Irritabel tarm-syndrom (IBS) Jørgen Valeur Unger-Vetlesens Institutt
Agenda What is IBS? How common is IBS? What causes IBS? How to treat IBS?
What is IBS?
«Physicians think that they do a lot for a patient when they give his disease a name» Immanuel Kant (1724-1804)
Irritabel tarm-syndrom (IBS) Kardinalsymptomer Forstoppelse Diaré Smerte Ubehag T R I A D E Gassproblemer Oppblåsthet Flatulens
«Negativ diagnostikk»
«Positiv diagnostikk»
<http://www.romecriteria.org>
«Organisk» versus «Funksjonell»
Bathroom mapping: «Anxious search for a bathroom in all venues» Habba, Medical Hypotheses (2010)
How common is IBS?
El-Salhy (2012)
What causes IBS?
Sentralnervesystemet Hvilken rolle spiller psykiske forstyrrelser? Psykiske forstyrrelser kan gi symptomer fra mage-tarm-kanalen Forstyrrelser i mage-tarm-kanalen kan gi psykiske symptomer Psykiske forstyrrelser kan påvirke opplevelsen og tolkningen av symptomer fra mage-tarm-kanalen
Dr. William Beaumont & Alexis St. Martin William Beaumont (1785-1853) Alexis St. Martin (1794-1880)
Dr. Stewart Wolf & Tom Stewart Wolf (1914-2005)
Brain-gut axis top-down Gut-brain axis bottom-up Neural axis (nerve signals) Humoral axis (hormones)
NTS = nucleus tractus solitarii; reléstasjon for viscerale afferente fibre Berntson GG et al, Eur J Neurosci 2003
Modified from Drossman
«It is much more important to know what sort of a patient has a disease, than what sort of a disease a patient has» Sir William Osler (1849-1919)
«The second brain» The enteric nervous system
Inflammasjon i plexus myentericus ved IBS Forstyrret motilitet? Törnblom et al., 2002
Økt antall TRPV1-positive sensoriske fibre ved IBS Forstyrret sensibilitet?
5-hydroxytryptamine (5-HT) = Serotonin
Fra Eva T. Janson
Klamydiainfeksjon i EC-cellen ved IBS?
Cani & Delzenne, Pharmacology and Therapeutics 2011; 130: 202-212
Kinross et al, Genome Medicine (2011)
Collins & Bercik, Gastroenterology (2009)
Mikrobielle metabolitter assosiert med sykdom Trends in Microbiology (2011)
Berstad & Valeur. NGF-nytt 2013; 1: 33
How to treat IBS?
Functional gastrointestinal disorders Approach and treatment 1) Establish a therapeutic alliance 2) Examinations to exclude organic diseases 3) Examinations to exclude psychiatric disorders 4) Explanation and reassurance. Keyword: Stress 5) Life style modifications. Keyword: Regularity 6) Psychotherapy, if indicated 7) Drugs, if indicated
The therapeutic alliance Is the customer always right? Cooperation between two experts The patient Symptom perception cannot be questioned The patient is best qualified The therapist Symptom interpretation and attribution can be questioned The patient is not necessarily best qualified Together, the two experts should explore the most realistic and useful explanations
Diagnostikk av IBS
IBS-SSS
Explanation and reassurance
Life style modifications...
Tarmen liker regelmessighet
«Alt som er hyggelig er godt for maven» Mummipappa
www.lmfnorge.no
Noen (forholdsvis ukontroversielle) kostholdsråd Avslapping før og under måltid Små og hyppige måltider regelmessig Forsiktighet med Sterkt krydder, kaffe, te, tobakk Fett? Kan gi gassretensjon Mat som gir stor gassdannelse, i.e. FODMAP Giuseppe Arcimboldo (1527-1593): Vertumnus (ca. 1590) Fiber? Vannuløselig: Gjør ofte vondt verre Vannløselig: Havregrøt!
Avspenning «Unquiet meals make ill digestions» The Comedy of Errors, William Shakespeare (1564-1616) Ina Hjelland: Lifestyle aspects in functional dyspepsia. Influence of relaxation and meals on vagal activity, gastric accommodation and symptoms. Doktoravhandling (2007)
http://www.helse-bergen.no/no/omoss/avdelinger/mage-tarmsykdommer/sider/default.aspx
Havre Samuel Johnson (1709-1784), definerte havre slik: "A grain, which in England is generally given to horses, but in Scotland supports the people Patrick Murray, 5 th Lord Elibank (1703 1778), parerte: "Yes, and where else will you see such horses and such men?"
Berstad & Valeur. NGF-nytt 2012; nr. 4: 10-12 (www.gastroenterologen.no)
Probiotics?
Psychotherapy? If a psychiatric disorder is present Specific treatment, often combined with drugs If psychological factors are predominant (dysfunctional thinking patterns) Cognitive behavioral therapy (CBT) (help to cope with the impact of the disorder)
Drugs?
Fra Magnus Simrén
Jan Tack Bringing science into the management of functional GI disorders From Major part of GI practice Symptoms are non-specific No abnormalities are found during routine testing: «you have nothing (serious)» Symptoms perceived as «imagined» This is all coming from the brain rather than the GI tract This is psychopathology: treatment is best left to psychologists or psychiatrists There are no effective drugs for these conditions To Major part of GI practice Symptom pattern is variable and specific Advanced functional testing reveals abnormalities in subsets of patients Symptoms are real and related to underlying pathophysiology Abnormalities can be demonstrated in the GI tract The impact of psychological therapies is probably modest: psychotropics may have other effects Exciting new therapeutic approaches are coming!
Organisk Funksjonell
Keep an open mind but not so open that your brain falls out! Richard Feynman Lykke til!