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“Functional” Bowel Disorders

“Functional” Bowel Disorders. Eamonn M M Quigley MD November 2010. “Functional” Bowel Disorders. Refer to disorders of gut function where there is no obvious abnormality of structure or morphology Cause symptoms Impair Quality of Life Do NOT imply/equate to psychological/psychogenic!!.

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“Functional” Bowel Disorders

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  1. “Functional” Bowel Disorders Eamonn M M Quigley MD November 2010

  2. “Functional” Bowel Disorders • Refer to disorders of gut function where there is no obvious abnormality of structure or morphology • Cause symptoms • Impair Quality of Life • Do NOT imply/equate to psychological/psychogenic!!

  3. A Sub-Classification • Defined disorders of function; i.e. motility disorders • Putative disorders of function; “functional disorders”

  4. Well-Defined Motility Disorders Symptoms Dysfunction Pathology Pathophysiology

  5. Motility Disorders • Primary • Achalasia • Diffuse Oesophageal Spasm • Gastroparesis • Acute/Chronic Intestinal Pseudo-obstruction • Megacolon • Hirschsprung’s disease

  6. Achalasia • Non-relaxing LOS • Drop-out of Inhibitory neurons (NO, VIP) • Aperistalsis in the oesophageal body • Causes: • Chagas’ disease • Pseudo-achalasia • Cancers • Idiopathic

  7. Chagas’ Disease Symptoms Dysfunction Pathology Pathophysiology

  8. Achalasia - Management • Muscle relaxants • Ca++ - blockers • Nitrates • Dilatation • Bougie; transient benefit only • Balloon forced dilatation • Surgery • Heller myotomy • Botox Ineffective

  9. Diffuse Oesophageal Spasm • True idiopathic spasm rare; usually secondary to GORD • Non-cardiac chest pain • Treat: • Muscle relaxants • Dilatation • ? Surgery

  10. Pseudoobstruction • Rare disorders resulting in diffuse motor dysfunction: • Oesophageal dysmotility • Gastroparesis • Small bowel pseudobstruction • Colonic pseudobstruction • Myopathy or Neuropathy • Congenital or Acquired • Primary or Secondary • Connective tissue diseases • Muscle disease • Neurologic disorders • Metabolic disorders e.g. Diabetes

  11. Pseudoobstruction

  12. Presents as acute or recurrent “obstruction”: • Small intestine • Colon • Acute e.g acute colonic pseudo- • obstruction (acute megacolon) • post-op (Ogilvie’s syndrome) • Chronic • results in intestinal failure • small intestinal bacterial overgrowth • inability to tolerate p.o. nutrition

  13. Scleroderma Symptoms Dysfunction Pathology Genetics Immunology Pathophysiology

  14. Neurological Disease:1. Brain Stem Tumor Neurological Disease:2. Parkinson’s Disease Symptoms Dysfunction Pathology Dysphagia Nausea Ileus Constipation Incontinence Dysphagia Nausea Ileus Constipation Incontinence Pathophysiology

  15. Hirschsprung’s Disease • Children; rarely presents in adulthood • Loss of inhibitory neurons • Genetics understood • Svenson’s pull-through procedure

  16. Hirschsprung’s Disease Symptoms Dysfunction Pathology Pathophysiology

  17. “Functional” Disorders • Functional Heartburn • Globus Sensation • Functional Dyspepsia • Irritable Bowel Syndrome • Functional Abdominal pain • Functional Diarrhoea/Constipation Often overlap; one disorder or a number of discrete disorders

  18. Functional GI Disorders • Responsible for over 50% of all G.I. Complaints seen by a G.P.!

  19. How do you make a diagnosis? • Symptoms • No pathology • No abnormal blood tests • No abnormal X Ray’s

  20. Diagnosis • By exclusion • Definitive, based on symptoms ( a consensus approach)

  21. Rome • Functional Dyspepsia “ A chronic pain or discomfort centred in the upper abdomen; may be additional symptoms such as fullness, bloating, early satiety, nausea, vomiting”

  22. Rome • IBS • “ chronic abdominal pain or discomfort associated with bowel movement; may be additional symptoms such as bloating, distension, constipation, diarrhoea”

  23. IBS • Abdo Pain + • Urge to b.m. • Relief by b.m. • Alternating diarrhoea and constipation • Bloating, distension • Difficult defaecation

  24. Functional Bowel DisordersCause(s) • Motor Dysfunction • Visceral Hypersensitivity • Low-grade inflammation • Central Perception • Psyche

  25. FD – Pathophysiology; motility • Gastroparesis • Impaired Fundic Accommodation • Antral Dilatation • Gastric Hypersensitivity • Abnormal Cerebral Perception • Helicobacter Pylori

  26. IBS - Pathophysiology • Motility • Visceral Hypersensitivity • Central Perception • Inflammation • Post-infective • Immune activation • Microbiota different • Psyche

  27. Case History • 24 year-old female graduate student, volunteers in Africa • 2000 presented with a 2 year history of abdominal cramps and constipation • Went on wheat-free diet • Substituted soya for cows milk • Lived in: • Malawi age 3-10 • Malaysia age 14-16 • December 2003 • Every 2 weeks: diarrhoea, nausea lasting 2-3 days • Loperamide helped • April 2004 • Anticholinergic, antispasmodic and antidiarrhoeal: some help • July 2004

  28. Case History • July 2004 • Despite 6 diphenoxylate/day • Every 3-4 days borborygmi and cramps followed by diarrhoea (b.o. X 5 in a.m.) and urgency • Took tinidazole for 4 days – no effect • Family history of pernicious anaemia, coeliac disease and Crohn’s disease

  29. Case History • April 2009 • Intermittent symptoms • Worse after meals and when stressed • Has had a number of anti-biotic and anti-parasitic regimes • No weight loss • Extensive and repeated investigations • Blood work, gastroscopy, colonoscopy, small bowel x-rays, abdominal imaging • All negative

  30. Management • Listen and appreciate • Understand aggravating factors and modify • Symptomatic • Anti-diarrhoeals • Laxatives • Anti-spasmodics • Tricyclic anti-depressants (low dose); SSRI’s • Behavioral and psychological therapies

  31. Summary • Motility disorders • Not common • May cause considerable disability • Based on disorders of intestinal nerve or muscle or their central connections • “Functional” disorders • Common • May cause considerable impairment in quality of life • Pathophysiology not fully understood

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