“functional” bowel disorders
DESCRIPTION
“Functional” Bowel Disorders. Eamonn M M Quigley MD November 2010. “Functional” Bowel Disorders. Refer to disorders of gut function where there is no obvious abnormality of structure or morphology Cause symptoms Impair Quality of Life Do NOT imply/equate to psychological/psychogenic!!. - PowerPoint PPT PresentationTRANSCRIPT
“Functional” Bowel Disorders
Eamonn M M Quigley MD November 2010
“Functional” Bowel Disorders
• Refer to disorders of gut function where there is no obvious abnormality of structure or morphology– Cause symptoms– Impair Quality of Life– Do NOT imply/equate to
psychological/psychogenic!!
A Sub-Classification
• Defined disorders of function; i.e. motility disorders
• Putative disorders of function; “functional disorders”
SymptomsSymptoms DysfunctionDysfunction PathologyPathology
PathophysiologyPathophysiology
Well-Defined Motility Disorders
Motility Disorders
• Primary– Achalasia– Diffuse Oesophageal Spasm– Gastroparesis– Acute/Chronic Intestinal Pseudo-
obstruction– Megacolon– Hirschsprung’s disease
Achalasia• Non-relaxing LOS
– Drop-out of Inhibitory neurons (NO, VIP)
• Aperistalsis in the oesophageal body
• Causes:– Chagas’ disease– Pseudo-achalasia
• Cancers
– Idiopathic
SymptomsSymptoms DysfunctionDysfunction PathologyPathology
PathophysiologyPathophysiology
Chagas’ Disease
Achalasia - Management
• Muscle relaxants– Ca++ - blockers– Nitrates
• Dilatation– Bougie; transient
benefit only– Balloon forced
dilatation
• Surgery– Heller myotomy
• Botox
Ineffective
Diffuse Oesophageal Spasm
• True idiopathic spasm rare; usually secondary to GORD
• Non-cardiac chest pain
• Treat:– Muscle relaxants– Dilatation– ? Surgery
Pseudoobstruction
• Rare disorders resulting in diffuse motor dysfunction:– Oesophageal dysmotility– Gastroparesis– Small bowel pseudobstruction– Colonic pseudobstruction
• Myopathy or Neuropathy• Congenital or Acquired• Primary or Secondary
– Connective tissue diseases– Muscle disease– Neurologic disorders– Metabolic disorders e.g. Diabetes
Pseudoobstruction
Presents as acute or recurrent “obstruction”:• Small intestine• Colon• Acute e.g acute colonic pseudo- obstruction (acute megacolon)• post-op (Ogilvie’s syndrome)
• Chronic• results in intestinal failure• small intestinal bacterial overgrowth• inability to tolerate p.o. nutrition
SymptomsSymptoms DysfunctionDysfunction PathologyPathology
PathophysiologyPathophysiology
Scleroderma
GeneticsImmunologyGeneticsImmunology
SymptomsSymptoms DysfunctionDysfunction PathologyPathology
PathophysiologyPathophysiology
Neurological Disease:1. Brain Stem TumorNeurological Disease:2. Parkinson’s Disease
DysphagiaNauseaIleusConstipationIncontinence
DysphagiaNauseaIleusConstipationIncontinence
Hirschsprung’s Disease
• Children; rarely presents in adulthood
• Loss of inhibitory neurons
• Genetics understood
• Svenson’s pull-through procedure
SymptomsSymptoms DysfunctionDysfunction PathologyPathology
PathophysiologyPathophysiology
Hirschsprung’s Disease
“Functional” Disorders
• Functional Heartburn• Globus Sensation• Functional Dyspepsia• Irritable Bowel Syndrome• Functional Abdominal pain• Functional Diarrhoea/Constipation
Often overlap; one disorder or a number of discrete disorders
Functional GI Disorders
• Responsible for over 50% of all G.I. Responsible for over 50% of all G.I. Complaints seen by a G.P.!Complaints seen by a G.P.!
How do you make a diagnosis?
• Symptoms• No pathology• No abnormal blood tests• No abnormal X Ray’s
Diagnosis
• By exclusion• Definitive, based on symptoms ( a
consensus approach)
Rome
• Functional Dyspepsia “ A chronic pain or discomfort centred
in the upper abdomen; may be additional symptoms such as fullness, bloating, early satiety, nausea, vomiting”
Rome
• IBS– “ chronic abdominal pain or
discomfort associated with bowel movement; may be additional symptoms such as bloating, distension, constipation, diarrhoea”
IBS
• Abdo Pain +– Urge to b.m.– Relief by b.m.– Alternating diarrhoea and
constipation
• Bloating, distension• Difficult defaecation
Functional Bowel DisordersCause(s)
• Motor Dysfunction• Visceral Hypersensitivity• Low-grade inflammation• Central Perception• Psyche
FD – Pathophysiology; motility
• Gastroparesis • Impaired Fundic Accommodation• Antral Dilatation • Gastric Hypersensitivity • Abnormal Cerebral Perception • Helicobacter Pylori
IBS - Pathophysiology
• Motility• Visceral Hypersensitivity• Central Perception• Inflammation
– Post-infective– Immune activation– Microbiota different
• Psyche
Case History
• 24 year-old female graduate student, volunteers in Africa
• 2000 presented with a 2 year history of abdominal cramps and constipation
– Went on wheat-free diet– Substituted soya for cows milk– Lived in:
» Malawi age 3-10» Malaysia age 14-16
• December 2003– Every 2 weeks: diarrhoea, nausea lasting 2-3 days– Loperamide helped
• April 2004– Anticholinergic, antispasmodic and antidiarrhoeal: some
help• July 2004
Case History
• July 2004• Despite 6 diphenoxylate/day
– Every 3-4 days borborygmi and cramps followed by diarrhoea (b.o. X 5 in a.m.) and urgency
– Took tinidazole for 4 days – no effect– Family history of pernicious anaemia, coeliac
disease and Crohn’s disease
Case History
• April 2009• Intermittent symptoms
– Worse after meals and when stressed
• Has had a number of anti-biotic and anti-parasitic regimes
• No weight loss• Extensive and repeated investigations
– Blood work, gastroscopy, colonoscopy, small bowel x-rays, abdominal imaging
» All negative
Management
• Listen and appreciate– Understand aggravating factors and modify
• Symptomatic– Anti-diarrhoeals– Laxatives– Anti-spasmodics
• Tricyclic anti-depressants (low dose); SSRI’s• Behavioral and psychological therapies
Summary• Motility disorders
– Not common– May cause considerable disability– Based on disorders of intestinal nerve or
muscle or their central connections
• “Functional” disorders– Common– May cause considerable impairment in quality
of life– Pathophysiology not fully understood