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“IRRITABLE BOWEL

SYNDROME”
(IBS)
Diagnosis dan Tatalaksana

Nyoman Purwadi
Div. Gastro-Entero-Hepatology
Bagian Penyakit Dalam
FK Unud/ RS Sanglah
Denpasar Bali
Apakah IBS ?

Ggn Fungsi tanpa kelainan struktural dan


kelainan biokimia

Bukan Radang, infeksi atau keganasan

Keluhan bisa dicetuskan oleh : bahan


makanan tertentu dan stres

Sangat mempengaruhi kwalitas hidup

Drossman DA et al. Gastroenterology 1997;112:2120-37;


Drossman DA et al. The Functional Gastrointestinal Disorders, 2000 p366.
Perubahan Fungsi Usus pada IBS

Perubahan fs. Usus

Perubahan
Perubahan Straining
frekuensi Urgensi
konsistensi
dan gerakan usus
feses

Bloating Babf Feses bercampur


(fullness/swelling) tidak lampias mukus
IBS
 20% pdd. USA dilaporkan memiliki keluhan yang
1
sesuai dengan IBS
 Diagnosis tersering pada gastroenterologist di
1
USA
 Satu diantara 10 alasan untuk tidak masuk kerja
 Terbanyak mengenai wanita (~70% ) 4

 “functional bowel disorder” tersering


1. Camilleri and Choi. Aliment Pharmacol Ther. 1997;11:13–15
2. Everhart and Renault. Gastroenterology. April 1991;100:998–1005
3. Physician Drug & Diagnosis Audit (PDDA), April 1999, Scott–Levin
4. Sandler. Gastroenterology. August 1990;99:409–415
5. Thompson et al. Gastroenterol Int. 1992;5:75–91
IBS : Patofisiologi

 Kelainan pada “enteric nervous system”


merupakan “hallmark” keluhan IBS
1
 Visceral hypersensitivity
• Meningkatnya respon aferen terhadap
rangsangan
• Mediators : 5-HT, bradykinin, tachykinins, CGRP,
and neurotropins
2
 Gangguan motilitas pada GI tract
• di perantarai oleh : 5-HT, acetylcholine, ATP,
motilin, nitric oxide, somatostatin, substance P,
and VIP

1. Bueno et al. Gastroenterology. May 1997;112:1714–1743


2. Goyal and Hirano. N Engl J Med. April 1996;334:1106–1115
Distribusi Normal 5-HT

CNS – 5%

GI tract – 95%
– enterochromaffin cells
– neuronal

Gershon. Aliment Pharmacol Ther 1999;13(suppl 2):15–30


Patogenesis IBS:
Factors Pencetus
Makanan dan zat yg dikandung

Obat obatan

Problems psikis /stress

Hormones (siklus menstruasi)

Perubahan musim
Faktor Psikis yang mempengaruhi
Fungsi Saluran Cerna

Ansietas, panik, depresi

“Unexplained bodily symptoms”

Fisikal, sexual atau emosional abuse

Alkohol atau penyalah guna obat

Gangguan makan
IBS: Understanding the condition
Early life
Genetics,
environment

Psychosocial CNS
factors Physiology
Life stress, Motility, sensation
ENS
psychological state,
coping, social support
IBS
Symptom
experience,
behaviour

Outcome
Medications, physician
visits, daily function,
Drossman, 1997; 1999
quality of life
Diagnosis
“Irritable Bowel Syndrome”
(IBS)
Perkembangan Diagnosis IBS

1950s – Meningkatnya “gut motility”


1970s – Petanda kusus motilitas usus
1980 to 1999 – kriteria khusus
• Manning criteria
• Rome criteria

1999 – kriteris Rome II

1. Drossman. Aliment Pharmacol Ther. 1999;13(suppl 2):3–14


2. Thompson et al. Gut. 1999;45(suppl 2):1143–1147
The Manning Criteria (1978)
Four symptoms significantly more common in IBS:

Pain relieved by defecation


More frequent stools at the onset of pain
Looser stools at the onset of pain
Visible abdominal distention

A strong trend for the following:


Passage of mucus
Sensation of incomplete bowel emptying

Manning AP et al. Br Med J 1978;2:653–4


The Rome Criteria (1992)
3 months continuous/recurrent symptoms:
1. Abdominal pain or discomfort that is
• Relieved with defecation
• Associated with a change in frequency of stool and/or
• Associated with a change in consistency of stool; and

2. Two or more of the following at least on one quarter


of the time
• Altered stool frequency (>3 / day or <3 / week)
• Altered stool form (lumpy/hard or loose/watery stool)
• Altered stool passage (straining, urgency)
• Passage of mucus
• Bloating or feeling of abdominal distention
Thompson WG et al. Gastroenterol Int 1992;5:75–91
Rome II Criteria

 At least 12 weeks, which need not be consecutive,


in the preceding 12 months, of abdominal discomfort
or pain that has 2 of 3 features:

• Relieved with defecation

• Onset associated with a change in frequency of


stool

• Onset associated with a change in form


(appearance) of stool

Thompson et al. Gut. 1999;45(suppl 2):1143–1147


1 2
Rome I Criteria Rome II Criteria
1. At least 3 months of continuous or 1. At least 12 weeks, which need not be
recurrent symptoms of abdominal consecutive, in the past 12 months of
pain or discomfort that is: abdominal discomfort or pain that has
• Relieved by defecation and/or 2 of 3 features:
• Associated with a change in • Relieved by defecation; and/or
frequency of stool; and/or • Onset associated with a change in
• Associated with a change in frequency of stool; and/or
consistency of stool • Onset associated with a change in form
(appearance) of stool
2. 2 or more of the following at least
25% of the time:
• Altered stool frequency
• Altered stool form
• Altered stool passage (straining,
urgency, feeling of incomplete evacuation)
• Passage of mucous; and/or
• Bloating or feeling of abdominal
distension 1Thompson WG et al. Gastroentrol Int 1992;5:75–91;
2Thompson WG et al. Gut 1999;45(Suppl II):II43–II47.
Rome III criteria for IBS if your symptoms
began at least 6 months ago, you have had
abdominal (belly) pain or discomfort at least
3 days each month in the last 3 months, and
at least two of the following statements are
true: 1
The pain is relieved by having a bowel
movement.
The pain is linked to a change in how often
you have a bowel movement.
The pain is linked to a change in the
appearance or consistency of your stool.
Perubahan Motilitas Usus

Hipomotilitas Hipermotilitas

Gerakan
Usus

C-IBS D-IBS
Subtipe IBS (~Rome)
C-IBS: D-IBS:
Rome II Rome II
$1 of A + none of B $1 of B + none of A
$ 2 of A + 1 of B $ 2 of B + 1 of A

A - <3 bowel movements / week


- hard lumpy stool
- straining during bowel movements

B - >3 bowel movements / week


- loose or watery stool
- urgency of bowel movements
Evaluasi IBS

Pemeriksaan Darah
Pemeriksaan feses
Pemeriksaan Radiologi
Sigmoidoskopi

Drossman, 1997; 1999


Differential Diagnosis
Malabsorpsi
“Food Intolerance”
Infeksi
“Inflammatory bowel disease” (IBD)
Kelainan Psikis
Gangguan ginekologis

1. Drossman. Aliment Pharmacol Ther. 1999;13(suppl 2):3–14


2. Moore et al. Br J Obstet Gynaecol. December 1998;105:1322–1325
Defining IBS: by exclusion of disease
Infection
IBD
Dietary Factors Giardia lamblia UC
Lactose Bacterial CD
Coffeine Ameba
Alcohol
Fat Psychologic
Gas-producing Differential Anxiety/panic
foods
Diagnosis Depression
Somatization

Malabsorption Miscellaneous
Post-gastrectomy
Intestinal Endometriosis
Pancreatic Endocrine tumours
AIDS
‘Red Flags’ May Suggest an
Alternative or Coexisting Diagnosis
Additional diagnostic screening needed for atypical
presentations such as

 Anemia  Nocturnal symptoms of


pain and abnormal bowel
 Fever function
 Persistent diarrhea  Family history of GI cancer,
 Rectal bleeding inflammatory bowel disease,
or celiac disease
 Severe constipation
 New onset of symptoms in
 Weight loss patients 50+ years of age

Paterson et al. Can Med Assoc J. July 1999;161:154–160


Tatalaksana
Irritable Bowel Syndrome
(IBS)
Tatalaksana Umum
 Hubungan dokter - Pasien yang baik
= Lakukan anamnesa yang baik dan teliti
= Identifikasi “Patient’s concern”
= Jelaskan : ini penyakit medis
Diet dan stres : pencetus
 Singkirkan penyakit organik
 Ongoing review
 Atasi Stres dan modifikasi gaya hidup
 Obat obat
Terapi IBS

Screening for Organic Diseases

Symptomatic subgroups

Constipation Diarrhoea Pain / gas

Fiber/Laxative Loperamide Antispasmodic


Prokinetic Diphenoxylate Antiflatulence
Tegaserod

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