Case Problems in GI รศ.นพ.พิศาล ไม้เรียง รศ.นพ.กิตติ จันทร์เสิศฤทธิ์

งานนำเสนอเรื่อง: "Case Problems in GI รศ.นพ.พิศาล ไม้เรียง รศ.นพ.กิตติ จันทร์เสิศฤทธิ์"— ใบสำเนางานนำเสนอ:

1 Case Problems in GI รศ.นพ.พิศาล ไม้เรียง รศ.นพ.กิตติ จันทร์เสิศฤทธิ์
รศ.นพ.พิศาล ไม้เรียง รศ.นพ.กิตติ จันทร์เสิศฤทธิ์ อ.นพ.เทพสรรค์ สีอร่ามรุ่งเรือง

2 Disclosure of commercial support
This lecture is support by Berlin pharmaceutical industrial company. The speakers are free to present their own information and their personal view without any influence from the company.

3 สถิติโรคที่พบบ่อยที่เวชปฏิบัติทั่วไป รพ.ศรีนครินทร์
จำนวนครั้งและร้อยละของผู้ป่วยนอก จำแนกตาม ICD อันดับแรก ปี พศ. 2547 ลำดับ รหัสโรค ชื่อโรค จำนวนครั้ง ร้อยละ 1. I10 Essential (primary) hypertension 11,905 2.32 2. K30 Dyspepsia 9,594 1.87 3. E11 Non-insulin-dependent diabetes mellitus 8,944 1.74 4. E05 Thyrotoxicosis (Hyperthyroidism) 8,399 1.63 5. J45 Asthma 7,342 1.43 6. I05 Rheumatic mitral valve disease 6,346 1.24 7. J30 Vasomotor and allergic rhinitis 5,912 1.15 8. J06 Acute upper respiratory infections of multiple or unspecified sites 5,406 1.05 9. C22 Malignant neoplasm of liver and intrahepatic bile duct 5,377 10. H90 Conductive and sensorineural hearing loss 5,305 1.03

4 สถิติโรคที่พบบ่อยที่เวชปฏิบัติทั่วไป รพ.ศรีนครินทร์
จำนวนคนและร้อยละของผู้ป่วยนอก จำแนกตาม ICD10 10 อันดับแรก ปี พศ. 2547 ลำดับ รหัสโรค ชื่อโรค จำนวนครั้ง ร้อยละ 1. K30 Dyspepsia 3,634 2. T14 Injury of unspecified body region 2,771 3. I10 Essential (primary) hypertension 2,580 4. J06 Acute upper respiratory infections of multiple or unspecified sites 2,363 5. E05 Thyrotoxicosis (Hyperthyroidism) 2,292 6. J45 Asthma 2,083 7. J02 Acute pharyngitis 1,957 8. J30 Vasomotor and allergic rhinitis 1,702 9. A09 Diarrhoea and gastroenteritis of presumed infectious origin 1,687 10. M62 Other disorders of muscle 1,686

5 สถิติโรคที่พบบ่อยที่เวชปฏิบัติทั่วไป รพ.ศูนย์ขอนแก่น
สถิติผู้ป่วยนอก จำแนกตาม ICD10 10 อันดับแรก ปี พศ. 2546 ลำดับ รหัสโรค ชื่อโรค รวม รวมทั้งหมด ชาย หญิง ร้อยละ 1. I10 Essential (primary) hypertension 6,011 10,413 16,424 2.85 2. E119 Non-insulin dependent diabetes mellitus 4,870 10,290 15,160 2.63 3. J069 Acute upper respiratory infection 3,714 4,711 8,425 1.46 4. N200 Calculus of kidney 4,770 3,082 7,852 1.36 5. K30 Dyspepsia 2,525 3,859 6,384 1.11 6. H251 Senile nuclear cataract 2,036 3,010 5,046 0.88 7. K021 Caries of dentine 1,408 2,707 4,115 0.71 8. A09 Diarrhoea 1,798 2,283 4,081 9. J00 Acute nasopharyngitis (common cold) 1,833 2,186 4,019 0.70 10. S099 Unspecified injury of head 2,763 872 3,635 0.63

6 สถิติโรคที่พบบ่อยที่เวชปฏิบัติทั่วไป รพ.ศูนย์ขอนแก่น
สถิติผู้ป่วยนอก จำแนกตาม ICD10 10 อันดับแรก ปี พศ. 2547 ลำดับ รหัสโรค ชื่อโรค รวม รวมทั้งหมด ชาย หญิง ร้อยละ 1. I10 Essential (primary) hypertension 7,624 12,809 20,433 3.54 2. E119 Non-insulin dependent diabetes mellitus 4,961 11,039 16,000 2.77 3. J069 Acute upper respiratory infection 4,230 5,639 9,869 1.71 4. H251 Senile nuclear cataract 2,796 4,181 6,977 1.21 5. N200 Calculus of kidney 4,159 2,800 6,959 1.20 6. K30 Dyspepsia 2,562 3,993 6,555 1.13 7. A09 Diarrhoea 2,520 3,185 5,705 0.99 8. J00 Acute nasopharyngitis (common cold) 1,995 2,078 4,073 0.70 9. B24 Unspecified human immunodeficiency virus (HIV) disease 1,915 1,612 3,527 0.61 10. H110 Pterygium 889 2,142 3,031 0.52

7 สถิติโรคที่พบบ่อยที่เวชปฏิบัติทั่วไป รพ.ศูนย์ขอนแก่น
สถิติผู้ป่วยนอก จำแนกตาม ICD10 10 อันดับแรก ปี พศ (ครึ่งปีงบประมาณ) ลำดับ รหัสโรค ชื่อโรค รวม รวมทั้งหมด ชาย หญิง ร้อยละ 1. I10 Essential (primary) hypertension 4,933 8,481 13,240 4.19 2. E119 Non-insulin dependent diabetes mellitus 3,338 6,967 10,305 3.22 3. K30 Dyspepsia 1,720 2,634 4,354 1.36 4. J069 Acute upper respiratory infection 1,858 2,440 4,298 1.34 5. H251 Senile nuclear cataract 1,468 2,271 3,739 1.17 6. N200 Calculus of kidney 2,155 1,502 3,657 1.14 7. K021 Caries extending into dentine 1,033 1,886 2,919 0.91 8. A09 Diarrhea 1,156 1,170 2,626 0.82 9. J00 Acute nasopharyngitis (common cold) 1,226 1,285 2,511 0.78 10. B24 Unspecified human immunodeficiency virus (HIV) disease 1,240 1,007 2,247 0.70

8 Case 1 ชายไทยคู่ อายุ 40 ปี อาชีพ พ่อค้า
ชายไทยคู่ อายุ 40 ปี อาชีพ พ่อค้า แสบร้อน จุกเสียด แน่นท้อง 3 สัปดาห์ ไม่สัมพันธ์กับอาหาร บางครั้งมีลมบริเวณลิ้นปี่ร่วมด้วย ไม่มีน้ำหนักลด อุจจาระปัสสาวะปกติ ไม่มีไข้ ไม่กินเหล้า แต่กินอาหารบางครั้งไม่ตรงเวลา ไม่กินยาชุดแก้ปวด

9 Case 1 Thai man, not pale, no jaundice No lymphadenopathy
Lung and Heart are normal Abdominal soft, no distension, liver & spleen can’t be palpable No signs of chronic liver disease

10 สาเหตุที่คิดถึงในผู้ป่วยรายนี้ ?
Clue ในการ diagnosis?

11 Centered in the upper abdomen
Pain or Discomfort Centered in the upper abdomen

12 Dyspepsia

13 แสบร้อน จุกเสียด แน่นท้อง
What is/are causes? Clues for diagnosis Normal physical examination

14 Causes of dyspepsia Organ Pathogenesis Disease Stomach and Duodenum
Acid NSAID Helicobacter pylori Tumor Infiltration Gastric ulcer Duodenal ulcer Gastritis Duodenitis CA stomach Eosinophilic

15 Causes of dyspepsia Organ Pathogenesis Disease Stomach and Duodenum
Acid sensitivity Gastric hypersensitivity Duodenal hypersensitivity Failure of fundic relaxation to meal Vagal neuropathy Gastric dysrhythmias Delayed gastric emptying / antral hypomotility H.pylori Small bowel dysmotility NUD Or Functional dyspepsia

16 Liver and biliary tract
Causes of dyspepsia Organ Pathogenesis Disease Liver and biliary tract Infection Tumor Stone Hepatitis Liver abscess GS CBD stone Cholangiocarcinoma HCC

17 Causes of dyspepsia Organ Pathogenesis Disease Pancrease Inflammation
Tumor Pancreatitis Pancreatic duct stone CA pancrease

18 Diagnosis A) Peptic ulcer - DU or GU B) Gastroduodenitis
C) Functional dyspepsia

19 Etiology of dyspepsia N = 221 N = 208 CA 1.8 % combined Functional
53.4% PUD 26.4% Hepatobiliary 16.9% J Med Assoc Thai 1992;75:341- 8 N = 208 combined 65.6% PUD 11.3% CA 1.8 % Hge & Erosion 15.4% 2.6% N = 221 Stomach Research group 1999

20 Stomach Research Group 1999
Etiology of dyspepsia (endoscopically) NUD 77 % GU 11.3% DU 8.2% CA 2.1% Misc N = 4222 Stomach Research Group 1999 NUD 67 % GU 11.1% 10.1% CA 2.2% N = 2926 Siriraj Hospital 1997 Esophagitis 4.9%

21 Scand J Gastroenterol 1995;30:519 - 23
Etiology of dyspepsia in Primary care Functional 34% Esophagitis 15% PU 13% GERD 12% Scand J Gastroenterol 1995;30: IBS Misc Lactose CA N = 400 J Med Assoc Thai 1992;75:341- 8 53.4% PUD 26.4% Hepatobiliary N = 208 combined

22 Etiology of dyspepsia รพ.ศรีนครินทร์ 2000-2002 J Med Asso Thai 1992
N = 531 N = 208 NUD 76.6% GERD 4.75% PU 17.11% CA 0.19% รพ.ศรีนครินทร์ J Med Asso Thai 1992 Functional 53.4% PUD 26.4% Hepatobiliary combined

23 Clues on clinical evaluation
Disease Clues on clinical 1. Functional Young patient, no alarm feature 2. Chronic peptic ulceration NSAID used, HP-positive serologically, smoker, Hx of bleeding or anemia 3. Gastro-esophageal reflux Heartburn or acid regurgitation 4. Gastric cancer Advanced age at onset, alarm feature such as weight loss, HP- positive serologically 5. Biliary tract disease Biliary type pain

24 Clues on clinical evaluation
Disease Clues on clinical 6. Chronic pancreatitis - Constant pain, radiates to back, alcohol abuse, DM 7. Intestinal angina - Only postprandial pain, afraid to eat, weight loss, smoker 8. Diabetes mellitus - Hx of DM, other DM complication 9. Drugs - Theophyllin, Iron, potassium, digoxin, antibiotic

25 อาจารย์มีแนวทางในการดูแลรักษาผู้ป่วยอย่างไร?

26 Management of dyspepsia
Uninvestigated Investigated Organic disease Functional Ulcer - like Dysmotility - like

27 Initial management strategies for uninvestigated dyspepsia
1. Empirical treatment 2. Prompt endoscope 3. HP. Testing follow by eradication treatment or endoscope

28 Empirical treatment Who should empirical treatment ?
What is appropriate medication ?

29 Who should empirical treatment ?
No alarm features

30 Alarm features 1. Age of onset > 40 years 2. Awakening pain
3. Significant weight loss (> 5% BW within one month or > 10% within three months) 4. History of GI bleeding 5. Persistent vomiting 6. Dysphagia 7. Strong family history of GI malignancy 1999 Thailand Consensus SRG - GAT

31 Alarm features 8. Anemia 9. Jaundice 10. Hepatomegaly, splenomegaly,
lymphadenopathy 11. Fever 12. Abdominal mass 13. Significant abdominal distension 14. Bowel habit change 1999 Thailand Consensus SRG - GAT

32 Prompt endoscopy : Alarm features or High – risk
New – onset dyspepsia over age 50 years old Dyspepsia associated with dysphagia and / or weight loss Evidence of GI bleeding Occult blood Anemia Hematemesis Hematochezia or melena 4. Using NSAID or ulcerogenic agent 5. Signs or Symptoms of UGI tract obstruction Early satiety Vomiting 6. Strong family history of GI malignancy American Society for Gastrointestinal Endoscopy

33 H.pylori Test-and-Treat Strategies
Three direct comparative studies of early endoscopy and H.pylori Test-and-Treat Strategies Heaney A,1999 Lassen AT,2000 Duggan A,1998 measured dyspeptic symptom resolution Finding : H.pylori Test-and-Treat Strategies to be at least as effective as prompt endoscopy in patients with no alarm symptoms

34 Initial management strategies for uninvestigated dyspepsia
a) Empirical treatment b) Prompt endoscope c) HP. Testing follow by eradication treatment or endoscope

35 N = 1,171 Overall H.pylori + ve 52.52%
A survey of etiology of dyspepsia and prevalence of H.pylori infection in every regions of Thailand N = 1,171 Overall H.pylori + ve % Kachintorn U, et al.1999

36 อาจารย์จะเลือกใช้ยาอะไร?

37 Pharmacological intervention for uninvestigated dyspepsia
Subtype of Dyspepsia (Ulcer – like or dysmotility – like or reflux-like dyspepsia) PPI were significant more effective than H2RA and antacid 40% improved with H2RA or antacid 60% improved with PPI The Cochrane Database of Systemic – Review 2005

38 This patient Empirical treatment PPI for 2 – 4 weeks
Advise : Natural history of disease : Life – style modification Follow up

39 Case 1 The patient was advised to modified the life style.
He was on omeprazole (20mg) 1x1 domperidone (10 mg)1x3 Simethicone 1x3 At 2 week follow up his symptoms were improved and he was advised to continue the same treatment for 6 weeks.

40 Case 1 คำแนะนำในการปฏิบัติตัว งดเหล้า บุหรี่ กินอาหารตรงเวลา งดอาหารรสจัด หลีกเลี่ยงยาที่กระตุ้นให้เกิดอาการ การติดตามการรักษา

41 Case 1 episode 2 หลังจากหยุดยา เดือน มีอาการปวดแสบท้อง ถ่ายดำเล็กน้อย ไม่กินยาบำรุง ซื้อยา omeprazole กินเองตามร้านขายยา 1 wk อาการแสบท้องไม่ดีขึ้นจึงมาตรวจซ้ำ

42 Case 1 episode2 Thai man, mild pale, no jaundice No lymphadenopathy
Lung & Heart normal Abdominal soft, not tender, liver & spleen can’ t be palpable PR melena, no mass No signs of chronic liver disease

43 ผู้ป่วยกลับมาอีกครั้งจะทำอย่างไร ?

44 ถ่ายดำ PU CA Endoscope Recurrence dyspepsia Anemia Gastritis Biopsy
HP. Test HP. Pathology malignancy Inflammatory cell

45 ถ้าอาจารย์คิดถึง H.pylori infection จะให้การรักษาเลยโดยที่ไม่ต้องส้องกล้องได้หรือไม่ หลังจากเจาะเลือดพบ positive serology test

46 N = 1,171 Overall H.pylori + ve 52.52%
A survey of etiology of dyspepsia and prevalence of H.pylori infection in every regions of Thailand N = 1,171 Overall H.pylori + ve % Kachintorn U, et al.1999

47 Natural history of H.pylori infection
weeks to months Chronic superficial gastritis (Histological gastritis) years Peptic ulcer disease Chronic gastritis ( NUD ) MALT lymphoma Chronic atrophic gastritis GERD Gastric cancer NSAIDs users Cover,T.L.,et al.:ASM News, 61(1),21,1995

48 H.Pylori and peptic ulcer

49 Laboratory findings CBC:Hct 33%, Wbc 9000 PMN 65% L 30% Mono 3% Eos 2%
Stool examination : no parasite ,no wbc no rbc stool occult blood positive

50

51 ถ้าผลการตรวจ Rapid urease test ให้ผล negative จะ rule out H
ถ้าผลการตรวจ Rapid urease test ให้ผล negative จะ rule out H.pylori ได้หรือไม่ และอาจารย์จะรักษาอย่างไร

52 การวินิจฉัย H. pylori Diagnostic test Sensitivity Specificity
Histology % % Urea breath test - 13CO % % - 14CO % % Serology % % Rapid urease test % % Culture % %

53 False negative for rapid urease test
High dose H2RA PPI Antibiotic Active UGI bleeding

54 Pathologic findings: mild gastritis with presence of H pylori.

55 HP. Eradication First line therapy (7-14 days)
PPI or Amoxycillin 1 gm bid* RBC Clarithromycin or bid mg bid Metronidazole 500 mg bid or PPI/RBC + Amoxycillin + Metronidazole Second line therapy (7-14 days) PPI bid + Bismuth subsalicylate/subcitrate 120 mg qid + Metronidazole 500 mg tid + Tetracycline 500 mg qid

56 The Maastricht Who to treat (strongly recommended)

57 HP triple therapy is more effective than long-term maintenance antisecretory treatment in the prevention of recurrence of DU N = 114, prospective randomized study Gr1: C 250 qds + M 300 qds for 2 wks + Sucralfate 1 g qds for 4 wk Gr2: O 20 mg daily for 1 yr Gr1 Gr2 Ulcer relapse at one year (P = 0.44) 4.2% 9.8% HP - HP + Ulcer relapse 1 yr FU (P=0.018) 0% 12.5% Overall ulcer relapse (P=0.0005) 26.8% (mean FU of 4.07 yrs) Wong BCY, Aliment Pharmacol Ther 1999

58 Recurrent PU in patients following successful H.pylori eradication
N = 4940, FU = up to 4 yrs Crude recurrence rate = 3.02% GU DU GDU Annual recurrent rate (overall) 2.3% 1.6% Annual recurrence rate (excluded NSAID) 1.9% 1.5% 1.3% * GU is more likely to relapse than DU * Recurrent ulcer tended to recur at the site of the original ulcer and were significant in those who smoked, consumed alcohol and used NSAID Miwa H, et al. Helicobacter 2004

59 Test-and-Scope Strategies
It should be noted that as the prevalence of HP infection falls, the benefit of a test-and-treat strategy may also decline a test-and-treat strategy may miss gastric cancer, thus HP testing followed by endoscopy in positive patients may be appropriate Talley NJ. 1998 Sung JY. 2000

60 Role of H.pylori in NUD HP + NUD vs HP- NUD
No consistent differences in: - symptom severity - frequency of symptoms - delayed gastric emptying - altered visceral gastric perception Veldhuyzen van Zanten SJO, Aliment Pharmacol Ther 1997

61 H. pylori eradication in NUD
Large ‘optimised’ clinical trials give inconsistent results for the long-term benefit of eradication on dyspeptic symptoms 3 ‘No’ Blum et al., 1998 Talley et al., 1998 Talley et al., 1999 (all multicenter trials) 1 ‘Yes’ McColl et al., 1998 (single-center trial) versus

62 Eradication of H.pylori for non - ulcer dyspepsia (Cochrane review)
15 RCT, 2903 patients Follow up 3-12 months - RRR in H.pylori eradication compared to placebo = 9% (95% CI=5%-14%) - NNT to cure one case of dyspepsia =15 (95% CI = 10-28) If there is a benefit, it is limited to a subgroup of patients Moayyedi P,et al. Cochrane Database Syst Rev 2005

63

64 Case 2 หญิงไทย โสด 28 ปี อาชีพ รับราชการครู
หญิงไทย โสด 28 ปี อาชีพ รับราชการครู จุกแน่นท้อง ร่วมกับถ่ายอุจจาระบ่อย 2 เดือน จุกแน่นท้องบริเวณลิ้นปี่เล็กน้อย ร่วมกับอาการถ่ายอุจจาระบ่อย วันละ 3-4 ครั้ง หลังรับประทานอาหาร บางครั้งมีมูกปน แต่ไม่พบเลือด น้ำหนักไม่ลดหรือเบื่ออาหาร ไปพบแพทย์ 4 ท่าน บอกเป็นโรคกระเพาะ โรคประสาทลงกระเพาะ ได้ยากินไม่ดีขึ้น กังวลว่าจะเป็นมะเร็ง ไม่ดื่มสุรา กินอาหารตรงเวลา

65 Case 2 A Thai woman not pale, no jaundice, No signs of hyperthyroidism, no signs of malnutrition (edema, vitamin deficiency) BP 120/80 torr, Pulse 75/min, BT 36.7 ๐C Lung & heart WNL Abdomen: soft ,no distension, liver & spleen can’t be palpable No sign chronic liver disease PR normal

66 สาเหตุที่น่าคิดถึงในผู้ป่วยรายนี้
Case 2 สาเหตุที่น่าคิดถึงในผู้ป่วยรายนี้ A) IBS B) IBD C) Parasitic D) CA colon

67 A young lady with : Abdominal discomfort (epigastrium),
Chronic diarrhea ( no bloody stool). Normal physical examination.

68 Chronic diarrhea Functional Organic

69 Some ‘red-flag’ symptoms and signs suggesting organic gut disease
Rectal bleeding Weight loss* Continuous diarrhea Constant and recent distension Anemia Fever * Occasionally IBS patients lose weight because they food intake to avoid meal-induced symptoms

70 IBS Abdominal discomfort Constipation Diarrhea

71 Distribution of abdominal pain induced by balloon inflation

72 Prevalence of IBS among Thai, American and British
Thai American British Rural Urban No of subjects Mean age NA % women Change bowel pattern due to NA stress(%) Abdominal pain due to stress NA Painless diarrhea Painless constipation Spastic colon syndrome

73 Diagnoses Most likely diagnosis is IBS Differentiate diagnoses :
Giardiasis Strogyloidiasis Lactose intolerance IBD Drugs

74 Some drugs commonly disturb bowel function
Drugs causing constipation Opiates (e.g. codeine, morphine) Phenothiazines (e.g. chlorpromazine) Tricyclic antidepressants (e.g. amitriptyline) 5-HT3 antagonist (e.g. ondansetron) Calcium channel blockers Anticholinergics Calcium carbonate Drugs causing diarrhea Misoprostol Cisapride Antacids containing magnesium hydroxide Herbal teas containing senna Alcohol Caffeine

75 Criteria for diagnosing irritable bowel syndrome
Rome I criteria 1. Abdominal pain or discomfort relieved with defecation or associated with a change in stool frequency or associated with a change in stool consistency and 2. Two or more of the following on at least 25% of occasions or days : Altered stool frequency Altered stool form Altered stool passage Passage of mucus Bloating or distension

76 Criteria for diagnosing irritable bowel syndrome
Rome II criteria 12 weeks or more in the last 12 months of abdominal discomfort or pain that has two of the following three features : 1. Relieved by defecation 2. Associated with a change in frequency of stool 3. Associated with a change in consistency of stool The second group of criteria included in Rome I are now considered supportive rather than mandatory in the diagnosis. Thomson

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78

79

80 ในผู้ป่วยรายนี้ อาจารย์จะตรวจเพิ่มเติมอะไรหรือไม่

81

82 Symptom criteria to exclude organic disease in patients with possible IBS
Young age group Chronic recurrent symptoms Mild to moderate symptoms No signs of organic disease Middle age New onset of symptoms No signs of organic disease Age > 50 yr Change in symptoms or new onset of symptoms Severe symptoms Sign of organic disease Minimal diagnostic work up Limited diagnostic work up Full diagnostic work up

83 Initial work-up in patients with suspected IBS
History Physical examination (including digital examination of rectum) CBC Erythrocyte sedimentation rate Occult faecal blood test Colonic examination (discussed on an individual basis) Abdominal ultrasound (discussed on an individual basis)

84 Stage in the evaluation of the irritable bowel syndrome (IBS)
High probability of IBS Increased risk of organic disease General practice management Management of presumed IBS Investigation for organic disease Hospital based Progression change in symptoms Negative investigations CBC,ESR, stool exam, stool culture,TFT, endomysial Ab - Sigmoidoscopy/colonoscopy + biopsy + barium enema - Simple diarrhea/malabsorption screen - Other imaging studies - Lactose challenge/tolerance test - Laxative screen Jone J, et al. BSG guideline. NEJM. 2001

85 CBC : Hct 40%, Wbc 8500, PMN 82% L18%, Mono 1%, Plt 180000
Stool exam : no parasite, no rbc no wbc, occult blood –ve Sigmoidoscopy : normal

86 อาจารย์จะให้การรักษาคนไข้อย่างไร

87 Randomized , Double-Blind, Placebo-Controlled Treatment Trial for
the Irritable Bowel Syndrome Reference a Antispasmodic agents Bertherlot,1981, France General Practitioner Research Group, 1976, U.K. Kruis ,1986, Germany Page,1981, U.S.A. Test agent Mebeverine Dicyclomine Patients entered 111 29 80 97 Length of treatment period (wk) 8 2 16 Rx groups’ baseline characteristic compared? Y - Active response (%) 86 38 13 94 Placebo 73 25 30 54 Kenneth D Klein. Gastroenterology

88 Randomized , Double-Blind, Placebo-Controlled Treatment Trial for
the Irritable Bowel Syndrome Reference a Bulking agents Arthurs, 1983, Ireland Longstreth, 1981, U.S.A. Prior, 1987, U.K. Opioids Hovdenak, 1987, Norway Patients entered 80 77 60 Length of treatment period (wk) 4 8 12 3 Rx groups’ baseline characteristic compared? N Y Active response (%) 73 82 100 Placebo 63 71 53 45 Kenneth D Klein. Gastroenterology Test agent Ispaghula Psyllium Loperamide

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90 Newly approved prescription treatment for IBS
Tegaserod maleate1 5 – HT4 receptor partial agonist Indicated for the short – term treatment of women with IBS whose primary bowel symptom is constipation Alosetron hydrochloride2 5 – HT3 receptor partial agonist Indicated only for women with severe diarrhea – predominant IBS who have Chronic IBS symptoms (generally lasting 6 months or longer) Has anatomic or biochemical abnormalities of the GI tract excluded Failed to respond to conventional therapy

91 ท่านจะเลือกใช้ยาอะไร
A) Imodium B) Buscopan C) Mebeverine D) Psyllium

92 Recommendations Various antispasmodics can be given to
reduce pain, those with an anticholinergic action appearing to be slightly more effective Tricyclic antidepressants can be beneficial for pain, initially at a low dose, but occasionally higher doses may be required. They are best avoided if constipation is a major feature

93 Recommendations Patients with urgency and diarrhea can be
successfully treated with loperamide at doses of mg daily. Codeine is a reasonable alternative but more likely to cause unwanted sedation A small number of patients with diarrhea predominant IBS have bile salt malabsorption and may response to cholestyramine

94 Case 2 Treatment ให้ Mebeverine 1x3 , Imodium 1 tab prn, Buscopan 1 tab prn นัดมาดีขึ้น ให้รักษาใกล้บ้าน 6 เดือน ต่อมามีอาการปวดท้องมากขึ้นใหม่ นอนไม่หลับ กังวลมาก ว่าจะเป็นมะเร็งอีก โดยมีลูกของคุณอาเป็นมะเร็งลำไส้ใหญ่ ตอนอายุ 40 ปี เมื่อ 1 เดือนก่อน จึงมาตรวจซ้ำ ไม่มีน้ำหนักลด ไม่มีไข้ ยังกินได้ดีไม่อาเจียน

95 คำแนะนำและการรักษาเพิ่มเติม
Case 2 episode 2 CBC normal Stool exam normal คำแนะนำและการรักษาเพิ่มเติม

96 Patients in English general practice with fear of cancer
or other serious disease Percentage of Percentage of patients patients with IBS* with organic disease (n = 76) (n = 100) Fear of cancer (p < 0.04) Fear of other disease Total with fear (p < 0.05)

97 FOBT vs SIGMOIDOSCOPY (FS) vs COLONOSCOPY in detection of colorectal cancer among Chinese
505 asymptomatic adults older than 50 years were recruited from the general public through health exhibitions. All enrolled subjects were offered FOBT and full colonoscopy under sedation. 476 (94.3%) had a complete colonoscopy were recorded. Lesions at the distal 40 cm in the left colon and rectum were taken as findings of FS. Advanced colonic lesions* sensitivity specificity FOBT % % FS % % Combining FOBT with FS would not significantly improve the results of FS alone. Among the 385 subjects with a normal distal colon, 14 (3.6%) had advanced lesions in the proximal colon that would be missed by FS alone. * Advanced colonic lesions = adenoma > or = 10 mm, villous adenoma, adenoma with moderate or severe dysplasia, or invasive cancer Sung JJ et al Gastroenterology Mar;124(3):608-14

98 Management guideline for IBS
Listen to the patient Explanation and reassurance Healthy lifestyle advice Dietary advice Psychological considerations Psychological treatment Pharmacological approach

99 Dietary advice for IBS Simple dietary advice will benefit some patients with diarrhea who have excessively large intakes of indigestible carbohydrate, fruits or caffeine. Those with diarrhea , whose intake of lactose is substantial (> 0.5 pint 280 ml)milk/day may benefit from a trial of lactose exclusion and/or a lactose tolerance test. Constipated patients with low fiber intake should be given a trial of a high fiber diet.

100 Phrases to introduce a patient to the possible role of psychological factors
We may not know what causes IBS but we do know it gets worse when people are under stress or are upset This is especially likely to happen in people who have strong feelings It’s especially likely to happen when people don’t share their feelings but bottle them up inside Some of us express our feelings through our guts, so people talk about gut reactions and gut-wrenching experiences Having gut symptoms is stress in itself, especially if you don’t tell anyone about them Getting upset can make symptoms worse, so it’s easy to get into a vicious circle

101 Do’s and don’ts of IBS management
Approach the patient empathically Explore any hidden agenda Explain nature of the disorder thoroughly Don’ts Discourage the patient from seeing you again Punish the patient Assume psychogenic origin of the symptoms without proper assessment Feel forced into repeated or needless investigations

102 Thank you for your attention
This presentation is placed on the website of Department of Medicine, KKU.