Treatment of irritable bowel syndrome is usually divided into non-pharmacological and medicinal.
  Non-drug treatment.
  Diet. The diet allows you to exclude conditions that mimic IBS (lactose and fructose intolerance). Reduce gas formation and bloating, as well as the discomfort associated with it. But today there is no evidence that people with IBS should completely exclude any foods from their diet.
  Plant fiber supplementation has similar efficacy to placebo and has not been shown to be effective in patients complaining of abdominal pain and constipation. British guidelines recommend a fiber intake of 12 grams per day, as higher amounts may be associated with the onset of clinical symptoms of IBS.
  Psychotherapy. Psychotherapy, hypnosis, and the biofeedback method can reduce the level of anxiety, reduce the patient’s tension and more actively involve him in the treatment process. At the same time, the patient learns to react differently to a stress factor and increases tolerance to pain.
  Drug treatment for IBS targets the symptoms that prompt patients to seek medical attention or cause them the most discomfort. Therefore, treatment of IBS is symptomatic and many groups of pharmaceutical drugs are used.
  Antispasmodic drugs show short-term effectiveness and do not show sufficient effectiveness with long courses of use. Recommended for use in patients with flatulence and imperative urge to defecate. The analysis showed that antispasmodic drugs were more effective than placebo. Their use is considered optimal for reducing abdominal pain in IBS in a short course. Among the drugs in this group, the most commonly used are dicyclomine and hyoscyamine.
  Means aimed at combating dysbiosis. Quite often the cause of irritable bowel syndrome is dysbiosis. Treatment of flatulence, bloating, colic and other symptoms of dysbacteriosis should work in two directions: eliminating the symptoms of bloating, as well as restoring and maintaining the balance of intestinal microflora. Among the agents that have both of these actions at once, Redugaz is distinguished. Simethicone, one of the components contained in the composition, combats abdominal discomfort and delicately frees the intestines from gas bubbles, weakening their surface tension throughout the intestine. The second component, prebiotic Inulin, helps prevent the re-formation of gases and restores the balance of beneficial bacteria necessary for normal digestion. Inulin inhibits the growth of bacteria that cause gas, so re-bloating does not occur. Another plus is that the product is available in a convenient form in the form of chewable tablets and has a pleasant mint taste.
  Antidepressants are prescribed to patients with neuropathic pain. Tricyclic antidepressants can slow down the transit time of intestinal contents, which is a beneficial factor in the diarrheal form of IBS.
  A meta-analysis of the effectiveness of antidepressants showed a decrease in clinical symptoms when taking them, and their greater effectiveness compared to placebo. Amitriptyline is most effective in adolescents suffering from IBS. The dosage of antidepressants for the treatment of IBS is lower than for the treatment of depression. Antidepressants should be prescribed with extreme caution to patients who tend to experience constipation. Published results on the effectiveness of other groups of antidepressants are contradictory.
  Antidiarrheal drugs. The use of loperamide for the treatment of diarrhea in IBS has not been analyzed using standardized criteria. But available data showed it to be more effective than placebo. Contraindications to the use of loperamide are constipation in IBS, as well as intermittent constipation and diarrhea in patients with IBS.
  Benzodiazepines have limited use in IBS due to a number of side effects. Their use can be effective in short courses to reduce mental reactions in patients that lead to exacerbation of IBS.
  Type 3 serotonin receptor blockers help reduce abdominal pain and discomfort.
  Activators of type 4 serotonin receptors - used for IBS with constipation. The effectiveness of lubiprostone (a drug in this group) was confirmed by two placebo-controlled studies.
  Guanylate cyclase activators in patients with IBS are useful for constipation. Preliminary studies show their effectiveness in increasing bowel frequency in IBS patients with constipation.
  Antibiotics can reduce bloating, presumably by inhibiting gas-forming intestinal flora. However, there is no evidence that antibiotics reduce abdominal pain or other symptoms of IBS. There is also no evidence that bacterial overgrowth causes IBS.
  Alternative therapies for IBS include herbal remedies, probiotics, acupuncture and enzyme supplementation. The role and effectiveness of alternative treatments for IBS remains uncertain.

ICD-10 was introduced into healthcare practice throughout the Russian Federation in 1999 by order of the Russian Ministry of Health dated May 27, 1997. No. 170

The release of a new revision (ICD-11) is planned by WHO in 2017-2018.

With changes and additions from WHO.

Processing and translation of changes © mkb-10.com

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Definition

Irritable bowel syndrome (IBS) is a functional bowel disorder characterized by recurrent abdominal pain and/or abdominal discomfort lasting at least 3 days per month for the past 3 months, in combination with two of the following three symptoms: decreased pain after bowel movements , pain accompanied by a change in stool frequency, pain accompanied by a change in stool consistency, subject to the presence of complaints within the last 3 months, with the onset of the disease at least 6 months ago (Rome III criteria, 2006).

The prevalence of IBS is 10-45% among the total population in the world. Among the population of developed countries in Europe, the prevalence of IBS is, on average, 15-20%, in the USA - 17-22%. The highest prevalence of the disease is observed among older people. Women suffer from IBS 2 times more often than men. IBS occurs much less frequently in rural residents than in urban residents.

One of the main etiological causes is acute (or chronic) psycho-emotional stress (chronic stress at work, loss of a loved one, divorce, etc.). Hereditary predisposition also plays a certain role in the development of IBS - the disease is much more common in identical twins than in fraternal twins. Important factors are dietary habits, the presence of other diseases and disorders (for example, changes in the intestinal microbiocenosis, previous intestinal infections, etc.).

One of the main factors is considered to be a disruption of the interaction between the central nervous system and the intestines, which leads to the development of increased sensitivity of the intestine. “Sensitizing” factors (previous intestinal infection, psycho-emotional stress, physical trauma, etc.) cause changes in intestinal motor function, contribute to the activation of spinal neurons and, subsequently, the development of the phenomenon of increased spinal excitability, when stimuli of ordinary strength (for example, distension of the intestines with a small amount of gas) cause an increased reaction, manifested by pain. In addition, the process of descending suppression of pain perception may also be impaired in patients with IBS. Also, the sensitivity of intestinal mucosal receptors may be increased by exposure to short-chain fatty acids, malabsorbed bile salts, or immune mechanisms.

Of great importance in the formation of IBS is also a violation of intestinal motility due to changes in the neurohumoral regulation of its functions (violation of the ratio of the level of stimulating (substance P, serotonin, gastrin, motilin, cholecystokinin) and inhibiting (secretin, glucagon, somatostatin, enkephalin) muscle activity of the intestinal wall of gastrointestinal hormones ) or due to disturbances in the general hyperreactivity of smooth muscles (which can manifest itself not only in changes in intestinal motility, but also in increased frequency of urination, changes in the tone of the uterus, etc.).

Classification

By 58.0 IBS with diarrhea.

By 58.9 IBS without diarrhea.

Classification according to Rome III criteria (2006):

IBS with constipation: hard stool (corresponds to type 1-2 of the Bristol scale) - more than 25% of stool and soft, pasty or watery (corresponds to

6-7 type of the Bristol scale) stool - less than 25% of the number of bowel movements.

IBS with diarrhea: soft, pasty or watery stool - more than 25% of stool (corresponding to type 6-7 of the Bristol scale) and hard stool (corresponding to type 1-2 of the Bristol scale) - less than 25%.

Mixed IBS: hard stool (corresponding to type 1-2 of the Bristol scale) - more than 25% of stool, in combination with soft, pasty or watery stool - more than 25% of bowel movements (without the use of antidiarrheals and mild laxatives).

Unclassified IBS: insufficient severity of abnormal stool consistency to support the criteria for IBS with diarrhea, constipation, or mixed type.

Diagnostics

Noteworthy is the abundance of complaints that do not correspond to the severity of the patient’s condition.

Abdominal pain (in intensity can reach severe colic) of a diffuse nature or localized in the sigmoid region, ileocecal zone, hepatic and splenic flexures of the colon. Pain can be triggered by eating, without a clear connection with its nature, can begin immediately after waking up, intensify before and decrease after defecation, passing gas, or taking antispasmodics. An important feature of the pain syndrome in IBS is the absence of pain at night, as well as during rest;

Feeling of increased peristalsis;

Disturbances in the act of defecation in the form of constipation/diarrhea, unstable stool or pseudodiarrhea (acts of defecation are frequent or accelerated with normal stool) and pseudoconstipation (a feeling of incomplete evacuation even with normal stool, unproductive urge to defecate). In IBS with diarrhea, the frequency of stools is, on average, 3-5 times a day with a relatively small volume of feces (the total mass of feces does not exceed 200 g per day). Frequent loose stools may be observed only in the morning (after eating - “morning onslaught syndrome” (or “gastrocolytic reflex”) without further disorders during the day. There may also be an imperative (urgent) urge to defecate without passing feces. Diarrhea often occurs under stress (“bear disease”), overwork. But diarrhea never occurs at night. With IBS with constipation, patients are forced to strain more than 25% of the time they defecate, they often have no urge to defecate, which forces them to use enemas or laxatives. – 2 times a week or less. The stool resembles the shape of “sheep feces” or has a ribbon-like shape (in the form of a pencil). It must be remembered that the same patient may have alternating diarrhea and constipation.

The presence of “extraintestinal” symptoms - symptoms of a neurological and autonomic nature (in the absence of any subjective manifestations of the disease at night):

Pain in the lumbar region;

Feeling of a lump in the throat;

Frequent urination, nocturia and other dysuria;

Fatigue, etc.;

Cancerophobia (noted in more than half of patients).

Criteria confirming the diagnosis of IBS are:

Altered bowel movements: either less than 3 bowel movements per week or more than 3 bowel movements per day;

Changed stool shape: hard stools or loose, watery stools;

Passage disturbance (straining during bowel movements) and/or a feeling of incomplete bowel movement;

Urgency to have a bowel movement or a feeling of incomplete bowel movement;

Discharge of mucus, bloating, feeling of fullness in the abdomen.

The presence of pain and diarrhea at night, “alarm symptoms” (“red flags”): blood in the stool, fever, unmotivated weight loss, anemia, increased ESR, indicating an organic disease.

When collecting anamnesis, it is necessary to pay special attention to the time of onset of the first symptoms of the disease - as a rule, the disease begins at a young age, so the first appearance of IBS symptoms in old age makes the diagnosis of IBS doubtful. In addition, it is necessary to find out whether there is a history of psychotrauma, nervous strain, or stress.

Particular attention should be paid to the relative stability of clinical symptoms, their stereotypicality and connection with neuropsychic factors.

Also, symptoms that cast doubt on the diagnosis of IBS include a family predisposition - the presence of colon cancer in close relatives.

On physical examination, the picture is uninformative. Most often, one can note the emotional lability of the patient; palpation of the abdomen reveals an area of ​​spastic and painful compaction of the intestine and its increased peristalsis.

Mandatory laboratory tests

Clinical blood and urine tests (without deviations from the norm) - once;

Blood sugar (within normal limits) – once;

Liver tests (AST, ALT, ALP, GGT) (within normal values) – once;

Stool analysis for dysbacteriosis (mild or moderate dysbiotic changes may be observed) - once;

Fecal analysis for eggs and segments of helminths (negative) - once;

Coprogram (absence of steatorrhea, polyfecal matter) – once;

Fecal occult blood test (absence of hidden blood in stool) - once.

Mandatory instrumental studies

Sigmoidoscopy – to exclude organic diseases of the distal parts of the colon – once;

Colonoscopy (if necessary, biopsy of the intestinal mucosa) – to exclude organic diseases of the colon – once;

Ultrasound of the digestive and pelvic organs - to exclude pathology of the biliary system (cholelithiasis), pancreas (the presence of cysts and calcifications in the pancreas), space-occupying formations in the abdominal cavity and in the retroperitoneal space - once.

It should be remembered that the diagnosis of IBS is a diagnosis of exclusion. That is, the diagnosis of IBS is established by excluding clinical and laboratory-instrumental signs of the above diseases, accompanied by symptoms similar to IBS.

Additional laboratory and instrumental follow-ups

To exclude pathology of the thyroid gland, the content of thyroid hormones in the blood (T 3, T 4) is examined; to exclude pathology of the pancreas, a stool test for elastase-1 is performed.

If necessary, a test for lactase and disaccharide deficiency is carried out (prescription of an elimination diet for 2 weeks that does not contain milk and its products, sorbitol (chewing gum)).

If there are indications, to exclude organic changes in the colon, intestinal radiography (irrigoscopy), computed tomography and magnetic resonance therapy are performed.

Psychotherapist/neurologist (to prescribe etiopathogenetic therapy);

Gynecologist (to exclude gynecological pathology);

Urologist (to exclude pathologies of the urinary system);

Physiotherapist (to prescribe etiopathogenetic therapy).

If indicated:

Treatment

Achieving complete remission (relief of disease symptoms or a significant reduction in their intensity, normalization of stool and laboratory parameters), or partial remission (improvement of well-being without significant positive dynamics in objective data).

Inpatient treatment – ​​up to 14 days upon initial treatment, followed by continued treatment on an outpatient basis. Outpatient repeated courses of treatment are carried out upon request. Patients are subject to annual examination and examination in an outpatient setting.

Treatment of patients with IBS involves general measures - recommendations to avoid neuro-emotional overstrain, stress, etc., including showing the patient the results of studies indicating the absence of severe organic pathology.

Dietary recommendations are based on a syndromological principle (predominance of constipation, diarrhea, pain, flatulence). In general, the diet should contain an increased amount of protein and exclude refractory fats, limit carbonated drinks, citrus fruits, chocolate, vegetables rich in essential oils (radishes, radishes, onions, garlic).

If constipation predominates, you should limit fresh white bread, pasta, slimy soups, and excessive amounts of cereals. Products containing fiber, vegetable dishes, fruits (baked and dried apples, dried apricots, apricots, prunes) are shown. We recommend mineral waters “Essentuki No. 17”, “Slavyanovskaya” and others at room temperature, 1 glass 3 times a day, one minute before meals, in large sips and at a fast pace.

If diarrhea predominates, include in the diet tannin-containing products (blueberries, strong tea, cocoa), dried bread, warm mineral waters “Essentuki No. 4”, “Mirgorodskaya”, “Berezovskaya” (45-55 ° C) 3 once a day, before meals, in small sips and at a slow pace.

For pain combined with flatulence, cabbage, legumes, and fresh black bread are excluded from the diet.

The choice of drug treatment tactics depends on the leading symptom (pain, flatulence, diarrhea, constipation) and the psychological state of the patient.

In patients with IBS with pain, the following is used:

Selective myotropic antispasmodics (orally, parenterally): mebeverine 200 mg 2 times a day for days, pinaverium bromide 100 mg

3 times a day for 7 days, then - 50 mg 4 times a day for 10 days, drotaverine 2 ml intramuscularly 2 times a day (to relieve severe spastic pain);

Selective neurotropic antispasmodics – priphinium bromide pomg per day;

With a combination of pain and increased gas formation in the intestines:

a) antifoam agents (simethicone, dimethicone) – 3 capsules 3 times a day for 7 days, then – 3 capsules 2 times a day for 7 days, then – 3 capsules 1 time a day for 7 days;

b) meteospasmil – 1 capsule 3 times a day for 10 days.

For IBS with diarrhea the following is prescribed:

M-opiate receptor agonists – loperamide 2 mg 1-2 times a day;

Antagonists of 5-HT3-serotonin receptors - sturgeon 8 ml intravenously in a bolus of 10 ml of 0.9% isotonic sodium chloride solution for 3-5 days, then orally 4 mg 2 times a day or 8 mg 1 time per day during the day;

Cholestyramine up to 4 g per day with meals.

For constipation in patients with IBS, the following is prescribed:

Serotonin 5-HT4 receptor agonists: mosapride citrate 2.5 mg and 5 mg orally 3 times a day after meals, course of treatment – ​​3-4 weeks;

Peristalsis stimulants: metoclopramide or domperidone 10 mg 3 times a day;

Laxatives – lactulose poml 1-2 times a day, forlax

1-2 sachets per day at the end of meals every morning, Senadexin 1-3 tablets

1-2 times a day, bisacodyl 1-2 tablets 1-2 times a day or 1 suppository per rectum before bedtime, guttalax drops before bedtime, mucofalk 1-2 sachets 1-2 times a day, softovak 1-2 tea spoons at night, docusate sodium 0.12 g per rectum in the form of microenemas if the patient has the urge to defecate (the laxative effect occurs 5-20 minutes after administration of the drug into the rectum). Castor, Vaseline and olive oils are also used;

Combined enzyme preparations containing bile acids and hemicellulase (festal, digestal, enzistal) - 1-3 tablets with meals or immediately after meals 3-4 times a day, course - up to 2 months.

For increased anxiety, the following are prescribed:

Tricyclic antidepressants - amitriptyline, doxepin. Start with a dose

10-25 mg/day, gradually increasing it to 50 (150) mg/day, course of treatment – ​​6-12 months;

Anxiolytics (improves sleep quality, normalizes psychovegetative symptoms typical of neuroses and psychosomatic pathologies) - etifoxine 50 mg 2-3 times a day, course of treatment - 2-3 weeks;

Serotonin reuptake inhibitors (increase the bioavailability of 5-HT receptors, improve bowel movements in IBS with diarrhea, reduce abdominal pain): sulpiridmg 2-3 times a day, fevarin 1-2 tablets

2-3 times a day.

Additionally (if necessary), antacids (Maalox, Almagel, etc.) - diosmectite 3 g 3 times a day, sorbents (activated carbon, enterosgel, polyphepan, etc.) and probiotics can be prescribed.

Physiotherapeutic methods of treatment (reflexotherapy, electro- (diadynamic currents, amplipulse) and laser treatment, balneotherapy (warm baths, ascending and circular shower, contrast shower)).

In general, the prognosis for life is favorable, since IBS does not tend to progress. However, the prognosis of the disease largely depends on the severity of accompanying psychological manifestations.

Prevention

Prevention of IBS, first of all, should include measures to normalize lifestyle and diet, and avoid unnecessary use of drugs. Patients with IBS must set their own daily routine, including eating, exercising, working, social activities, housework, etc.

Treatment of irritable bowel syndrome in adults and children

Good day, dear visitors of my site! Let's figure out what the symptoms and treatment of irritable bowel syndrome are.

There are diseases for which people do not go to the hospital, but they cause great discomfort. One of them is irritable bowel syndrome, which is accompanied by cramps and pain in the abdomen, as well as chronic discomfort.

Often the cause of this problem is psycho-emotional disorders.

Reasons

IBS is a disease that causes abdominal pain. This disrupts the stable functioning of the intestines. More than 60% of patients do not consider it necessary to seek medical help. The disease has a code according to ICD 10 - K 58.

Let's look at the main causes of the problem:

1. Regular stressful situations.
2. Impaired intestinal motility. This disrupts the rhythm of contractions and relaxations.
3. Problems with hormonal levels. This happens during pregnancy and menopause.
4. Poor nutrition.
5. Dysbiosis is characterized by rapid growth of bacteria in the small intestine. This causes flatulence, weight loss, diarrhea and pain.
6. Hereditary factor.
7. Infections in the intestines.

Symptoms

Before we find out whether the disease can be treated, let's find out its main symptoms. First of all, an intense urge to defecate is felt even while eating food.

This is felt in the morning and early afternoon.

Diarrhea often occurs with strong emotional excitement. There is pain around the navel, which goes away after defecation. Soreness in the rectum is similar to colic, which goes away after visiting the toilet.

With the mixed type of irritable bowel syndrome, constipation alternates with diarrhea.

The following symptoms are observed:

1. Spasmodic pain.
2. When you have the urge, it seems that it is impossible to stop the process.
3. Stool disorder.
4. High gas production and bloating.
5. Clear or white mucus may be discharged.
6. In this condition, the intestines appear normal, but do not function normally.

If such signs are observed in children, then it is necessary to immediately seek medical help. Diagnosing young children is often difficult because they cannot correctly explain what is bothering them.

Parents should respond to the following symptoms:

1. The baby began to be more capricious and cry often.
2. Time spent on the potty has lengthened.
3. Having problems with stool.

If there is any suspicion, the doctor will prescribe an examination. At the same time, nutritional adjustments are made. Only a doctor can prescribe medication. It is important to follow certain dosages.

Diagnostic features

If you have problems with your intestines, you should consult a gastroenterologist. Since the symptoms of the syndrome are in many ways similar to other digestive diseases, a full examination is necessary to make a correct diagnosis and find out how to treat the intestines.

The following tests will be required for diagnosis:

1. A general blood test to detect a high white blood cell count and anemia with hidden bleeding.
2. A stool occult blood test can detect bleeding.
3. Testing for thyroid hormones.
4. Abdominal ultrasound helps identify complex diseases.
5. Gastroscopy with biopsy.
6. X-rays are performed to determine the relief of the large intestine.
7. Sigmoidoscopy and colonoscopy are done if inflammatory bowel disease is suspected.
8. CT scans can help determine the cause of symptoms.

In this case, the doctor will be able to identify the cause of the irritable bowel and prescribe treatment with special medications. Also, detailed diagnostics will help differentiate the condition from other pathologies.

Additional diagnostic methods are prescribed if symptoms progress, if blood is released during bowel movements, and if the patient’s weight decreases.

How to treat irritable bowel syndrome

When treating the disease in adults, an integrated approach is used. In this case, medication in combination with psychological correction and a special diet allows you to get a good result.

Even before starting treatment, you should follow the following recommendations:

1. Lead a healthy lifestyle.
2. Review your diet.
3. Avoid alcohol-containing drinks and tobacco.
4. Daily physical activity is required.
5. Spend more time outdoors.

Medicines

Drugs are selected taking into account the predominance of certain symptoms - diarrhea, constipation or pain.

Here are the remedies that can be prescribed:

1. Antispasmodics reduce pain and muscle spasms. These medications include Sparex, Niaspam and Mebeverine.
2. Probiotics stimulate intestinal function with the help of beneficial bacteria - Lactovit, Bifiform and Hilak-Forte.
3. Astringents such as Smecta, Almagel and Tanalbin are prescribed for exacerbations.
4. To reduce gas formation, sorbents are used - Polyphepan, Enterosgel and Polysorb.
5. For constipation, Portolac, Goodlac and Duphalac are used.
6. If IBS is accompanied by diarrhea, then Loperamide and Diphenoxylate should be used.
7. Antibiotics are often used for irritable bowel syndrome. This allows you to reduce the number of pathogenic microorganisms.
8. For apathy and severe anxiety, antidepressants are used.

Psychotherapy

Since such a pathology is often accompanied by stress, quality treatment may require the help of a psychotherapist. In this case, sedatives and antidepressants are prescribed.

Breathing exercises and yoga help you quickly relax. Therapeutic gymnastics are used to improve the nervous system and strengthen the body.

Diet

An important point is diet. At the same time, you should not limit yourself to the maximum in foods, but diversify the menu taking into account the characteristics of the digestive system.

A lack of certain components, magnesium, omega 3, 6 and zinc will lead to problems with the condition of the intestinal mucosa. Avoid foods that may aggravate symptoms of irritable bowel syndrome.

The following products may cause problems:

• alcohol, carbonated and alcohol-containing drinks;
• chocolate;
• drinks containing caffeine;
• dairy products.

The menu should include poultry broths, compotes, baked and boiled vegetables, cereals and first courses.

Remember that eating plums, beets, and apples can cause diarrhea. Flatulence and gas formation can be affected by legumes, cabbage, nuts and grapes.

Fatty and fried foods are effective for constipation.

For diarrhea, it is necessary to limit foods that stimulate irritability in the intestines, as well as secretory processes. It is recommended to eat at certain hours in a quiet environment.

It is better to choose food cooked in the oven, steamer or grill.

Folk remedies

In some cases, treatment is carried out with folk remedies.

Extracts of various herbs may be especially beneficial:

1. To improve the condition, bird cherry fruits, licorice root, blueberry leaf and dill seeds are used.
2. Freshly squeezed potato juice can help with colic and nausea.
3. Decoctions of chamomile, valerian, mint or marshmallow will help reduce inflammation and remove spasms.
4. For constipation, an infusion of thorn leaves is used.
5. Plantain seeds, as well as fennel and nettle are also used for constipation.
6. For diarrhea, an infusion of pomegranate peels is effective.
7. Cumin, fennel and anise are used to eliminate flatulence.

Preventive measures

Irritable bowel disease is one of the diseases that is difficult to prevent.

But special prevention will alleviate the condition:

1. Automotive training and psychological training will help alleviate the condition.
2. Balanced diet. Meals are taken 4-5 times a day.
3. Regular physical activity.

Remember not to overuse medications for constipation and diarrhea.

When diagnosed with irritable bowel syndrome, do not panic. In this case, the forecasts are most often positive. With such a disease, no complications arise and life expectancy does not decrease.

Just by changing your physical activity and diet, you can make big changes in your health. That's all I have for today!

See you soon, friends!

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Irritable bowel syndrome

ICD-10 code

Associated diseases

Symptoms

You are more likely to have IBS if symptoms began at least 6 months ago, abdominal pain or discomfort has continued for at least 3 days in the past 3 months, and at least two of the following statements are true:

*Pain decreases after defecation.

*Pain varies depending on the frequency of bowel movements.

*Pain varies depending on the appearance and consistency of the stool.

*The presence of any of the following symptoms supports the diagnosis of IBS.

With IBS, the pattern of bowel movements may change over time. Two or more of the following conditions may be present:

*Stools more often (diarrhea) or less frequently (constipation) than normal, that is, more than 3 times a day or less than 3 times a week.

*Changes in stool volume and consistency (hard and granular, thin, or loose and watery).

*Changes in the process of defecation. In this case, there may be a strong urge to defecate or a feeling of incomplete bowel movement.

*Bloating with gases (flatulence), sometimes increased release of gases (flatulence).

Other intestinal symptoms:

Some patients complain of pain in the lower abdomen and constipation followed by diarrhea. Others experience pain and mild constipation, but no diarrhea. Sometimes symptoms include gas buildup in the intestines and mucus in the stool.

*General anxiety, melancholy up to depression, frequent mood swings.

*Unpleasant taste in the mouth.

*Sleep disorders (insomnia) not caused by IBS symptoms.

*Sexual disorders, such as pain during intercourse or decreased sex drive.

*Feeling of interruptions in the heart (a feeling of fading or fluttering of the heart).

*Disorders of urination (frequent or strong urge, difficulty starting urination, incomplete emptying of the bladder).

Symptoms often occur after eating, occur and worsen in stressful situations and experiences, and intensify during menstruation.

Symptoms similar to those of IBS occur in many other diseases.

Differential diagnosis

If the disease began in old age.

If symptoms progress.

If acute symptoms appear, IBS is not acute, it is a chronic disease.

Symptoms appear at night.

Loss of body weight, loss of appetite.

Bleeding from the anus.

Steatorrhea (fat in stool).

High body temperature.

Fructose and lactose intolerance (lactase deficiency), gluten intolerance (symptoms of celiac disease).

Presence of inflammatory diseases or bowel cancer in relatives.

Reasons

For some people with this syndrome, pain and other symptoms may be triggered by poor diet, stress, lack of sleep, hormonal changes in the body and the use of certain types of antibiotics. Chronic stress plays an important role, since IBS often develops after prolonged stress and anxiety.

Treatment

Diet. The diet allows you to exclude conditions that mimic IBS (lactose and fructose intolerance). Reduce gas formation and bloating, as well as the discomfort associated with it. But today there is no evidence that people with IBS should completely exclude any foods from their diet.

Plant fiber supplementation has similar efficacy to placebo and has not been shown to be effective in patients complaining of abdominal pain and constipation. British guidelines recommend a fiber intake of 12 grams per day, as higher amounts may be associated with the onset of clinical symptoms of IBS.

Psychotherapy. Psychotherapy, hypnosis, and the biofeedback method can reduce the level of anxiety, reduce the patient’s tension and more actively involve him in the treatment process. At the same time, the patient learns to react differently to a stress factor and increases tolerance to pain.

Antispasmodic drugs show short-term effectiveness and do not show sufficient effectiveness with long courses of use. Recommended for use in patients with flatulence and imperative urge to defecate. The analysis showed that antispasmodic drugs were more effective than placebo. Their use is considered optimal for reducing abdominal pain in IBS in a short course. Among the drugs in this group, the most commonly used are dicyclomine and hyoscyamine.

Means aimed at combating dysbiosis. Quite often the cause of irritable bowel syndrome is dysbiosis. Treatment of flatulence, bloating, colic and other symptoms of dysbacteriosis should work in two directions: eliminating the symptoms of bloating, as well as restoring and maintaining the balance of intestinal microflora. Among the agents that have both of these actions at once, Redugaz is distinguished. Simethicone, one of the components contained in the composition, combats abdominal discomfort and delicately frees the intestines from gas bubbles, weakening their surface tension throughout the intestine. The second component, prebiotic Inulin, helps prevent the re-formation of gases and restores the balance of beneficial bacteria necessary for normal digestion. Inulin inhibits the growth of bacteria that cause gas, so re-bloating does not occur. Another plus is that the product is available in a convenient form in the form of chewable tablets and has a pleasant mint taste.

Antidepressants are prescribed to patients with neuropathic pain. Tricyclic antidepressants can slow down the transit time of intestinal contents, which is a beneficial factor in the diarrheal form of IBS.

Alternative therapies for IBS include herbal remedies, probiotics, acupuncture and enzyme supplementation. The role and effectiveness of alternative treatments for IBS remains uncertain.

ICD 10 irritable bowel syndrome

Irritable bowel syndrome: symptoms and treatments

Irritable bowel syndrome (IBS) is a dysfunction of the digestive system. People often call the pathology “bear disease.” It leads to intestinal spasms, constipation or diarrhea. IBS often occurs with flatulence. This phenomenon is not dangerous to health, but causes noticeable discomfort.

Reasons

IBS is considered one of the most common pathologies - about 20% of adults are affected by it. Usually the syndrome appears early, but sometimes it is diagnosed in children. According to ICD 10, irritable bowel syndrome is coded under the code K58.

Today, most doctors are confident that the key cause of the development of the disease is stress. Chronic depression, negative emotions, and increased anxiety negatively affect the functioning of the nervous system. As a result, she is constantly in a state of excitement.

This causes disturbances in intestinal motility and leads to increased susceptibility of the mucous membranes of the organ. In such conditions, even small changes in the diet for irritable bowel syndrome cause pain.

The reasons for the development of the disease also include the following:

1. A change in the neural connections between the intestines and a certain area of ​​the brain that is responsible for the functions of the digestive system.
2. Impaired intestinal motility. When it intensifies, there is a risk of diarrhea, while slowing it down provokes the development of constipation.
3. Dysbiosis. This condition consists of increased proliferation of bacterial microorganisms in the small intestine. As a result, IBS symptoms such as flatulence, diarrhea, and weight loss occur.
4. Hereditary predisposition. The risk of developing pathology is significantly higher in those people whose parents were diagnosed with IBS.
5. The presence of bacterial gastroenteritis in combination with psychological disorders.
6. Overeating, eating fatty foods and foods that cause flatulence.
7. Deficiency of foods that include dietary fiber.
8. Excessive consumption of coffee, carbonated drinks and alcohol.
9. Eating poor quality food.

It is important to consider that the more factors involved, the more severe the irritable bowel symptoms.

Symptoms

Bear disease has several types of manifestations - with pain and increased flatulence, with a predominance of symptoms of diarrhea or constipation. In some situations, signs of pathology are combined and change over time.

As a result, this gradation is considered rather arbitrary. Pathology can have different course options. Key symptoms of irritable bowel syndrome include:

• Excessive gas formation;
• spasms and pain that persist after bowel movements;
• diarrhea or constipation - sometimes these phenomena replace each other;
• swelling and flatulence;
• sudden onset of urge to defecate;
• mucous masses in stool;
• feeling of insufficient emptying.

Just a note. All of these symptoms are often combined with each other. Thus, diarrhea with irritable bowel syndrome is often replaced by constipation. Signs are usually present in a person for more than 3 months of the year.

Since the appearance of pathology is often caused by emotional experiences, patients experience headaches, general weakness, and insomnia. Patients also complain of pain in the heart and lower back, difficulty urinating, etc.

There are 4 possible options for the development of pathology:

1. Constipation syndrome. Hard stools account for more than 25% of cases.
2. Irritable bowel syndrome with diarrhea. In this situation, loose stools are observed in more than 25% of cases.
3. Mixed form. Loose stools are observed in more than 25% of cases. The number of cases of hard stool also exceeds 25%.
4. Indeterminate form. In this case, the consistency of the stool does not change enough, which prevents the correct diagnosis.

Very often, signs of pathology appear after eating. Their appearance can also be provoked by stressful situations. In women, symptoms of the disease often occur during menstruation.

Diagnostics

Today, there is no specific diagnosis of the pathology. This is due to the fact that the syndrome does not provoke obvious changes in the structure of the digestive organs. To make an accurate diagnosis, studies are prescribed that make it possible to exclude other pathologies with a similar clinical picture.

You can suspect the presence of IBS if a person has the following symptoms for 3 months:

1. Discomfort and bloating, which are accompanied by stool disorders.
2. Abdominal pain that disappears after defecation.
3. Constant urge to defecate.

To confirm the doctor’s assumption, you should pay attention to the presence of at least 2 more symptoms:

• Mucous discharge from the anus;
• heaviness and tension in the abdomen;
• insufficient emptying, strong tension and a strong urge to defecate;
• an increase in symptoms after eating.

If the syndrome is suspected, a detailed diagnosis is carried out in the presence of other signs that indicate serious disorders. These include the following:

• Anemia;
• bleeding from the anal area;
• weight loss for no apparent reason;
• compaction or swelling in the abdomen or anus.

To make an accurate diagnosis, the following types of diagnostic procedures must be prescribed:

• Stool analysis;
• sigmoidoscopy;
• colonoscopy, which is accompanied by a biopsy;
• Ultrasound of the abdominal cavity;
• clinical blood test and biochemistry;
• esophagogastroduodenoscopy - this examination of the duodenum helps to exclude celiac disease.

Treatment

Treatment of irritable bowel syndrome must certainly be comprehensive. Therapy consists of using medications and normalizing a person’s psychological state. Nutrition is important for irritable bowel syndrome.

Drug therapy

The following medications can treat irritable bowel syndrome:

1. Probiotics – Bifiform, Lactobacterin. These products contain beneficial bacteria. Thanks to their use, it is possible to improve the functioning of the intestines. Systematic use of probiotics helps eliminate signs of the disease.
2. Antispasmodics – Mebeverine, Niaspan, Sparex. Such remedies help cope with spasms of muscle tissue, which significantly reduces pain.
3. Anti-diarrhea medications – Loperamide, Imodium, Trimedat. These medications are used to treat IBS with diarrhea. The active substances of such drugs lead to a decrease in intestinal motility and compaction of stool. As a result, it is possible to achieve normalization of stool. It is important to consider that such drugs are prohibited from being used if an acute intestinal infection is suspected. Pregnancy is also a contraindication to their use.
4. Astringents – Tanalbin, Smecta. For IBS with diarrhea, treatment requires the use of such drugs.
5. Maalox and Almagel are used for a similar purpose.
6. Laxatives – Duphalac, Metamucil, Citrudel. These medications are prescribed for constipation. Their use should be combined with drinking plenty of fluid. These products contain fiber. When exposed to water, it swells in the stomach, leading to an increase in the volume of feces. Thanks to this, it is possible to establish easy and painless bowel movements.
7. Antidepressants. Drugs such as Amitriptyline and Imipramine are used to relieve diarrhea, depression and neuropathic pain. Adverse reactions from the use of such drugs are drowsiness, dry mouth and constipation. If depression is accompanied by constipation, doctors prescribe Fluoxetine or Citalopram. Antidepressants should be taken for a short time, strictly adhering to the dosage prescribed by the doctor.

Nutrition

Diet for irritable bowel disease plays a key role. It helps normalize the functioning of the digestive organs. Food should contain many vitamins and beneficial elements.

For constipation, foods should cleanse the body. The diet for irritable bowel syndrome with diarrhea is aimed at reducing the symptoms of the disorder. You should eat often, in small portions. It is recommended to eat every 3-4 hours. The daily amount of calories cannot be more than 2800.

The diet for IBS excludes foods that provoke nausea, flatulence, putrefaction or fermentation. If you have a bear illness, you should eat foods that include a lot of protein components and dietary fiber.

Nutrition for IBS, which is accompanied by constipation, should be based on foods that improve intestinal motility. These include:

• Vegetables and fruits;
• rye bread;
• lean meat and fish;
• vegetable soups;
• buckwheat and pearl barley;
• jam;
• fresh dairy products;
• sparkling water;
• compotes.

It is important to give up flour products, baked goods, and slimy soups. You should not eat chocolate and jelly. Puree porridge, strong tea and coffee are prohibited. A diet for irritable bowel syndrome with flatulence requires the exclusion of legumes and cabbage. Avoid eating whole milk, grapes, rye bread and potatoes.

Just a note. To improve intestinal motility, you should consume beets, fresh juices, carrots, pumpkin and prunes. It is not recommended to eat hot food - all dishes should be warm.

The principles of the diet for IBS with diarrhea should be based on the consumption of foods that reduce intestinal motility. Avoid eating foods that loosen stools and stimulate bowel movements.

It is worth consuming the following products:

• Dry biscuits and wheat crackers;
• hard-boiled eggs;
• coffee and strong tea;
• slimy infusions of rice and oatmeal;
• cocoa on water;
• fermented milk products - they should be three days old;
• a little butter.

Bear disease requires the exclusion of sugar, sausage, salt, hot spices and marinades. You should not eat fresh dairy products, vegetables and fruits, fatty meats and fish. Carbonated drinks, bran bread, and baked goods are also prohibited.

Food should be consumed in small portions up to 6 times a day. It is important to consider that a low-calorie diet is not recommended for a long time, as it can cause a deficiency of vitamins and proteins. As a result, there is a risk of exhaustion of the body.

Psychotherapy

Bear disease often appears under the influence of stressful situations. That’s why it’s so important to try to avoid conflicts and master techniques aimed at increasing stress resistance. These include the following:

To reduce the influence of the subconscious on the occurrence of pathological symptoms, hypnotherapy can be used. To strengthen the nervous system, it is worth taking part in trainings that use relaxation techniques.

To learn how to relax properly, you can do yoga and breathing exercises. Therapeutic exercise will strengthen the body and improve the functions of the nervous system.

Folk remedies

In addition to traditional therapy, folk remedies can be used to treat irritable bowel syndrome. The most effective recipes include the following:

1. Apples. With the help of this fruit, it is possible to reduce the symptoms of intoxication, improve the digestive process and eliminate signs of illness. To do this, it is enough to eat 1 apple a day.
2. Cinnamon and ginger. These products help cope with flatulence and eliminate pain. To achieve the required results, it is enough to add them to various dishes.
3. Collection of herbs. To make a healthy decoction, you need to mix buckthorn bark, chamomile flowers, mint leaves and valerian rhizome in the same ratio. Take 1 large spoon of the mixture and add a glass of water. Cook in a steam bath for a quarter of an hour. Then filter the product and drink 50 ml twice a day. Thanks to this, you will be able to cope with intestinal spasms, diarrhea and pain.
4. Peppermint. Its leaves are put in salads or used to prepare decoctions. Thanks to this, it will be possible to relax the intestinal muscles, reduce pain and cope with flatulence.

Prevention

To prevent the development of pathology, it is very important to follow these rules:

• Normalize nutrition;
• avoid stress;
• use medications only as indicated.

Irritable bowel syndrome is a very unpleasant pathology that leads to serious discomfort. To reduce its manifestations, you should consult a doctor in a timely manner and strictly follow his instructions.

Irritable bowel syndrome

It is necessary to exclude smoked and spicy foods, alcohol, coffee, chocolate, and foods that cause excessive gas formation (cabbage, flour products) from the diet.

The basis of nutrition should be a variety of vegetables, fruits, and dairy products. Steamed or boiled meat and fish dishes are healthy.

The diet can include jelly, porridge (semolina, oatmeal, rice), pasta, mashed potatoes. It is necessary to exclude vegetables (containing coarse dietary fiber), berries and fruits, and fried meat from the diet; legumes; fresh baked goods; spicy canned food; fatty and spicy seasonings; fresh dairy products, dry wine, beer, kvass, carbonated drinks.

Read more: Therapeutic nutrition for diarrhea.

Irritable bowel syndrome (IBS) is a functional disease of the gastrointestinal tract, characterized by pain and/or discomfort in the abdomen that goes away after defecation.

These symptoms are accompanied by changes in stool frequency and consistency and are combined with at least two persistent symptoms of bowel dysfunction:

• change in stool frequency (more than 3 times a day or less than 3 times a week);
• changes in stool consistency (lumpy, hard stool or watery stools);
• change in the act of defecation;
• imperative urges;
• feeling of incomplete bowel movement;
• the need for additional effort during bowel movements;
• secretion of mucus in feces;
• bloating, flatulence;
• rumbling in the stomach.

The duration of these disorders must be at least 12 weeks over the past 12 months. Among defecation disorders, special importance is attached to urgency, tenesmus, a feeling of incomplete bowel movement, and additional effort during defecation (Roman criteria II).

The cause is unknown and the pathophysiology is not fully understood. The diagnosis is made clinically. Treatment is symptomatic, consisting of dietary nutrition and drug therapy, including anticholinergic drugs and substances that activate serotonin receptors.

Irritable bowel syndrome is a diagnosis of exclusion, i.e. its establishment is possible only after excluding organic diseases.

ICD-10 code

K58 Irritable bowel syndrome.

ICD-10 code

K58 Irritable bowel syndrome

K58.0 Irritable bowel syndrome with diarrhea

K58.9 Irritable bowel syndrome without diarrhea

Epidemiology of irritable bowel syndrome

Irritable bowel syndrome is especially common in industrialized countries. According to world statistics, from 30 to 50% of patients visiting gastroenterology offices suffer from irritable bowel syndrome; It is estimated that 20% of the world's population has symptoms of irritable bowel syndrome. Only 1/3 of patients seek medical help. Women get sick 2-4 times more often than men.

After 50 years, the ratio of men to women approaches 1:1. The occurrence of the disease after 60 years of age is doubtful.

What causes irritable bowel syndrome?

The cause of irritable bowel syndrome (IBS) is unknown. No pathological cause was found. Emotional factors, diet, medications or hormones can accelerate and aggravate gastrointestinal symptoms. Some patients experience anxiety states (especially panic, major depressive syndrome and somatization syndrome). However, stress and emotional conflict do not always coincide with the onset of the disease and its relapse. Some patients with irritable bowel syndrome exhibit symptoms defined in the scientific literature as symptoms of atypical pain behavior (i.e., they express emotional conflict in the form of complaints of gastrointestinal disorders, usually abdominal pain). Clinicians assessing patients with irritable bowel syndrome, especially those who are treatment-resistant, should explore unresolved psychological problems, including the possibility of sexual or physical abuse.

There are no permanent motor impairments. Some patients experience impaired gastrocolic reflex with delayed, prolonged colonic activity. In this case, there may be a delay in gastric emptying or impaired motility of the jejunum. In some patients, no objectively proven abnormalities are found, and in those cases where abnormalities have been identified, there may be no direct correlation with symptoms. The passage through the small intestine changes: sometimes the proximal segment of the small intestine shows hyperreactivity to food or to parasympathomimetics. A study of the intraintestinal pressure of the sigmoid colon showed that functional stool retention can be combined with hyperreactive segmentation of the haustra (i.e., increased frequency and amplitude of contractions). In contrast, diarrhea is associated with decreased motor function. Thus, strong contractions may at times speed up or delay the passage.

Excess mucus production, which is often observed in irritable bowel syndrome, is not associated with damage to the mucous membrane. The reason for this is unclear but may be related to cholinergic hyperactivity.

There is hypersensitivity to normal distension and enlargement of the intestinal lumen, as well as increased pain sensitivity with normal accumulation of gas in the intestine. The pain is most likely caused by abnormally strong contractions of intestinal smooth muscle or increased sensitivity of the intestine to distension. Hypersensitivity to the hormones gastrin and cholecystokinin may also be present. However, hormonal fluctuations do not correlate with symptoms. High-calorie foods can lead to an increase in the magnitude and frequency of electrical activity of smooth muscles and gastric motility. Fatty foods can cause a delayed peak in motor activity, which can be significantly increased in irritable bowel syndrome. The first few days of menstruation can lead to a transient increase in prostaglandin E2, which most likely stimulates increased pain and diarrhea.

Symptoms of irritable bowel syndrome

Irritable bowel syndrome tends to begin in adolescents and young adults, with symptoms that occur intermittently and intermittently. Development of the disease in adults is not uncommon, but it is uncommon. Symptoms of irritable bowel syndrome rarely occur at night and can be triggered by stress or food intake.

Features of irritable bowel syndrome include abdominal pain associated with delayed bowel movements, changes in stool frequency or consistency, bloating, mucus in the stool, and a sensation of incomplete emptying of the rectum after a bowel movement. In general, the nature and location of pain, provoking factors and the nature of stool are different for each patient. Changes or deviations from usual symptoms suggest intercurrent illness and these patients should undergo a full evaluation. Patients with irritable bowel syndrome may also experience extraintestinal symptoms of irritable bowel syndrome (eg, fibromyalgia, headaches, dysuria, temporomandibular joint syndrome).

Two main clinical types of irritable bowel syndrome have been described.

In irritable bowel syndrome with predominant stool retention (irritable bowel syndrome with predominant constipation), most patients experience pain in more than one area of ​​the large intestine with periods of stool retention alternating with normal frequency. The stool often contains clear or white mucus. The pain has a paroxysmal nature, like colic, or a constant aching pain; pain may decrease after defecation. Eating usually triggers symptoms. Bloating, frequent passing of gas, nausea, indigestion and heartburn may also occur.

Diarrhea-predominant irritable bowel syndrome is characterized by urgency diarrhea that develops immediately during or after eating, especially when eating quickly. Nocturnal diarrhea is rare. Pain, bloating and a sudden urge to stool are typical, and stool incontinence may develop. Painless diarrhea is uncommon and should prompt the physician to consider other possible causes (eg, malabsorption, osmotic diarrhea).

Hyperthyroidism, carcinoid syndrome, medullary thyroid cancer, VIPoma, and Zollinger-Ellison syndrome are additional possible causes of diarrhea in patients. The bimodal age distribution of patients with inflammatory bowel disease allows us to evaluate groups of younger and older patients. In patients over 60 years of age, ischemic colitis should be excluded. Patients with stool retention and no anatomical cause should be evaluated for hypothyroidism and hyperparathyroidism. If symptoms suggest malabsorption, sprue, celiac disease, and Whipple's disease, further evaluation is necessary. Cases of stool retention in patients with complaints of the need for strong straining during bowel movements (eg, dysfunction of the pelvic floor muscles) require examination.

Anamnesis

Particular attention should be paid to the nature of the pain, bowel characteristics, family history, medications used and diet. It is also important to assess the patient's individual problems and emotional status. Physician patience and persistence is the key to effective diagnosis and treatment.

Based on the symptoms, the Rome criteria for diagnosing irritable bowel syndrome have been developed and standardized; The criteria are based on the presence for at least 3 months of the following:

1. abdominal pain or discomfort that improves after bowel movements or is associated with a change in stool frequency or consistency,
2. a defecation disorder characterized by at least two of the following: a change in the frequency of stools, a change in the shape of the stool, a change in the character of the stool, the presence of mucus and bloating or a feeling of incomplete emptying of the rectum after a bowel movement.

Physical examination

In general, the patients' condition is satisfactory. Palpation of the abdomen may reveal tenderness, especially in the left lower quadrant, associated with palpation of the sigmoid colon. All patients should have a digital rectal examination, including a stool occult blood test. In women, a pelvic examination (bimanual vaginal examination) helps rule out ovarian tumors and cysts or endometriosis, which may mimic irritable bowel syndrome.

Instrumental diagnosis of irritable bowel syndrome

It is necessary to perform proctosigmoidoscopy with a flexible endoscope. Insertion of the sigmoidoscope and air insufflation often cause intestinal spasm and pain. The mucous membrane and vascular pattern in irritable bowel syndrome are usually not changed. Colonoscopy is preferable in patients over 40 years of age with complaints suggesting changes in the colon and especially in patients without previous symptoms of irritable bowel syndrome in order to exclude polyposis and colon tumors. In patients with chronic diarrhea, especially older women, a mucosal biopsy can rule out possible microscopic colitis.

Many patients with irritable bowel syndrome tend to be over-diagnosticized. In patients whose clinical presentation meets the Rome criteria but who do not have any other symptoms or signs suggestive of other pathology, laboratory results do not influence the diagnosis. If the diagnosis is in doubt, the following tests should be performed: complete blood count, ESR, biochemical blood test (including liver function tests and serum amylase), urinalysis, and determine the level of thyroid-stimulating hormone.

Additional Research

Intercurrent illness

The patient may develop other gastrointestinal disorders that are not characteristic of irritable bowel syndrome, and the clinician should take these complaints into account. Changes in symptoms (eg, location, nature, or intensity of pain; bowel condition; palpable stool retention and diarrhea) and the appearance of new signs or complaints (eg, nocturnal diarrhea) may indicate the presence of another disease. New symptoms that may require further investigation include: fresh blood in the stool, weight loss, severe abdominal pain or unusual abdominal enlargement, steatorrhea or foul-smelling stools, fever, chills, persistent vomiting, hematomesis, symptoms that interfere with sleep (eg, pain, urge to stool), as well as persistent progressive deterioration of the condition. Patients over 40 years of age are more likely to develop somatic pathology than younger ones.

If psychological stress, anxiety or mood changes occur, an assessment and appropriate therapy are necessary. Regular physical activity helps reduce tension and improve bowel function, especially in patients with bowel retention.

Nutrition and irritable bowel syndrome

In general, normal nutrition should be maintained. Food should not be excessively plentiful, and meals should be leisurely and measured. Patients with abdominal bloating and increased gas formation should limit or eliminate the consumption of beans, cabbage and other foods containing carbohydrates that are amenable to microbial intestinal fermentation. Reducing your intake of apples and grape juice, bananas, nuts and raisins may also reduce flatulence. Patients with signs of lactose intolerance should reduce their intake of milk and dairy products. Intestinal dysfunction may be caused by ingestion of foods containing sorbitol, mannitol or fructose. Sorbitol and mannitol are artificial sugar substitutes used in diet foods and chewing gum, while fructose is a common element in fruits, berries and plants. A low-fat, high-protein diet may be recommended for patients with postprandial abdominal pain.

Dietary fiber may be effective due to water absorption and stool softening. It is indicated for patients with stool retention. Soft stool-forming substances may be used [eg, raw bran, starting with 15 ml (1 tablespoon) at each meal, increasing fluid intake]. Alternatively, hydrophilic psyllium mucilloid can be used with two glasses of water. However, excessive use of fiber can lead to bloating and diarrhea. Therefore, the amount of fiber should be adapted to individual needs.

Drug treatment of irritable bowel syndrome

Drug treatment for irritable bowel syndrome is not recommended, except for short-term use during periods of exacerbation. Anticholinergic drugs (eg, hyoscyamine 0.125 mg 30-60 minutes before meals) can be used as antispastic agents. Newer selective M muscarinic receptor antagonists, including zamifenacin and darifenacin, have fewer cardiac and gastric side effects.

Modulation of serotonin receptors may be effective. The 5HT4 receptor agonists tegaserod and prucalopride may be effective in patients with stool retention. 5HT4 receptor antagonists (eg, alosetron) may benefit patients with diarrhea.

Patients with diarrhea can be given oral diphenoxylate 2.5-5 mg or loperamide 2-4 mg before meals. However, the constant use of antidiarrheal drugs is undesirable due to the development of drug tolerance. In many patients, tricyclic antidepressants (eg, desipramine, imizin, amitriptyline 50-150 mg orally once daily) reduce symptoms of stool retention and diarrhea, abdominal pain and flatulence. These medications are thought to reduce pain through postregulatory activation of the spinal cord and cortical afferents from the gut. Finally, certain aromatic oils can relieve irritable bowel syndrome by promoting the passage of gas, helping to relieve spasms of smooth muscles and reducing pain in some patients. Peppermint oil is the most commonly used drug in this group.

Irritable bowel syndrome- a chronic, relapsing, functional disease in which patients have pain and discomfort in the abdominal cavity for at least 12 months, which goes away after defecation and is accompanied by a change in the frequency and consistency of stool.

Other manifestations of the disease include: constipation (stool less than 3 times a week); diarrhea (stool more than 3 times a day); tension during defecation; imperative urge to defecate; feeling of incomplete bowel movement; secretion of mucus during bowel movements; feeling of bloating and fullness in the abdomen.

The following signs support the functional nature of the disease: variability of complaints; recurrent nature of complaints; absence of disease progression; no weight loss; increased symptoms of illness under stress.

To confirm the diagnosis, it is necessary to exclude organic gastrointestinal pathology. For this purpose, ultrasound of the abdominal cavity, gastroduodenoscopy, irrigoscopy are performed; Intestinal biopsies are examined. The diagnosis is established on the basis of the clinical manifestations of the disease, the absence of deviations in the results of blood and stool tests; absence of pathological manifestations during sigmoid or colonoscopy.

Treatment of irritable bowel syndrome is symptomatic and includes changes in diet and courses of psychotherapy. Drug treatment methods are carried out taking into account the predominance of certain symptoms of the disease in the clinical picture (pain, flatulence, diarrhea, constipation), and consist of prescribing drugs with antispasmodic activity, antidiarrheal or laxative drugs, antidepressants.

• Classification of irritable bowel syndrome The classification of irritable bowel syndrome is based on taking into account the main clinical manifestations of the disease. The following manifestations of irritable bowel syndrome are analyzed:
  1. Constipation (stool less than 3 times a week).
  2. Diarrhea (stool more than 3 times a day).
  3. Hard consistency of stool; loose or pasty stools.
  4. Tension during defecation; imperative urge to defecate.
  5. Feeling of incomplete bowel movement.
  6. Discharge of mucus during bowel movements; feeling of bloating and fullness in the abdomen.

  There are two clinical forms of irritable bowel syndrome:

  • Syndrome with predominance of diarrhea (characteristic signs 2,4,6).
  • Syndrome with a predominance of diarrhea and constipation (characteristic signs 1,3,5).

• Epidemiology of irritable bowel syndrome

  The worldwide incidence of irritable bowel syndrome is 5-11%; among residents of developed European countries - 15-20%.

  This syndrome is detected in 28% of patients seeking help from gastroenterologists, and in 12% of patients visiting general practitioners (in the USA, their number reaches 2.4-3.5 million people annually).

  Each year in the United States, the cost of treating patients with irritable bowel syndrome is $25 billion (as of 2003).

  In women, the disease is diagnosed 2 times more often than in men.

  The average age of patients with irritable bowel syndrome is 20-45 years.

• ICD-10 codes
  • K58 - Irritable bowel syndrome.
  • K58.0 - Irritable bowel syndrome with diarrhea.
  • K58.9 - Irritable bowel syndrome without diarrhea.

Treatment

• Treatment Goals
  • Normalization of diet.
  • Restoration of normal intestinal microflora in the colon.
  • Normalization of digestion and absorption processes.
  • Normalization of emotional state.
  • Elimination of deficiency of vitamins and microelements.
  • Normalization of the act of defecation.

• Treatment methods
  • Non-drug treatments
    • Diet therapy.

      It is necessary to exclude smoked and spicy foods, alcohol, coffee, chocolate, and foods that cause excessive gas formation (cabbage, flour products) from the diet.

      The basis of nutrition should be a variety of vegetables, fruits, and dairy products. Steamed or boiled meat and fish dishes are healthy.

      • Nutrition of patients with irritable bowel syndrome with a predominance of diarrhea.

        The diet can include jelly, porridge (semolina, oatmeal, rice), pasta, mashed potatoes. It is necessary to exclude vegetables (containing coarse dietary fiber), berries and fruits, and fried meat from the diet; legumes; fresh baked goods; spicy canned food; fatty and spicy seasonings; fresh dairy products, dry wine, beer, kvass, carbonated drinks.

        Read more: Therapeutic nutrition for diarrhea.

      • Nutrition of patients with irritable bowel syndrome with a predominance of constipation.

        The diet can include porridge (buckwheat and barley), prunes or dried apricots, baked apples (1-2 pieces per day). Some of the sugar can be replaced with sorbitol or xylitol. You can eat dried seaweed (1-2 teaspoons per day); wheat bran (15-30 g/day); vegetable oil (preferably olive or corn) from 1 tsp. up to 2 tbsp. l. in the morning, on an empty stomach.

        It is necessary to exclude jelly, strong tea, cocoa, chocolate, slimy soups, pureed porridge, and butter dough from the diet. Do not take hot food or drinks. In the presence of concomitant flatulence, the consumption of cabbage, potatoes, peas, beans, watermelons, grapes, rye bread, and whole milk is limited.

        Read more: Medical nutrition for constipation.) orally, 200 mg 2 times / day or 135 mg 3 times / day (20 minutes before meals) until a clinical effect is achieved, followed by a dose reduction over several weeks. Herbal medicines can be used origin, obtained from the seeds of the plantain Plantago ovata. Laxatives are used for symptomatic purposes: lactulose, macrogol.

        Patients with irritable bowel syndrome must adhere to a specific diet, depending on the clinical form of the syndrome.

        In the most favorable course of the disease, following dietary recommendations and conducting psychotherapeutic measures is sufficient.

        Drug treatment methods are carried out taking into account the predominance of certain symptoms of the disease in the clinical picture (pain, flatulence, diarrhea, constipation), and consist of prescribing drugs with antispasmodic activity, antidiarrheal or laxative drugs, antidepressants.

ICD-10 was introduced into healthcare practice throughout the Russian Federation in 1999 by order of the Russian Ministry of Health dated May 27, 1997. No. 170

The release of a new revision (ICD-11) is planned by WHO in 2017-2018.

With changes and additions from WHO.

Processing and translation of changes © mkb-10.com

Coding of irritable bowel syndrome according to ICD 10

In medical institutions, according to ICD 10, it has code K58, which defines the general concept, etiology, pathogenesis and morphological aspects inherent in this disease.

Also, the code of this pathology determines a uniform worldwide local protocol for diagnostic, therapeutic and preventive measures and other aspects in the management of patients with this disease. The pathology, which is called irritable bowel syndrome (IBS), includes the general concept of various pathologies of the muscular system, individual parts of the digestive tract involved in the process of moving food fragments, absorbing nutrients and producing secretions for normal functioning.

Types of pathology determined by code K58

The IBS code in the ICD 10 revision has several subparagraphs that characterize the presence of certain clinical manifestations. The K58 code has the following subparagraphs:

• irritable bowel syndrome with diarrhea (58.0);
• irritable bowel syndrome without diarrhea (58.9).

It should be noted that etiological factors do not affect the type of pathology, since they largely depend on the individual characteristics of the human body.

Clinical picture of the disease

Irritable bowel syndrome affects 10% of the population worldwide. The majority of people who have manifestations of this disease do not turn to specialists, considering pathological symptoms to be individual characteristics of the body, which significantly reduces the quality of life and can provoke the development of organic lesions of internal organs and entire systems. The following symptoms are considered signs of IBS:

• constant flatulence;
• pain in the lower abdomen;
• constipation or diarrhea;
• pain during defecation;
• false urge to evacuate.

These symptoms should be a good reason to see a doctor who will help solve the problem and prevent a serious illness.

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Irritable bowel syndrome

Definition

Irritable bowel syndrome (IBS) is a functional bowel disorder characterized by recurrent abdominal pain and/or abdominal discomfort lasting at least 3 days per month for the past 3 months, in combination with two of the following three symptoms: decreased pain after bowel movements , pain accompanied by a change in stool frequency, pain accompanied by a change in stool consistency, subject to the presence of complaints within the last 3 months, with the onset of the disease at least 6 months ago (Rome III criteria, 2006).

The prevalence of IBS is 10-45% among the total population in the world. Among the population of developed countries in Europe, the prevalence of IBS is, on average, 15-20%, in the USA - 17-22%. The highest prevalence of the disease is observed among older people. Women suffer from IBS 2 times more often than men. IBS occurs much less frequently in rural residents than in urban residents.

One of the main etiological causes is acute (or chronic) psycho-emotional stress (chronic stress at work, loss of a loved one, divorce, etc.). Hereditary predisposition also plays a certain role in the development of IBS - the disease is much more common in identical twins than in fraternal twins. Important factors are dietary habits, the presence of other diseases and disorders (for example, changes in the intestinal microbiocenosis, previous intestinal infections, etc.).

One of the main factors is considered to be a disruption of the interaction between the central nervous system and the intestines, which leads to the development of increased sensitivity of the intestine. “Sensitizing” factors (previous intestinal infection, psycho-emotional stress, physical trauma, etc.) cause changes in intestinal motor function, contribute to the activation of spinal neurons and, subsequently, the development of the phenomenon of increased spinal excitability, when stimuli of ordinary strength (for example, distension of the intestines with a small amount of gas) cause an increased reaction, manifested by pain. In addition, the process of descending suppression of pain perception may also be impaired in patients with IBS. Also, the sensitivity of intestinal mucosal receptors may be increased by exposure to short-chain fatty acids, malabsorbed bile salts, or immune mechanisms.

Of great importance in the formation of IBS is also a violation of intestinal motility due to changes in the neurohumoral regulation of its functions (violation of the ratio of the level of stimulating (substance P, serotonin, gastrin, motilin, cholecystokinin) and inhibiting (secretin, glucagon, somatostatin, enkephalin) muscle activity of the intestinal wall of gastrointestinal hormones ) or due to disturbances in the general hyperreactivity of smooth muscles (which can manifest itself not only in changes in intestinal motility, but also in increased frequency of urination, changes in the tone of the uterus, etc.).

Classification

By 58.0 IBS with diarrhea.

By 58.9 IBS without diarrhea.

Classification according to Rome III criteria (2006):

IBS with constipation: hard stool (corresponds to type 1-2 of the Bristol scale) - more than 25% of stool and soft, pasty or watery (corresponds to

6-7 type of the Bristol scale) stool - less than 25% of the number of bowel movements.

IBS with diarrhea: soft, pasty or watery stool - more than 25% of stool (corresponding to type 6-7 of the Bristol scale) and hard stool (corresponding to type 1-2 of the Bristol scale) - less than 25%.

Mixed IBS: hard stool (corresponding to type 1-2 of the Bristol scale) - more than 25% of stool, in combination with soft, pasty or watery stool - more than 25% of bowel movements (without the use of antidiarrheals and mild laxatives).

Unclassified IBS: insufficient severity of abnormal stool consistency to support the criteria for IBS with diarrhea, constipation, or mixed type.

Diagnostics

Noteworthy is the abundance of complaints that do not correspond to the severity of the patient’s condition.

Abdominal pain (in intensity can reach severe colic) of a diffuse nature or localized in the sigmoid region, ileocecal zone, hepatic and splenic flexures of the colon. Pain can be triggered by eating, without a clear connection with its nature, can begin immediately after waking up, intensify before and decrease after defecation, passing gas, or taking antispasmodics. An important feature of the pain syndrome in IBS is the absence of pain at night, as well as during rest;

Feeling of increased peristalsis;

Disturbances in the act of defecation in the form of constipation/diarrhea, unstable stool or pseudodiarrhea (acts of defecation are frequent or accelerated with normal stool) and pseudoconstipation (a feeling of incomplete evacuation even with normal stool, unproductive urge to defecate). In IBS with diarrhea, the frequency of stools is, on average, 3-5 times a day with a relatively small volume of feces (the total mass of feces does not exceed 200 g per day). Frequent loose stools may be observed only in the morning (after eating - “morning onslaught syndrome” (or “gastrocolytic reflex”) without further disorders during the day. There may also be an imperative (urgent) urge to defecate without passing feces. Diarrhea often occurs under stress (“bear disease”), overwork. But diarrhea never occurs at night. With IBS with constipation, patients are forced to strain more than 25% of the time they defecate, they often have no urge to defecate, which forces them to use enemas or laxatives. – 2 times a week or less. The stool resembles the shape of “sheep feces” or has a ribbon-like shape (in the form of a pencil). It must be remembered that the same patient may have alternating diarrhea and constipation.

The presence of “extraintestinal” symptoms - symptoms of a neurological and autonomic nature (in the absence of any subjective manifestations of the disease at night):

Pain in the lumbar region;

Feeling of a lump in the throat;

Frequent urination, nocturia and other dysuria;

Fatigue, etc.;

Cancerophobia (noted in more than half of patients).

Criteria confirming the diagnosis of IBS are:

Altered bowel movements: either less than 3 bowel movements per week or more than 3 bowel movements per day;

Changed stool shape: hard stools or loose, watery stools;

Passage disturbance (straining during bowel movements) and/or a feeling of incomplete bowel movement;

Urgency to have a bowel movement or a feeling of incomplete bowel movement;

Discharge of mucus, bloating, feeling of fullness in the abdomen.

The presence of pain and diarrhea at night, “alarm symptoms” (“red flags”): blood in the stool, fever, unmotivated weight loss, anemia, increased ESR, indicating an organic disease.

When collecting anamnesis, it is necessary to pay special attention to the time of onset of the first symptoms of the disease - as a rule, the disease begins at a young age, so the first appearance of IBS symptoms in old age makes the diagnosis of IBS doubtful. In addition, it is necessary to find out whether there is a history of psychotrauma, nervous strain, or stress.

Particular attention should be paid to the relative stability of clinical symptoms, their stereotypicality and connection with neuropsychic factors.

Also, symptoms that cast doubt on the diagnosis of IBS include a family predisposition - the presence of colon cancer in close relatives.

On physical examination, the picture is uninformative. Most often, one can note the emotional lability of the patient; palpation of the abdomen reveals an area of ​​spastic and painful compaction of the intestine and its increased peristalsis.

Mandatory laboratory tests

Clinical blood and urine tests (without deviations from the norm) - once;

Blood sugar (within normal limits) – once;

Liver tests (AST, ALT, ALP, GGT) (within normal values) – once;

Stool analysis for dysbacteriosis (mild or moderate dysbiotic changes may be observed) - once;

Fecal analysis for eggs and segments of helminths (negative) - once;

Coprogram (absence of steatorrhea, polyfecal matter) – once;

Fecal occult blood test (absence of hidden blood in stool) - once.

Mandatory instrumental studies

Sigmoidoscopy – to exclude organic diseases of the distal parts of the colon – once;

Colonoscopy (if necessary, biopsy of the intestinal mucosa) – to exclude organic diseases of the colon – once;

Ultrasound of the digestive and pelvic organs - to exclude pathology of the biliary system (cholelithiasis), pancreas (the presence of cysts and calcifications in the pancreas), space-occupying formations in the abdominal cavity and in the retroperitoneal space - once.

It should be remembered that the diagnosis of IBS is a diagnosis of exclusion. That is, the diagnosis of IBS is established by excluding clinical and laboratory-instrumental signs of the above diseases, accompanied by symptoms similar to IBS.

Additional laboratory and instrumental follow-ups

To exclude pathology of the thyroid gland, the content of thyroid hormones in the blood (T 3, T 4) is examined; to exclude pathology of the pancreas, a stool test for elastase-1 is performed.

If necessary, a test for lactase and disaccharide deficiency is carried out (prescription of an elimination diet for 2 weeks that does not contain milk and its products, sorbitol (chewing gum)).

If there are indications, to exclude organic changes in the colon, intestinal radiography (irrigoscopy), computed tomography and magnetic resonance therapy are performed.

Psychotherapist/neurologist (to prescribe etiopathogenetic therapy);

Gynecologist (to exclude gynecological pathology);

Urologist (to exclude pathologies of the urinary system);

Physiotherapist (to prescribe etiopathogenetic therapy).

If indicated:

Treatment

Achieving complete remission (relief of disease symptoms or a significant reduction in their intensity, normalization of stool and laboratory parameters), or partial remission (improvement of well-being without significant positive dynamics in objective data).

Inpatient treatment – ​​up to 14 days upon initial treatment, followed by continued treatment on an outpatient basis. Outpatient repeated courses of treatment are carried out upon request. Patients are subject to annual examination and examination in an outpatient setting.

Treatment of patients with IBS involves general measures - recommendations to avoid neuro-emotional overstrain, stress, etc., including showing the patient the results of studies indicating the absence of severe organic pathology.

Dietary recommendations are based on a syndromological principle (predominance of constipation, diarrhea, pain, flatulence). In general, the diet should contain an increased amount of protein and exclude refractory fats, limit carbonated drinks, citrus fruits, chocolate, vegetables rich in essential oils (radishes, radishes, onions, garlic).

If constipation predominates, you should limit fresh white bread, pasta, slimy soups, and excessive amounts of cereals. Products containing fiber, vegetable dishes, fruits (baked and dried apples, dried apricots, apricots, prunes) are shown. We recommend mineral waters “Essentuki No. 17”, “Slavyanovskaya” and others at room temperature, 1 glass 3 times a day, one minute before meals, in large sips and at a fast pace.

If diarrhea predominates, include in the diet tannin-containing products (blueberries, strong tea, cocoa), dried bread, warm mineral waters “Essentuki No. 4”, “Mirgorodskaya”, “Berezovskaya” (45-55 ° C) 3 once a day, before meals, in small sips and at a slow pace.

For pain combined with flatulence, cabbage, legumes, and fresh black bread are excluded from the diet.

The choice of drug treatment tactics depends on the leading symptom (pain, flatulence, diarrhea, constipation) and the psychological state of the patient.

In patients with IBS with pain, the following is used:

Selective myotropic antispasmodics (orally, parenterally): mebeverine 200 mg 2 times a day for days, pinaverium bromide 100 mg

3 times a day for 7 days, then - 50 mg 4 times a day for 10 days, drotaverine 2 ml intramuscularly 2 times a day (to relieve severe spastic pain);

Selective neurotropic antispasmodics – priphinium bromide pomg per day;

With a combination of pain and increased gas formation in the intestines:

a) antifoam agents (simethicone, dimethicone) – 3 capsules 3 times a day for 7 days, then – 3 capsules 2 times a day for 7 days, then – 3 capsules 1 time a day for 7 days;

b) meteospasmil – 1 capsule 3 times a day for 10 days.

For IBS with diarrhea the following is prescribed:

M-opiate receptor agonists – loperamide 2 mg 1-2 times a day;

Antagonists of 5-HT3-serotonin receptors - sturgeon 8 ml intravenously in a bolus of 10 ml of 0.9% isotonic sodium chloride solution for 3-5 days, then orally 4 mg 2 times a day or 8 mg 1 time per day during the day;

Cholestyramine up to 4 g per day with meals.

For constipation in patients with IBS, the following is prescribed:

Serotonin 5-HT4 receptor agonists: mosapride citrate 2.5 mg and 5 mg orally 3 times a day after meals, course of treatment – ​​3-4 weeks;

Peristalsis stimulants: metoclopramide or domperidone 10 mg 3 times a day;

Laxatives – lactulose poml 1-2 times a day, forlax

1-2 sachets per day at the end of meals every morning, Senadexin 1-3 tablets

1-2 times a day, bisacodyl 1-2 tablets 1-2 times a day or 1 suppository per rectum before bedtime, guttalax drops before bedtime, mucofalk 1-2 sachets 1-2 times a day, softovak 1-2 tea spoons at night, docusate sodium 0.12 g per rectum in the form of microenemas if the patient has the urge to defecate (the laxative effect occurs 5-20 minutes after administration of the drug into the rectum). Castor, Vaseline and olive oils are also used;

Combined enzyme preparations containing bile acids and hemicellulase (festal, digestal, enzistal) - 1-3 tablets with meals or immediately after meals 3-4 times a day, course - up to 2 months.

For increased anxiety, the following are prescribed:

Tricyclic antidepressants - amitriptyline, doxepin. Start with a dose

10-25 mg/day, gradually increasing it to 50 (150) mg/day, course of treatment – ​​6-12 months;

Anxiolytics (improves sleep quality, normalizes psychovegetative symptoms typical of neuroses and psychosomatic pathologies) - etifoxine 50 mg 2-3 times a day, course of treatment - 2-3 weeks;

Serotonin reuptake inhibitors (increase the bioavailability of 5-HT receptors, improve bowel movements in IBS with diarrhea, reduce abdominal pain): sulpiridmg 2-3 times a day, fevarin 1-2 tablets

2-3 times a day.

Additionally (if necessary), antacids (Maalox, Almagel, etc.) - diosmectite 3 g 3 times a day, sorbents (activated carbon, enterosgel, polyphepan, etc.) and probiotics can be prescribed.

Physiotherapeutic methods of treatment (reflexotherapy, electro- (diadynamic currents, amplipulse) and laser treatment, balneotherapy (warm baths, ascending and circular shower, contrast shower)).

In general, the prognosis for life is favorable, since IBS does not tend to progress. However, the prognosis of the disease largely depends on the severity of accompanying psychological manifestations.

Prevention

Prevention of IBS, first of all, should include measures to normalize lifestyle and diet, and avoid unnecessary use of drugs. Patients with IBS must set their own daily routine, including eating, exercising, working, social activities, housework, etc.

Irritable bowel syndrome

Irritable bowel syndrome (IBS) is a functional disease of the gastrointestinal tract, characterized by pain and/or discomfort in the abdomen that goes away after defecation.

These symptoms are accompanied by changes in stool frequency and consistency and are combined with at least two persistent symptoms of bowel dysfunction:

• change in stool frequency (more than 3 times a day or less than 3 times a week);
• changes in stool consistency (lumpy, hard stool or watery stools);
• change in the act of defecation;
• imperative urges;
• feeling of incomplete bowel movement;
• the need for additional effort during bowel movements;
• secretion of mucus in feces;
• bloating, flatulence;
• rumbling in the stomach.

The duration of these disorders must be at least 12 weeks over the past 12 months. Among defecation disorders, special importance is attached to urgency, tenesmus, a feeling of incomplete bowel movement, and additional effort during defecation (Roman criteria II).

The cause is unknown and the pathophysiology is not fully understood. The diagnosis is made clinically. Treatment is symptomatic, consisting of dietary nutrition and drug therapy, including anticholinergic drugs and substances that activate serotonin receptors.

Irritable bowel syndrome is a diagnosis of exclusion, i.e. its establishment is possible only after excluding organic diseases.

ICD-10 code

K58 Irritable bowel syndrome.

ICD-10 code

Epidemiology of irritable bowel syndrome

Irritable bowel syndrome is especially common in industrialized countries. According to world statistics, from 30 to 50% of patients visiting gastroenterology offices suffer from irritable bowel syndrome; It is estimated that 20% of the world's population has symptoms of irritable bowel syndrome. Only 1/3 of patients seek medical help. Women get sick 2-4 times more often than men.

After 50 years, the ratio of men to women approaches 1:1. The occurrence of the disease after 60 years of age is doubtful.

What causes irritable bowel syndrome?

The cause of irritable bowel syndrome (IBS) is unknown. No pathological cause was found. Emotional factors, diet, medications or hormones can accelerate and aggravate gastrointestinal symptoms. Some patients experience anxiety states (especially panic, major depressive syndrome and somatization syndrome). However, stress and emotional conflict do not always coincide with the onset of the disease and its relapse. Some patients with irritable bowel syndrome exhibit symptoms defined in the scientific literature as symptoms of atypical pain behavior (i.e., they express emotional conflict in the form of complaints of gastrointestinal disorders, usually abdominal pain). Clinicians assessing patients with irritable bowel syndrome, especially those who are treatment-resistant, should explore unresolved psychological problems, including the possibility of sexual or physical abuse.

There are no permanent motor impairments. Some patients experience impaired gastrocolic reflex with delayed, prolonged colonic activity. In this case, there may be a delay in gastric emptying or impaired motility of the jejunum. In some patients, no objectively proven abnormalities are found, and in those cases where abnormalities have been identified, there may be no direct correlation with symptoms. The passage through the small intestine changes: sometimes the proximal segment of the small intestine shows hyperreactivity to food or to parasympathomimetics. A study of the intraintestinal pressure of the sigmoid colon showed that functional stool retention can be combined with hyperreactive segmentation of the haustra (i.e., increased frequency and amplitude of contractions). In contrast, diarrhea is associated with decreased motor function. Thus, strong contractions may at times speed up or delay the passage.

Excess mucus production, which is often observed in irritable bowel syndrome, is not associated with damage to the mucous membrane. The reason for this is unclear but may be related to cholinergic hyperactivity.

There is hypersensitivity to normal distension and enlargement of the intestinal lumen, as well as increased pain sensitivity with normal accumulation of gas in the intestine. The pain is most likely caused by abnormally strong contractions of intestinal smooth muscle or increased sensitivity of the intestine to distension. Hypersensitivity to the hormones gastrin and cholecystokinin may also be present. However, hormonal fluctuations do not correlate with symptoms. High-calorie foods can lead to an increase in the magnitude and frequency of electrical activity of smooth muscles and gastric motility. Fatty foods can cause a delayed peak in motor activity, which can be significantly increased in irritable bowel syndrome. The first few days of menstruation can lead to a transient increase in prostaglandin E2, which most likely stimulates increased pain and diarrhea.

Symptoms of irritable bowel syndrome

Irritable bowel syndrome tends to begin in adolescents and young adults, with symptoms that occur intermittently and intermittently. Development of the disease in adults is not uncommon, but it is uncommon. Symptoms of irritable bowel syndrome rarely occur at night and can be triggered by stress or food intake.

Features of irritable bowel syndrome include abdominal pain associated with delayed bowel movements, changes in stool frequency or consistency, bloating, mucus in the stool, and a sensation of incomplete emptying of the rectum after a bowel movement. In general, the nature and location of pain, provoking factors and the nature of stool are different for each patient. Changes or deviations from usual symptoms suggest intercurrent illness and these patients should undergo a full evaluation. Patients with irritable bowel syndrome may also experience extraintestinal symptoms of irritable bowel syndrome (eg, fibromyalgia, headaches, dysuria, temporomandibular joint syndrome).

Two main clinical types of irritable bowel syndrome have been described.

In irritable bowel syndrome with predominant stool retention (irritable bowel syndrome with predominant constipation), most patients experience pain in more than one area of ​​the large intestine with periods of stool retention alternating with normal frequency. The stool often contains clear or white mucus. The pain has a paroxysmal nature, like colic, or a constant aching pain; pain may decrease after defecation. Eating usually triggers symptoms. Bloating, frequent passing of gas, nausea, indigestion and heartburn may also occur.

Diarrhea-predominant irritable bowel syndrome is characterized by urgency diarrhea that develops immediately during or after eating, especially when eating quickly. Nocturnal diarrhea is rare. Pain, bloating and a sudden urge to stool are typical, and stool incontinence may develop. Painless diarrhea is uncommon and should prompt the physician to consider other possible causes (eg, malabsorption, osmotic diarrhea).

Where does it hurt?

What's troubling?

Diagnosis of irritable bowel syndrome

Hyperthyroidism, carcinoid syndrome, medullary thyroid cancer, VIPoma, and Zollinger-Ellison syndrome are additional possible causes of diarrhea in patients. The bimodal age distribution of patients with inflammatory bowel disease allows us to evaluate groups of younger and older patients. In patients over 60 years of age, ischemic colitis should be excluded. Patients with stool retention and no anatomical cause should be evaluated for hypothyroidism and hyperparathyroidism. If symptoms suggest malabsorption, sprue, celiac disease, and Whipple's disease, further evaluation is necessary. Cases of stool retention in patients with complaints of the need for strong straining during bowel movements (eg, dysfunction of the pelvic floor muscles) require examination.

Anamnesis

Particular attention should be paid to the nature of the pain, bowel characteristics, family history, medications used and diet. It is also important to assess the patient's individual problems and emotional status. Physician patience and persistence is the key to effective diagnosis and treatment.

Based on the symptoms, the Rome criteria for diagnosing irritable bowel syndrome have been developed and standardized; The criteria are based on the presence for at least 3 months of the following:

1. abdominal pain or discomfort that improves after bowel movements or is associated with a change in stool frequency or consistency,
2. a defecation disorder characterized by at least two of the following: a change in the frequency of stools, a change in the shape of the stool, a change in the character of the stool, the presence of mucus and bloating or a feeling of incomplete emptying of the rectum after a bowel movement.

Physical examination

In general, the patients' condition is satisfactory. Palpation of the abdomen may reveal tenderness, especially in the left lower quadrant, associated with palpation of the sigmoid colon. All patients should have a digital rectal examination, including a stool occult blood test. In women, a pelvic examination (bimanual vaginal examination) helps rule out ovarian tumors and cysts or endometriosis, which may mimic irritable bowel syndrome.

Instrumental diagnosis of irritable bowel syndrome

It is necessary to perform proctosigmoidoscopy with a flexible endoscope. Insertion of the sigmoidoscope and air insufflation often cause intestinal spasm and pain. The mucous membrane and vascular pattern in irritable bowel syndrome are usually not changed. Colonoscopy is preferable in patients over 40 years of age with complaints suggesting changes in the colon and especially in patients without previous symptoms of irritable bowel syndrome in order to exclude polyposis and colon tumors. In patients with chronic diarrhea, especially older women, a mucosal biopsy can rule out possible microscopic colitis.

Many patients with irritable bowel syndrome tend to be over-diagnosticized. In patients whose clinical presentation meets the Rome criteria but who do not have any other symptoms or signs suggestive of other pathology, laboratory results do not influence the diagnosis. If the diagnosis is in doubt, the following tests should be performed: complete blood count, ESR, biochemical blood test (including liver function tests and serum amylase), urinalysis, and determine the level of thyroid-stimulating hormone.

Additional Research

Intercurrent illness

The patient may develop other gastrointestinal disorders that are not characteristic of irritable bowel syndrome, and the clinician should take these complaints into account. Changes in symptoms (eg, location, nature, or intensity of pain; bowel condition; palpable stool retention and diarrhea) and the appearance of new signs or complaints (eg, nocturnal diarrhea) may indicate the presence of another disease. New symptoms that may require further investigation include: fresh blood in the stool, weight loss, severe abdominal pain or unusual abdominal enlargement, steatorrhea or foul-smelling stools, fever, chills, persistent vomiting, hematomesis, symptoms that interfere with sleep (eg, pain, urge to stool), as well as persistent progressive deterioration of the condition. Patients over 40 years of age are more likely to develop somatic pathology than younger ones.

What needs to be examined?

Who should I contact?

Treatment of irritable bowel syndrome

Treatment of irritable bowel syndrome is symptomatic and palliative. Compassion and psychotherapy are of utmost importance. The doctor must explain the main reasons and convince the patient of the absence of somatic pathology. This involves explaining normal bowel physiology, paying particular attention to bowel hypersensitivity and the effects of food or medication. Such explanations form the basis for prescribing regular, standard, but individualized therapy. The prevalence, chronic nature and need for continued treatment should be emphasized.

If psychological stress, anxiety or mood changes occur, an assessment and appropriate therapy are necessary. Regular physical activity helps reduce tension and improve bowel function, especially in patients with bowel retention.

Nutrition and irritable bowel syndrome

In general, normal nutrition should be maintained. Food should not be excessively plentiful, and meals should be leisurely and measured. Patients with abdominal bloating and increased gas formation should limit or eliminate the consumption of beans, cabbage and other foods containing carbohydrates that are amenable to microbial intestinal fermentation. Reducing your intake of apples and grape juice, bananas, nuts and raisins may also reduce flatulence. Patients with signs of lactose intolerance should reduce their intake of milk and dairy products. Intestinal dysfunction may be caused by ingestion of foods containing sorbitol, mannitol or fructose. Sorbitol and mannitol are artificial sugar substitutes used in diet foods and chewing gum, while fructose is a common element in fruits, berries and plants. A low-fat, high-protein diet may be recommended for patients with postprandial abdominal pain.

Dietary fiber may be effective due to water absorption and stool softening. It is indicated for patients with stool retention. Soft stool-forming substances may be used [eg, raw bran, starting with 15 ml (1 tablespoon) at each meal, increasing fluid intake]. Alternatively, hydrophilic psyllium mucilloid can be used with two glasses of water. However, excessive use of fiber can lead to bloating and diarrhea. Therefore, the amount of fiber should be adapted to individual needs.

Drug treatment of irritable bowel syndrome

Drug treatment for irritable bowel syndrome is not recommended, except for short-term use during periods of exacerbation. Anticholinergic drugs (eg, hyoscyamine 0.125 mg minutes before meals) can be used as antispastic agents. Newer selective M muscarinic receptor antagonists, including zamifenacin and darifenacin, have fewer cardiac and gastric side effects.

Modulation of serotonin receptors may be effective. The 5HT4 receptor agonists tegaserod and prucalopride may be effective in patients with stool retention. 5HT4 receptor antagonists (eg, alosetron) may benefit patients with diarrhea.

Patients with diarrhea can be given oral diphenoxylate 2.5-5 mg or loperamide 2-4 mg before meals. However, the constant use of antidiarrheal drugs is undesirable due to the development of drug tolerance. In many patients, tricyclic antidepressants (eg, desipramine, imizine, amitriptyline mg orally once daily) reduce symptoms of stool retention and diarrhea, abdominal pain, and flatulence. These medications are thought to reduce pain through postregulatory activation of the spinal cord and cortical afferents from the gut. Finally, certain aromatic oils can relieve irritable bowel syndrome by promoting the passage of gas, helping to relieve spasms of smooth muscles and reducing pain in some patients. Peppermint oil is the most commonly used drug in this group.

More information about treatment

Medicines

Medical Expert Editor

Portnov Alexey Alexandrovich

Education: Kyiv National Medical University named after. A.A. Bogomolets, specialty - “General Medicine”

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Irritable bowel syndrome

ICD-10 code

Associated diseases

Symptoms

You are more likely to have IBS if symptoms began at least 6 months ago, abdominal pain or discomfort has continued for at least 3 days in the past 3 months, and at least two of the following statements are true:

*Pain decreases after defecation.

*Pain varies depending on the frequency of bowel movements.

*Pain varies depending on the appearance and consistency of the stool.

*The presence of any of the following symptoms supports the diagnosis of IBS.

With IBS, the pattern of bowel movements may change over time. Two or more of the following conditions may be present:

*Stools more often (diarrhea) or less frequently (constipation) than normal, that is, more than 3 times a day or less than 3 times a week.

*Changes in stool volume and consistency (hard and granular, thin, or loose and watery).

*Changes in the process of defecation. In this case, there may be a strong urge to defecate or a feeling of incomplete bowel movement.

*Bloating with gases (flatulence), sometimes increased release of gases (flatulence).

Other intestinal symptoms:

Some patients complain of pain in the lower abdomen and constipation followed by diarrhea. Others experience pain and mild constipation, but no diarrhea. Sometimes symptoms include gas buildup in the intestines and mucus in the stool.

*General anxiety, melancholy up to depression, frequent mood swings.

*Unpleasant taste in the mouth.

*Sleep disorders (insomnia) not caused by IBS symptoms.

*Sexual disorders, such as pain during intercourse or decreased sex drive.

*Feeling of interruptions in the heart (a feeling of fading or fluttering of the heart).

*Disorders of urination (frequent or strong urge, difficulty starting urination, incomplete emptying of the bladder).

Symptoms often occur after eating, occur and worsen in stressful situations and experiences, and intensify during menstruation.

Symptoms similar to those of IBS occur in many other diseases.

Differential diagnosis

If the disease began in old age.

If symptoms progress.

If acute symptoms appear, IBS is not acute, it is a chronic disease.

Symptoms appear at night.

Loss of body weight, loss of appetite.

Bleeding from the anus.

Steatorrhea (fat in stool).

High body temperature.

Fructose and lactose intolerance (lactase deficiency), gluten intolerance (symptoms of celiac disease).

Presence of inflammatory diseases or bowel cancer in relatives.

Reasons

For some people with this syndrome, pain and other symptoms may be triggered by poor diet, stress, lack of sleep, hormonal changes in the body and the use of certain types of antibiotics. Chronic stress plays an important role, since IBS often develops after prolonged stress and anxiety.

Treatment

Diet. The diet allows you to exclude conditions that mimic IBS (lactose and fructose intolerance). Reduce gas formation and bloating, as well as the discomfort associated with it. But today there is no evidence that people with IBS should completely exclude any foods from their diet.

Plant fiber supplementation has similar efficacy to placebo and has not been shown to be effective in patients complaining of abdominal pain and constipation. British guidelines recommend a fiber intake of 12 grams per day, as higher amounts may be associated with the onset of clinical symptoms of IBS.

Psychotherapy. Psychotherapy, hypnosis, and the biofeedback method can reduce the level of anxiety, reduce the patient’s tension and more actively involve him in the treatment process. At the same time, the patient learns to react differently to a stress factor and increases tolerance to pain.

Drug treatment for IBS targets the symptoms that prompt patients to seek medical attention or cause them the most discomfort. Therefore, treatment of IBS is symptomatic and many groups of pharmaceutical drugs are used.

Antispasmodic drugs show short-term effectiveness and do not show sufficient effectiveness with long courses of use. Recommended for use in patients with flatulence and imperative urge to defecate. The analysis showed that antispasmodic drugs were more effective than placebo. Their use is considered optimal for reducing abdominal pain in IBS in a short course. Among the drugs in this group, the most commonly used are dicyclomine and hyoscyamine.

Means aimed at combating dysbiosis. Quite often the cause of irritable bowel syndrome is dysbiosis. Treatment of flatulence, bloating, colic and other symptoms of dysbacteriosis should work in two directions: eliminating the symptoms of bloating, as well as restoring and maintaining the balance of intestinal microflora. Among the agents that have both of these actions at once, Redugaz is distinguished. Simethicone, one of the components contained in the composition, combats abdominal discomfort and delicately frees the intestines from gas bubbles, weakening their surface tension throughout the intestine. The second component, prebiotic Inulin, helps prevent the re-formation of gases and restores the balance of beneficial bacteria necessary for normal digestion. Inulin inhibits the growth of bacteria that cause gas, so re-bloating does not occur. Another plus is that the product is available in a convenient form in the form of chewable tablets and has a pleasant mint taste.

Antidepressants are prescribed to patients with neuropathic pain. Tricyclic antidepressants can slow down the transit time of intestinal contents, which is a beneficial factor in the diarrheal form of IBS.

A meta-analysis of the effectiveness of antidepressants showed a decrease in clinical symptoms when taking them, and their greater effectiveness compared to placebo. Amitriptyline is most effective in adolescents suffering from IBS. The dosage of antidepressants for the treatment of IBS is lower than for the treatment of depression. Antidepressants should be prescribed with extreme caution to patients who tend to experience constipation. Published results on the effectiveness of other groups of antidepressants are contradictory.

Antidiarrheal drugs. The use of loperamide for the treatment of diarrhea in IBS has not been analyzed using standardized criteria. But available data showed it to be more effective than placebo. Contraindications to the use of loperamide are constipation in IBS, as well as intermittent constipation and diarrhea in patients with IBS.

Benzodiazepines have limited use in IBS due to a number of side effects. Their use can be effective in short courses to reduce mental reactions in patients that lead to exacerbation of IBS.

Type 3 serotonin receptor blockers help reduce abdominal pain and discomfort.

Activators of type 4 serotonin receptors - used for IBS with constipation. The effectiveness of lubiprostone (a drug in this group) was confirmed by two placebo-controlled studies.

Guanylate cyclase activators in patients with IBS are useful for constipation. Preliminary studies show their effectiveness in increasing bowel frequency in IBS patients with constipation.

Antibiotics can reduce bloating, presumably by inhibiting gas-forming intestinal flora. However, there is no evidence that antibiotics reduce abdominal pain or other symptoms of IBS. There is also no evidence that bacterial overgrowth causes IBS.

Alternative therapies for IBS include herbal remedies, probiotics, acupuncture and enzyme supplementation. The role and effectiveness of alternative treatments for IBS remains uncertain.

Guidelines for the treatment of irritable bowel syndrome (IBS)

Functional diseases of the digestive system, which include irritable bowel syndrome, continue to attract the inexhaustible interest of doctors of various specialties, microbiologists, geneticists and molecular biologists.

Analysis of the results of recent studies conducted in different countries, including Russia, suggests that it is biological changes, such as changes or loss of function of individual proteins, the uniqueness of the qualitative and quantitative composition of the microflora of the gastrointestinal tract, and not emotional disorders, perhaps serve as the root cause of the formation of symptoms in such patients.

Throughout the history of the study of functional disorders, the emergence of new knowledge about the pathogenesis entailed the use of new groups of drugs to relieve symptoms. This was the case when determining the role of muscle spasm, when drugs that normalized motor skills began to be widely used; visceral hypersensitivity, which led to the prescription of peripheral opioid receptor agonists to patients; emotional disorders, which made the use of psychotropic drugs justified, and a similar situation occurred with the study in patients suffering from irritable bowel syndrome, the cytokine profile, the structure and function of proteins of tight cell junctions, proteins of signaling receptors that bring the human body into contact with bacteria living in the lumen intestines, as well as studying the diversity of microbial cells.

Based on the data obtained, it becomes completely obvious the need and justification for prescribing probiotics to patients with functional intestinal disorders, drugs that can influence the motor activity of the intestine, suppress inflammation of the intestinal wall, take part in the synthesis of short-chain fatty acids, and restore the optimal composition of the intestinal microflora.

I would like to hope that the study of terra incognita, which includes functional disorders of the gastrointestinal tract, will be continued, and in the near future we will have a reasonable opportunity to prescribe even more effective treatment regimens to our patients.

Academician of the Russian Academy of Medical Sciences, Professor Ivashkin V.T.

IRRITABLE BOWEL SYNDROME

(irritable bowel syndrome, irritable bowel syndrome).

According to the Rome III criteria, irritable bowel syndrome (IBS) is defined as a complex of functional bowel disorders that includes abdominal pain or discomfort, relieved by defecation, associated with changes in bowel frequency and stool consistency, occurring for at least 3 days per month. for 3 months in the six months preceding diagnosis.

K 58.0 Irritable bowel syndrome with diarrhea. 58.9 Irritable bowel syndrome without diarrhea.

Globally, 10–20% of the adult population suffers from IBS. Two thirds of people suffering from this disease do not go to doctors due to the sensitive nature of the complaints. The peak incidence occurs in young working age - 30–40 years. The average age of patients is 24–41 years. The ratio of women to men is 1:1–2:1. Among men of “problem” age (after 50 years), IBS is as common as among women.

There are four possible variants of IBS:

• IBS with constipation (≥25% hard or fragmented stool, loose or watery stool<25% всех актов дефекации).
• IBS with diarrhea (loose or watery stools ≥25%, hard or fragmented stools<25% всех актов дефекации)
• mixed form of IBS (hard or fragmented stool in ≥25%, loose or watery stool in ≥25% of all bowel movements).
• unclassified form of IBS (insufficient change in stool consistency to establish a diagnosis of IBS with constipation, IBS with diarrhea, or mixed form of IBS).

This classification is based on the shape of the stool according to the Bristol scale, since a direct relationship has been identified between the time of passage through the intestine and the consistency of the stool (the longer the transit time of the contents, the denser the stool).

Bristol Chair Shape Scale

• Isolated solid fragments.
• The chair is decorated, but fragmented.
• The chair is decorated, but has an uneven surface.
• The chair is shaped or serpentine, with a smooth and soft surface.
• Soft fragments with smooth edges.
• Unstable fragments with jagged edges.
• Watery stools without solid particles, colored liquid.

Etiology

A direct dependence of the onset of the disease on the presence of stressful situations in the patient’s life has been proven. A psychotraumatic situation can be experienced in childhood (loss of one of the parents, sexual abuse), several weeks or months before the onset of the disease (divorce, bereavement), or occur in the form of chronic social stress at the present time (serious illness of a loved one ).

Personality traits can be genetically determined or shaped by the environment. Such features include the inability to distinguish between physical pain and emotional experiences, difficulties in verbally formulating sensations, high levels of anxiety, and a tendency to transfer emotional stress into somatic symptoms (somatization).

Studies devoted to the role of genetic predisposition in the pathogenesis of functional disorders generally confirm the role of genetic factors in the development of the disease, without at all diminishing the role of environmental factors.

Past intestinal infection

Studies devoted to the study of IBS have shown that the post-infectious form occurs in 6–17% of all cases of the disease; 7–33% of patients who have suffered an acute intestinal infection subsequently suffer from symptoms of IBS. In most cases (65%), the post-infectious form of the disease develops after a previous shigellosis infection, and in 8.7% of patients it is associated with an infection caused by Campylobacter jejuni.

PATHOGENESIS

According to modern concepts, IBS is a biopsychosocial disease. Psychological, social and biological factors take part in its formation, the combined influence of which leads to the development of visceral hypersensitivity, impaired intestinal motility and slower passage of gases through the intestine, which manifests itself as symptoms of the disease (abdominal pain, flatulence and stool disorders).

In recent years, based on research, a lot of information has been obtained regarding the biological changes that contribute to the formation of symptoms of the disease. For example, it has been proven that the permeability of the intestinal wall increases due to disruption of the expression of proteins that form tight cellular junctions between epithelial cells; changes in the expression of signaling receptor genes, including those responsible for recognizing elements of the bacterial cell wall (toll-like receptors, TLR); disruption of the cytokine balance in the direction of increasing the expression of pro-inflammatory and decreasing the expression of anti-inflammatory cytokines, resulting in the formation of an excessively strong and prolonged inflammatory response to the infectious agent; In addition, elements of inflammation are found in the intestinal wall of patients suffering from IBS. The difference in the qualitative and quantitative composition of the intestinal microflora in patients suffering from IBS and healthy individuals can also be considered proven. Under the influence of the combined influence of all of the above factors, such patients develop an increased sensitivity of nociceptors of the intestinal wall, the so-called peripheral sensitization, which consists in their spontaneous activity, a decrease in the threshold of excitation and the development of increased sensitivity to subthreshold stimuli. Next, the process of transforming information about the presence of inflammation into an electrical signal occurs, which is carried along sensitive nerve fibers to the central nervous system (CNS), in the structures of which foci of pathological electrical activity arise, and therefore the signal arriving through efferent neurons to the intestine is redundant , which can manifest itself as various motor impairments.

The multi-level mechanism of the formation of symptoms in patients with IBS presupposes a comprehensive pathogenetic approach to its treatment, which includes an impact on all stages of their formation.

CLINICAL PICTURE

Clinical manifestations of IBS have received detailed coverage in the works of domestic and foreign scientists. Clinical forms of the disease, possible combinations of intestinal and extraintestinal symptoms, and symptoms of “anxiety” that exclude the diagnosis of IBS are described in great detail. According to the literature, complaints made by patients with IBS can be divided into three groups:

• intestinal;
• related to other parts of the gastrointestinal tract;
• non-gastroenterological.

Each individual group of symptoms is not so important in diagnostic terms, however, the totality of symptoms belonging to the three groups listed above, combined with the absence of organic pathology, makes the diagnosis of IBS very likely.

Intestinal symptoms in IBS have a number of features.

The patient can characterize the pain experienced as vague, burning, dull, aching, constant, stabbing, twisting. The pain is localized mainly in the iliac regions, often on the left. “Splenic curvature syndrome” is also known - the occurrence of pain in the area of ​​the left upper quadrant when the patient is standing and relieved by lying down with the buttocks raised. The pain usually intensifies after eating, decreases after defecation, passing gas, or taking antispasmodic drugs. In women, pain increases during menstruation. An important distinguishing feature of the pain syndrome in IBS is the absence of pain at night.

The feeling of bloating is less pronounced in the morning, increases during the day, and intensifies after eating.

Diarrhea usually occurs in the morning, after breakfast, the frequency of stool varies from 2 to 4 or more times in a short period of time, often accompanied by urgency and a feeling of incomplete bowel movement. Often, during the first act of defecation, the stool is denser than during subsequent ones, when the volume of intestinal contents is reduced, but the consistency is more liquid. The total daily weight of feces does not exceed 200 g. There is no diarrhea at night.

With constipation, it is possible to pass “sheep” feces, “pencil-shaped” feces, as well as plug-like stools (discharge of dense, shaped feces at the beginning of defecation, then pasty or even watery feces). The stool does not contain any blood or pus, but mucus in the stool is a fairly common complaint among patients suffering from irritable bowel syndrome.

The clinical symptoms listed above cannot be considered specific to IBS, since they can also occur in other intestinal diseases; however, with this disease, a combination of intestinal symptoms with complaints related to other parts of the gastrointestinal tract, as well as non-gastroenterological complaints, is quite common.

At the end of the last century, a study was conducted in the USA, according to the results of which 56% of patients diagnosed with IBS had symptoms of a functional disorder of the esophagus, 37% of patients had signs of functional dyspepsia, and 41% of patients had symptoms of functional anorectal disorders.

Non-gastroenterological symptoms such as headache, feeling of internal trembling, back pain, feeling of incomplete inspiration very often come to the fore and play a major role in reducing the quality of life of a patient suffering from IBS. The authors of publications devoted to the clinical manifestations of irritable bowel syndrome draw attention to the discrepancy between the large number of complaints, the long course of the disease and the satisfactory general condition of the patient.

DIAGNOSTICS

Collecting a life history and medical history is extremely important for making a correct diagnosis. When questioning, they clarify the patient’s living conditions, family composition, health status of relatives, features of professional activity, violations of the diet and nature of nutrition, and the presence of bad habits. For the history of the disease, it is important to establish a connection between the occurrence of clinical symptoms and the influence of external factors (nervous stress, previous intestinal infections, the patient’s age at the onset of the disease, the duration of the disease before the first visit to the doctor, previous treatment and its effectiveness).

During a physical examination of the patient, the detection of any abnormalities (hepatosplenomegaly, edema, fistulas, etc.) argues against the diagnosis of IBS.

A mandatory component of the IBS diagnostic algorithm is laboratory (general and biochemical blood tests, scatological examination) and instrumental studies (ultrasound of the abdominal organs, endoscopy, colonoscopy in older people). If diarrhea predominates in the clinical picture of the disease, it is advisable to include in the patient’s examination plan a stool test to identify toxins A and B of Clostridium difficile, Shigella, Salmonella, Yersinia, dysenteric amoeba, and helminths.

Differential diagnosis of IBS is carried out with the following conditions.

• Reactions to food (caffeine, alcohol, fats, milk, vegetables, fruits, brown bread, etc.), large meals, changes in eating habits.
• Reactions to taking medications (laxatives, iron supplements, antibiotics, bile acid preparations).
• Intestinal infections (bacterial, amoebic).
• Inflammatory bowel diseases (ulcerative colitis, Crohn's disease).
• Psychopathological conditions (depression, anxiety, panic attacks).
• Neuroendocrine tumors (carcinoid syndrome, vasointestinal peptide-dependent tumor).
• Endocrine diseases (hyperthyroidism).
• Gynecological diseases (endometriosis).
• Functional conditions in women (premenstrual syndrome, pregnancy, menopause).
• Proctoanal pathology (dyssynergia of the pelvic floor muscles).

Indications for consultation with other specialists

For patients suffering from IBS, observation by a gastroenterologist and psychiatrist is provided. Indications for consulting a patient with a psychiatrist:

• the therapist suspects the patient has a mental disorder;
• patient expressing suicidal thoughts;
• the patient needs to be prescribed psychotropic drugs (to relieve pain);
• the patient’s medical history contains indications of visiting a large number of medical institutions;
• the patient has a history of sexual abuse or other mental trauma.

An example of a diagnosis formulation

Irritable bowel syndrome with diarrhea.

TREATMENT

The goal of treatment for a patient suffering from IBS is to achieve remission and restore social activity. Treatment in most cases is carried out on an outpatient basis, hospitalization is provided for examination and in case of difficulties in selecting therapy.

To treat patients suffering from IBS, firstly, general measures are indicated, including:

• patient education (familiarizing the patient in an accessible form with the essence of the disease and its prognosis);
• “Relieving tension” involves focusing the patient’s attention on the normal indicators of the tests performed. The patient should know that he does not have a serious organic disease that is life-threatening;
• dietary recommendations (discussion of individual eating habits, highlighting foods whose consumption causes increased symptoms of the disease). To identify foods that cause deterioration in a particular patient, keeping a “food diary” should be recommended.

Currently, from the standpoint of evidence-based medicine, in the treatment of patients suffering from IBS, the effectiveness of drugs that normalize motor skills, affect visceral sensitivity or affect both mechanisms, as well as drugs that affect the emotional sphere, has been confirmed.

Drugs that affect inflammatory changes in the intestinal wall have not yet found widespread use in this category of patients.

To relieve pain in IBS, various groups of antispasmodics are used: blockers of M-cholinergic receptors, sodium and calcium channels.

Based on a meta-analysis of 22 randomized placebo-controlled studies examining the effectiveness of antispasmodics for the treatment of abdominal pain in patients with IBS, which involved 1778 patients, it was shown that the effectiveness of this group of drugs is 53-61% (the effectiveness of placebo is 31-41%). The NNT indicator (the number of patients who need to be treated to achieve a positive result in one patient) when using antispasmodics varied from 3.5 to 9 (3.5 when treating hyoscine with butyl bromide). Hyoscine butylbromide was recommended as a first-line drug in this pharmacological group for the treatment of abdominal pain due to the high level of research conducted and a large sample of patients. Thus, the level of studies that confirmed the effectiveness of this group of drugs was quite high and was equal to category I, level of practical recommendations – category A.

For the treatment of IBS with diarrhea, drugs such as loperamide hydrochloride, smecta, the non-absorbable antibiotic rifaximin and probiotics are used.

By reducing the tone and motility of the smooth muscles of the gastrointestinal tract, loperamide hydrochloride improves stool consistency, reduces the number of urges to defecate, however, does not have a significant effect on other symptoms of IBS, including abdominal pain. Due to the lack of randomized clinical trials (RCTs) comparing loperamide with other antidiarrheal drugs, the level of evidence for the effectiveness of taking loperamide belongs to category II, the level of practical recommendations is classified by some authors as category A (for diarrhea not accompanied by pain) and category C - if you have abdominal pain.

Data are provided on the effectiveness of dioctahedral smectite in the treatment of IBS with diarrhea, however, the level of evidence corresponds to category II, and the level of practical recommendations corresponds to category C.

According to a meta-analysis of 18 randomized placebo-controlled trials, including 1803 IBS patients with diarrhea, a short course of the non-absorbable antibiotic rifaximin is quite effective in stopping diarrhea and also helps reduce abdominal bloating in such patients. At the same time, the NNT indicator turned out to be equal to 10.2. Despite the high effectiveness of rifaximin, there is no data on the long-term safety of taking the drug. Studies that confirmed the effectiveness of rifaximin can be classified as category I, the level of practical recommendations - category B.

Probiotics containing B. infantis, B. animalis, L. plantarum, B. breve, B. longum, L. acidophilus, L. casei, L. bulgaricus, S. thermophilus in various combinations are effective in relieving symptoms of the disease; level of evidence category II, level of practical recommendations - B.

Treatment of chronic constipation, including IBS with constipation, begins with general recommendations, such as increasing the volume of fluid consumed in the patient's diet to 1.5-2 liters per day, increasing the content of plant fiber, and increasing physical activity. However, from the perspective of evidence-based medicine, the level of research that examined the effectiveness of general interventions (diet rich in fiber, eating regularly, drinking enough fluids, physical activity) was low and was based mostly on expert opinion based on individual clinical trials. observations.

Thus, the level of evidence corresponds to category III, the reliability of practical recommendations corresponds to category C.

The following groups of laxatives are used to treat IBS with constipation:

• laxatives that increase the volume of feces (empty psyllium seed shells);
• osmotic laxatives (macrogol 4000, lactulose);
• laxatives that stimulate intestinal motility (bisacodyl).

Laxatives that increase the volume of stool. They increase the volume of intestinal contents and give stool a soft consistency. They do not irritate the intestines, are not absorbed, and are not addictive. A meta-analysis of 12 randomized placebo-controlled trials (591 patients) has been published to study the effectiveness of the use of laxatives of this group in the treatment of constipation in patients with IBS, however, most of these studies were carried out years ago. However, laxatives that increase stool volume were effective in 1 in 6 IBS patients with constipation (NNT=6).

The effectiveness of drugs in this group, in particular psyllium, has been proven in category II studies; the level of practical recommendations can be classified as category B (American College of Gastroenterology (ACG), American Society of Colon and Rectal Surgeons (ASCRS).

Osmotic laxatives. Helps slow down water absorption and increase the volume of intestinal contents. They are not absorbed or metabolized in the gastrointestinal tract, do not cause structural changes in the colon and addiction, and help restore the natural urge to defecate. Drugs in this group increase the frequency of stools in patients with IBS with constipation from 2.0 to 5.0 per week. An increase in the frequency and improvement in stool consistency three months after the start of treatment was observed in 52% of patients with IBS with a predominance of constipation while taking polyethylene glycol and only in 11% of patients taking placebo. The effectiveness of osmotic laxatives has been demonstrated in placebo-controlled studies, including long-term use (12 months) and pediatric use. However, when using individual laxatives of this group (for example, lactulose), a side effect such as bloating often occurs. To prevent the development of flatulence, while maintaining the original effectiveness, a combination preparation was synthesized based on micronized anhydrous lactulose powder in combination with paraffin oil (Transulose). Thanks to micronization, the osmotic effect of lactulose improves, which makes it possible to reduce the dose of the drug compared to a lactulose solution. Paraffin oil reduces the development of the laxative effect by up to 6 hours and provides additional softening and gliding effects.

According to the ACG and ASCRS, the level of evidence for the effectiveness of this group of drugs is I, however, the level of evidence for practical recommendations varies: from category A (according to AGG) to category B (according to ASCRS).

Laxatives that stimulate intestinal motility. Medicines in this group stimulate the chemoreceptors of the colon mucosa and enhance its peristalsis. According to the results of a recent study, the number of spontaneous bowel movements in patients with chronic constipation while taking bisacodyl increased from 0.9 to 3.4 per week, which was significantly higher than in patients taking placebo (increase in the number of bowel movements from 1.1 up to 1.7 per week).

However, despite the fairly high level of effectiveness and safety of this group of drugs, most of the studies conducted to determine these indicators were carried out more than 10 years ago and, according to the level of evidence, can be classified as category II. According to the ACG, the level of practice recommendation is category B, according to the ASCRS - C, which is likely due to the possibility of pain while taking stimulant laxatives.

Combination drugs

In addition to drugs that affect any specific symptom of the disease - abdominal pain, diarrhea or constipation, in the treatment of patients with IBS, drugs are also used that, taking into account their mechanism of action, help to reduce abdominal pain and normalize the frequency and consistency of stool .

Thus, for the treatment of abdominal pain and bowel disorders in patients suffering from IBS, agonists of peripheral opioid receptors are successfully used, normalizing intestinal motor activity as a result of their influence on various subtypes of peripheral opioid receptors, and, in addition, increasing the threshold of pain sensitivity due to their effect on glutamate receptors at synapses of the dorsal horns of the spinal cord. The drug of this group - trimebutine maleate - is safe with long-term use, effective for the treatment of combined functional pathology (in particular, with a combination of functional dyspepsia syndrome and IBS, and is also more effective than mebeverine in reducing the frequency and severity of abdominal pain.

The level of evidence for the effectiveness of the use of trimebutine corresponds to category II, the level of practical recommendations corresponds to category B.

Combined-action drugs for the treatment of patients with IBS may also include the drug Meteospasmil, which includes two active components - alverine citrate and simethicone.

The level of evidence from studies confirming the effectiveness of Meteospasmil is category I, the level of practical recommendations is category A.

Probiotic preparations are effective for the treatment and prevention of a number of diseases. Indications for the use of probiotics were formulated by a group of experts at Yale University based on an analysis of the results of studies published in the scientific literature.

Probiotics containing microorganisms such as B. Infantis, B. Animalis, B. breve, B. longum, L. acidophilus, L. plantarum, L. casei, L. bulgaricus, S. Thermophilus have been proven effective in the treatment of IBS. The level of evidence from studies confirming the effectiveness of probiotic preparations can be classified as category I, the level of practical recommendations – to category B.

In general, a probiotic preparation of appropriate quality must meet a number of requirements:

• the number of bacterial cells contained in one capsule or tablet at the time of sale should be 109;
• the drug should not contain substances not listed on the label (yeast, mold, etc.);
• The capsule or tablet shell must ensure delivery of bacterial cells to the intestine.

Probiotics are usually produced in the country of consumption to avoid violations of their storage conditions during transportation.

In the Russian Federation, Florasan D, which meets all the requirements for probiotic drugs, has been developed and used for the treatment of IBS patients, regardless of the course of the disease. Approved by the Russian Gastroenterological Association.

Psychotropic drugs (tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs)) are used to correct emotional disturbances and also to relieve abdominal pain.

According to a meta-analysis of 13 randomized placebo-controlled trials, including 789 patients, and conducted to evaluate the effectiveness of TCAs and SSRIs in patients suffering from this disease, the NNT was equal to 4 for TCAs and 3.5 for SSRIs. However, when prescribing psychotropic drugs, it should be taken into account that patients’ adherence to treatment with these drugs is low and 28% of patients stop taking them on their own.

The effectiveness of psychotropic drugs has been proven in studies that can be classified as category I, however, the level of practical recommendations, according to the American College of Gastroenterology (ACG), corresponds to category B, which is associated with insufficient data on their safety and tolerability in patients with IBS .

Surgical treatment for patients with IBS is not indicated.

Patient education

Patient education is an important part of the comprehensive treatment of IBS. The following patient information sheet is provided as an example of educational material.

What to do if you have been diagnosed with irritable bowel syndrome?

First, we must remember that the prognosis for this disease is favorable. Irritable bowel syndrome does not lead to the development of bowel cancer, ulcerative colitis, or Crohn's disease.

Secondly, you should be under the supervision of a doctor in whose competence you are confident, whom you completely trust and can tell about the most minor changes in your well-being and the reasons, in your opinion, that caused them.

Thirdly, you need to pay attention to how you eat. It is completely unacceptable to eat 1-2 times a day, in large quantities. This diet will undoubtedly cause pain, bloating and abnormal bowel movements. Eating 4-5 times a day in small portions will make you feel better.

It is well known that certain foods increase unpleasant symptoms, so it is advisable to keep a food diary in order to eliminate foods that worsen your condition.

How to keep a food diary?

It is necessary to write down what foods you consumed during the day, and what unpleasant sensations arose. A fragment of the food diary is presented in Table. 17-1.

Table 17-1. Example of food diary entries

Remember! The choice of drug or combination of drugs and the duration of the course of treatment are determined by the doctor!

FORECAST

The prognosis of the disease for the patient is unfavorable - long-term clinical remission can be achieved only in 10% of patients, in 30% of patients there is a significant improvement in well-being. Thus, about 60% of patients, despite the treatment, continue to experience abdominal pain, suffer from excess gas formation and unstable stool.

The prognosis for the disease is favorable - the incidence of inflammatory bowel disease and colorectal cancer does not exceed that in the general population.

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