Irritable bowel syndrome

from Wikipedia, the free encyclopedia
Classification according to ICD-10
K58.- Irritable bowel syndrome
ibs
irritable colon
irritable bowel syndrome
K58.0 Irritable bowel syndrome with diarrhea
K58.9 Irritable bowel syndrome without diarrhea

Irritable Bowel Syndrome on A.

ICD-10 online (WHO version 2019)

In medicine ( gastroenterology ), the term irritable bowel syndrome ( IBS ) describes a group of functional bowel diseases that have a high prevalence (disease frequency in the population) and make up up to 50 percent of visits to specialists ( gastroenterologists ). Irritable bowel syndrome can be confused with symptoms of all possible intestinal diseases, but is harmless if these diseases are excluded. Synonymous terms are irritable bowel syndrome (IDS) or English irritable bowel syndrome (IBS) , formerly irritable bowel syndrome , irritable bowel syndrome , "intestinal nervous" u. a.

Symptoms

Symptoms of irritable bowel syndrome are pain or discomfort in the abdomen along with a change in bowel habits to the exclusion of a structural or biochemical cause. An increased sensitivity of the intestine to pain to mechanical stimuli is a very sensitive , less specific sign of irritable bowel syndrome. Depending on the nature of the pain and the bowel habits, one also speaks of the spastic colon. Irritable bowel syndrome can be classified into various sub-groups, including diarrhea -prädominantes (diarrhea, RDS-D) of constipation -prädominantes (constipation, IBS-C) Irritable bowel syndrome and irritable bowel syndrome with alternating bowel habits (IBS-M). Typical is the overlap with chronic pelvic pain, with fibromyalgia (chronic pain, mental and physical exhaustion) and mental illness .

Because symptoms such as flatulence, pain and changes in bowel habits increase when multiple sugars such as lactose in dairy products and starch in wheat flour are consumed, many seek a cause in food intolerance, which can, however , be ruled out by testing for lactose intolerance and celiac disease (gluten intolerance). Rather, an incorrect colonization of the small intestine could be responsible for this temporary intolerance.

diagnosis

According to the Rome IV consensus criteria of the American Gastroenterological Association and other medical societies, irritable bowel syndrome can be diagnosed if the following criteria are met:

Recurrent abdominal pain, averaging at least once a week for the past three months, associated with two of the following three factors:

  1. Defecation
  2. Change in the frequency of bowel movements
  3. Change in stool consistency

These criteria should have been met for the last three months, while symptoms should have started at least six months ago.

Additional criteria that support the diagnosis but do not allow a diagnosis are:

  • abnormal frequency of stools (more than three stools a day or fewer than three stools a week)
  • abnormal stool consistency (more than 25% of defecations)
  • Abnormal withdrawal of stool (e.g., strong pressing, imperative to defecate, feeling of incomplete evacuation) (more than 25% of defecations)
  • slimy stool (more than 25% of defecations)
  • Gas and bloating (more than 25% of days)

The diagnosis assumes that no structural or biochemical change can explain the symptoms. This must be ruled out by:

A stimulus threshold determination by barostat is discussed as a diagnostic test. However, sensitivity and specificity are not yet good enough to be used as a clinical method.

Pathophysiology

The etiology (cause) of irritable bowel syndrome is partly unclear. A decisive factor in a certain form (RDS-D) seems to be gluten sensitivity . Changes in motility , immune responses, and psychological factors have also been suggested. Another consistent finding in many patients is an increased sensitivity to pain ( hyperalgesia ) in the colon .

About 25 percent of irritable bowel syndromes develop after gastroenteritis (partly after the use of antibiotics ). In these cases, a prolonged immune reaction or neuroplastic processes at the level of the spinal cord are discussed as the cause, but these assumptions have so far only been based on animal models .

New studies from 2019 point out that excessive colonization of the intestine with fungi of the genera Candida , Saccharomyces and Aspergillus is responsible for the sensitization or hyperalgesia. However, these studies are experiments on rats. The β-glucan on the cell walls of the fungi is said to be recognized by C-type lectin receptors, which can then lead to degranulation of mast cells and thus to sensitization. Other potential interactions were also discussed. The gliotoxin produced by some fungi can lead to neuronal changes in the spinal cord . The hyperalgesia could be transmitted to other rats through stool transplants . It was also possible to plant the feces of healthy rats in pathological rats, thus reversing the sensitization. In addition to stool transplants, antimycotics (menthacarin) and antifungal substances (peppermint oil, caraway oil) were also able to reverse the sensitization. In addition to the mushrooms, however, their relationship to the rest of the intestinal flora is decisive. Thus, the risk of developing an irritable bowel syndrome is higher when between the fungi and certain bacteria ( Enterobacteriaceae, Escherichia coli, Serratia marcescens) a symbiosis exists, depending on the genes of the respective exciting addition to the irritable bowel syndrome is a dysbiosis of the intestinal flora also in correlation to some mental illnesses ( schizophrenia , depression ) and personality disorders ( autism ). It is worth mentioning here that personality changes were also observed in humans after stool transplants.

A correlation between the statistically more frequent occurrence of irritable bowel syndrome in women and the more frequent occurrence of fungal infections in women has not yet been demonstrated. However, it is advisable to distinguish between infection, colonization and passage in intestinal germs. A positive stool test (e.g. for Candida or Salmonella ) in asymptomatic people should not be equated with infection or colonization , although this is common in everyday medical practice for salmonella .

Irritable bowel syndrome is viewed by many as a conglomerate of disorders with similar symptoms but different etiology. As with many other diseases, there is speculation about the causes, including from alternative medicine . In a study with IBS-D patients, improvements were achieved with a gluten-free diet.

According to more recent findings, the enterochromaffin cells of the digestive tract should detect aromatic substances in the food and thus control digestion. Thus, flavorings could be partly responsible for irritable bowel problems.

Another explanatory approach blames small intestine colonization for the symptoms. According to this, a disturbed peristalsis of the small intestine leads to the fact that the porridge is not transported at the normal speed. The slowed transport leads to the fact that bacteria rise from the large intestine into the small intestine and can multiply there. Nutrients that are metabolized more slowly and thus descend into the lower part of the small intestine are available as a source of food for the bacteria. The number and composition of bacteria varies depending on the patient, and fermentation by bacteria produces different gases and pollutants that lead to the wide range of symptoms. For example, allergic reactions to the pollutants can lead to hives-like rashes. The gases liquefy the stool, and so the paradox arises that despite slowed bowel motility, the stool cannot be thickened and patients suffer from diarrhea. This fact could explain the lack of effectiveness of loperamide , which further slows down bowel movement. On the other hand, intestinal contractions that are too rapid can reverse the transit of porridge / stool, so that patients are more likely to cite symptoms of constipation.

Finally, chronic metabolic disorders flow into the intestinal processes. Among the classic underlying diseases with digestive disorders include diabetes . In addition to an infection, certain diabetes medications, such as metformin and acarbose, can regularly cause diarrhea. In addition, some sugar substitutes also have a laxative effect when consumed in excess. Furthermore, the predominantly increased sugar content of the blood and the inner mucous membranes leads to increased microbe formation. Permanently increased bacterial and fungal infestation in the digestive tract results in permanent over-stimulation of the intestine. Last but not least, diabetic nerve damage can also impair bowel function.

Sensitization

According to recent research, a major contributing factor appears to be nervous sensitization , including cross-sensitization, particularly with respect to other organs within the entire pelvic area.

treatment

If the symptoms are favorable, treatment can be limited to diet advice . The most effective diet for treating symptoms of irritable bowel syndrome is an FODMAP- reduced diet. The acronym FODMAP refers to a group of short-chain carbohydrates and polyhydric alcohols that are found in many foods and cause symptoms in patients with irritable bowel syndrome. Reducing FODMAPs in the diet specifically reduces the incidence of diarrhea, gas, and abdominal pain. In IBS-dominant IBS, laxatives can be taken, whereas in irritable bowel syndrome predominantly diarrhea, active substances that inhibit drainage can be taken. The effectiveness of various other approaches such as peppermint oil , dietary fiber or anticonvulsant medication has been proven by a new meta-examination of well-known studies.

Water-soluble dietary fibers such as B. Psyllium husks exposed. The intake of beta-glucan from barley via barley bread and foods made from barley with a high content of beta-glucan, such as barley muesli or barley flakes, is also suitable . These are also a suitable source of water-soluble dietary fiber. Better tolerance is achieved by peeling the barley before consumption. In addition, the growth of beneficial intestinal bacteria is stimulated by the supply of beta-glucan from barley. Herbal active ingredients such as peppermint oil or highly concentrated extract from lemon balm leaves have also proven effective in treating irritable bowel syndrome. The essential oils it contains have a calming effect on the intestines. (Chemically modified) alkaloids from nightshade plants (active ingredient: butylscopolamine ) also have an antispasmodic effect . Myrrh can also relieve irritable bowel symptoms: A multi-center study at 131 German medical practices showed that a myrrh extract (in combination with chamomile and coffee charcoal ) reduced flatulence and diarrhea in irritable bowel patients. Myrrh has an anti-inflammatory effect, relieves intestinal cramps and stabilizes the intestinal barrier, which is often defective in irritable bowel syndrome.

Schematic representation of the peptide linaclotide. The amino acid code is given

For irritable bowel patients with constipation (constipation (RDS-O)), a preparation called Constella came onto the market in the first half of 2013. The Spanish drug manufacturer Almirall received the required EU approval for the drug with the active ingredient linaclotide at the end of 2012. The active ingredient is said to stimulate fluid secretion in the intestine and thus increase stool frequency, reduce flatulence and alleviate abdominal pain. However, the IQWIG came to the conclusion that an additional benefit has not been proven. Almirall and the National Association of Health Insurance Funds were unable to agree on a reimbursement price in the Constella price negotiations. Almirall therefore announced in April 2014 that it would temporarily stop sales of Constella in Germany from May 2014.

Structural formula of tegaserod

Newer preparations such as alosetron and tegaserod, which are not yet approved in Germany, are heavily advertised by the pharmaceutical industry, but their use in everyday clinical practice has yet to be demonstrated. The manufacturer Novartis has stopped selling the drug Zelnorm® (active ingredient: tegaserod) in the USA, which was approved for the treatment of irritable bowel syndrome (Colon irritabile) since July 2002. The reason is a current evaluation of study results that showed an increased risk of cardiovascular ( cardiovascular ) complications compared to a placebo .

The guideline on irritable bowel treatment, which was reissued in 2011, also assigns greater importance to probiotics. If the right bacterial strain is chosen, probiotics can have a positive effect on the intestinal flora, which is often disturbed in irritable bowel patients. Foods that naturally have a high content of soluble fiber can be prebiotically effective. Scientific studies have shown positive effects for beta-glucan from barley . The bacteria of the colon ferment this soluble fiber into short-chain fatty acids (SCFA). Up to 91% more butyrate is formed. Butyrate has anti-inflammatory effects and is the main source of energy for the mucous membrane cells of the intestinal mucosa.

Psychotherapy is a form of treatment for irritable bowel syndrome in patients in whom psychological factors dominate or who have psychological comorbidities . The AWMF guideline (2011) states that psychotherapeutic methods are effective for treating IBS and should be integrated into a therapy concept. Psychotherapy should be the first choice for IBS with causal psychosomatic effects. The use of antidepressants is also a possibility, e.g. B. amitriptyline in low dosage. They suppress pain and have a positive effect on intestinal motility in some patients .

If an over-colonization of the small intestine has been detected by a hydrogen and methane breath test after administration of multiple sugars ( lactulose , but also lactose and fructose ) , this can be treated in various ways. One approach is high-dose antibiotic treatment with rifaximin (Xifaxan). Studies show a beneficial effect for a period of time. However, the symptoms usually come back because the antibiotics remove the cause of the symptoms, but not the cause of the small intestine colonization itself, so that it reappears after a while. The time until the symptoms recur can be significantly delayed with the administration of tegaserod.

If the rifaximin doesn't work because of bacterial resistance, doctors at Cedars Sinai Medical Center suggest a diet that uses only Vivonex , an artificial diet made from short-chain nutrients. Because the nutrients are absorbed very quickly in the small intestine, the bacteria do not have time to metabolize them and are literally "starved".

If the bacteria in the small intestine are responsible for the symptoms, several measures can provide relief. Diet that omits oligosaccharides (sugar, fruits, wheat flour, alcohol) and many polysaccharides (fiber) significantly reduces symptoms. However, this must be accompanied by a doctor because it exposes the patient to a great risk of malnutrition. Because the intestine only carries out the transit of food when there is no food in the stomach, meals (three a day) should be taken at a sufficient distance, and all nibbles in between are counterproductive. In addition, regular exercise and a healthy, regulated sleep rhythm have a positive effect on controlling bowel movements.

According to a 2009 study, about 6 percent of IBS patients had exocrine pancreatic insufficiency . In patients with reduced elastase values, the stool frequency and consistency can be improved by enzyme therapy ( pancreatin , fungal enzymes ).

Epidemiology

The point prevalence (disease frequency) in Western countries is around ten to twenty percent with a much higher lifetime prevalence . The prevalence in India , Japan, and the People's Republic of China is similar. Irritable bowel syndrome is less common in Thailand and rural South Africa . In western countries (but not in India or Sri Lanka, for example ) women are at higher risk of developing irritable bowel syndrome than men.

Most people with irritable bowel syndrome do not seek medical help. It has not yet been possible to predict which of the sick people will seek help.

forecast

Irritable bowel syndrome is not associated with the development of serious intestinal diseases or with a reduced life expectancy. Nevertheless, the quality of life can be severely restricted in individual cases, u. a. through constant pain, uncomfortable bowel habits, sick leave and the development of social phobias .

Mental illnesses, an overactive bladder (" irritable bladder ") and fibromyalgia syndrome occur more frequently in irritable bowel patients . The exact causes for this are so far unclear.

See also

literature

  • WG Thompson, GL Longstreth, DA Drossman u. a .: Functional Bowel Disorders. In: DA Drossman, E. Corazziari, NJ Talley et al. a. (Ed.): Rome II: The Functional Gastrointestinal Disorders. Diagnosis, Pathophysiology and Treatment. A Multinational Consensus . Allen Press, Lawrence KS 2000.
  • IB Jeffery, PW O'Toole, et al. a .: An irritable bowel syndrome subtype defined by species-specific alterations in faecal microbiota. In: Good. December 2011, ISSN  1468-3288 . doi: 10.1136 / gutjnl-2011-301501 . PMID 22180058 .
  • Brian E. Lacy, Fermín Mearin, Lin Chang, William D. Chey, Anthony J. Lembo, Magnus Simren, and Robin Spiller: Bowel Disorders. In: Gastroenterology , Vol. 150, No. 6: "Functional Gastrointestinal Disorders: Disorders of Gut-Brain Interaction", May 2016, pp. 1393-1407.

Web links

Individual evidence

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