lݽ3[,eî2fg⧗A4/E1nRr6 ;NyFy}鷳Zњ'A_X~ijζMtYHmڸW5z&aҗ_.jqhmbH|9lI^Iyv.HKYgę7 RKc9C$jחpOq &L6[%q%R#d• 1"7}({=eZ>CU4ꖾ%~T^z8!bx%,qŠ.qQ[> 񕎗,6U'0[qYȤOxEbu{!&xV wֵWLn'<|ȧs:u~U~"7$:mwrw>\`/e9(7Qp~5GzƏ kMyn뤅9b8%zzk<-yvnc#>~>/5ydM(Jn}88Ǻ-ޟc6m"3JUC'=jՂ|ԇ5{\?7 x+w_=#E0ןZ߻'\<*gwt4QE~x^" gshT|Ev:AI#g'=2HJ־nZIeg6.r T՟̶’}ȭKU@S"m*F={PUGD~񎕭-<ېA oI0$R!x06ѿ#=>\KQO9Z/وp=}k֏-ݱ XaeֆIsu"ș.G~uxk0IՠEh嶙Vmlg:'EܺTevZ`['+Z0VTIMiAŰ, *4-1Gt& ⦰m@c]Zۃ_Xԭ}G%Vd0**}: tv4_O:>KP9/ȚVf yy>|O3ҝZYwOCsyf/(/F{xjGAEWg|⋴MZX8iW ʁW}W)!?}ޓFIp~mr?,SdJHI0JX?O¶-$X:'AhXDM.yZwWE+UvX:ڸ@9WG_*& ,O|%] x9 >g򦤣*)+vZģnR}+P_盕}.nu (B ]M(]{bɏ\5\%'M|:_]z3_9m偍O~RdXwg>h1Tmpy?('+s&M\f'D3CҶUy2lx*HOo4C_3i9ٝ|10o=!ftm?*]O^7 ;PQE)\̳%dof\z^@OG^@O_%W'VNN_cN)*[+e$|zg?zg?r˃K r?+>ZC:Q:W;vKrǷ0V#H赵:Q:TŷÛrEc_lk:Q:Vƴe:zUcӕ>zg?zg?tDŽe}bέ?8&ǧqU淊lk?s/Lu_/Lu_5c!2zKy"n?.t \ uskZߕ ?Zߕ 'Z/صF*ѧo Ske+e+> rw/lpU:LJ6?i~W(?i~W+?3בvZzg?zg?;/lZ1&$+T'#:+?i~W(?i~W*R_^HDE 8Y,:iI*gll z^:Q:Wl8b!>/uWl7e+5\Uۖd/_Nm-k[b_XoZ(pX( / 0DArialngs00 PIn@     IBS:Diarrhea sNOT associated with: *large volume stools *blood *nocturnal diarrhea *greasy stools@4t  IBS:ConstipationDuration:daysmonths with interludes of normal stooling or diarrhea quality of stools:hard, pellet shaped Feeling of incomplete evacuation even when rectum is empty Can result in inappropriate straining, enema and laxative use( 6   IBS:Other GI Symptoms  WGERD Dysphagia Early satiety Dyspepsia Nausea Non-cardiac chest pain Abdominal bloating J IBS:Symptoms Increased gas as flatulence or belching(though normal volume of gas in GI tract and no signs of colonic distention) exaggerated visceral hyperalgesia response to gas=perception of a lot of pain with normal amount of gas Z,[ H IBS:Extra-Intestinal Symptoms Broad range Impaired sexual function Dysmenohrrea increased urinary freq and urgency Increased likelihood of HTN, RAD, rheumatic syndromes incl FM ,% [  IBS:Diagnosis History: 2 sets of diagnostic criteria Manning Criteria(1978) Rome Criteria(1992 revised 1999) American Gastroenterological Assoc recs using combination and focusing on the positive symptoms9  IBS:Diagnosis vManning Criteria *pain relief after BM *loose,freq stools at onset *passage of mucus *sense of incomplete emptying fw* C Rome Criteria *functional group of discomfort or bowel d/o s with abd pain assoc with defecation, or a change in bowel habits, and disordered defecation *continuous or recur abd pain for 3 months >8j IBS:Diagnosis Make diagnosis based on constellation of symptoms and ABSENCE of  alarm symptoms *hematochesia *wt loss > 10 lbs *fhx colon cancer *recurrent fever *anemia *chronic severe diarrhea$RZpZ,U F IBS:Work-upJFor pt without red flags in history Take a good history-exp find out why pt is seeking medical assistance *cancer phobia *disability *interpersonal distress *sx exacerbation Understanding pt s motivation will help MD address the individual s needs and will result in superior outcome.$jPP&~)# IBS:Workup Look for dietary and medical causes Caffiene, antacids with Mg, anticholinergics, CCBD, lactose, sorbitol Rule out physical, sexual, emotional abuse-known correlation b/t certain GI illnesses and abuse P$>!IBS:Work-up recs by AGA$Diagnositic studies:CBC and Chem 7-normal in IBS If diarrhea predominant:TSH, stool studies (3 separate, fresh samples for o+p), consider celiac dx if of northern european ancestry, fhx, DM I Flex sig:consider if >40yo to exclude malig, or young pt to exclude IBD This conservative approach misses <5% of pt s with other organic dz $LPPM  /  ^ IBS:Treatment After r/o other dz and rule in IBS, do a 3-6 week treatment trial based on symptoms and then follow-up Treatment Options: *Education *Dietary Modification *psycho-social therapy *pharmacologic medical tx .zZZZZ>IBS Treatment:Education Three Pronged:validate,reassure,inform 1.Validate: yes, your dz is uncomfortable and inconvenient 2.Reassure: IBS is a benign dz with a good prognosis and you will have a normal life span 3.Inform: IBS is a chronic condition and the diagnosis will not change Z> @IBS Treatment:EducationJThe  therapeutic relationship is the most important part in pt compliance with IBS. Often takes multiple visits to accomplish the trust needed for a good outcome. *$IBS Treatment:EducationPatient s who feel understood(validate), are more compliant with their often life-long therapy(inform), and feel less anxious therefore do better(reassure). These pts respond better to limits set by MD and have more realistic expectations for results>1&aIBS TX:dietary modification Trial of lactose free diet For pt s c/o gas, exclude foods that increase flatulence (beans, onions, celery, carrots, dried fruit, wheat germ, simple carbs, bananas) Increase fiber-diet and/or commercial bulking agents-works by increasing stool bulk and drawing in water for better lubrication. Start with 1/2Tbsp daily AA+%IBS TX:dietary modification W2 week food/symptom diary helps to identify specific foods that may exacerbate symptomsIBS TX:Psycho-Social Therapy If symptoms are assoc with anxiety, depression, identifiable stressors Hypnosis, biofeedback, behavioral thearapy-useful when IBS sx s assoc with stressors Psychotherapy-decrease anxiety and increase health promoting behaviors, helps pt tolerate IBS sx sZ>itIBS TX:MedicationsDrug therapy is adjunctive tx ONLY, not primary mode of tx Drug choice depends on sx constellation(diarrhea v constipation) Minimize chronic use of meds since dz is lifelongb4 IBS TX:MedicationsZAntispasmotics Antidepressants Antidiarrheals Zelnorm Lotronex Integrative medical choicesHIBS Meds:AntispasmoticsMost frequently used Works by selective inhibition of GI smooth muscle to decrease colonic activity Useful for those with post prandial abd pain, gas, bloating, fecal urgency,$IBS Meds:AntispasmoticsBentyl(dicyclomine)-20mg po qid prn Levsin(hyoscyamine)-0.125-0.25mg po or SL tid-qid prn These act via anticholinergic /antimuscarinic properties Best use is PRN and prohylactically in anticipation of known stressors and exacerbating factorsZ""=IBS Meds:Antidepressantswork via analgesic properties which are independent of antidepressant properties TCA s and SSRI s useful for those with neuropathic pain TCA s-anticholinergic effectsslow transit time, good for diarrhea. Low dose only needed, lower than for antidepressant effect Amitriptyline, imipramine, nortriptyline-10-25mg po qhs, and increase for desired effect. Need 4-6 weeks to see results 0PQ  ]  CIBS TX:AntidepressantsZSSRI s-Paxil and Prozac 20mg po daily, Zoloft 100mg po daily Useful esp if depression is a cofactor Studies showing good results with Zoloft, rec continuing for 6-12 months.Z G IBS TX:antidiarrhealLoperamide-PRN only  !IBS TX:Zelnorm wGeneric=Tegaserod 5-hydroxytryptamine 4 receptor agonist Best for women with constipation Stimulates colonic motility  g"IBS TX:Lotronex Alosetron is generic 5-hydroxytryptamine(SRT)3 receptor antagonist Was pulled off marked by FDA for association with ischemic colitis secondary to severe constipation Reinstated but under tight control based on high patient demand Best for women with diarrheaZ # IBS TX:IntegrativefNot well researched Options include certain herbal medications, probiotics, enzymes, and psychotherapy@ $! 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