Olgularla İrritabl Barsak Sendromu

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1 Olgularla İrritabl Barsak Sendromu
Halis Şimşek 13 Nisan 2013, AHGE ANTALYA

2 Olgu 29 Y Kadın, 10 aydır sol alt kadranda yemek sonrası artan ağrı, şişkinlik ve günde 3 kez şekilsiz dışkılaması var, bazan geceleri karın ağrısı ile uyanıp tuvalete gidermiş bazan uykudan uyandıran ishali olurmuş Tuvalette uzun oturuyor, tam boşalmama hissi var Stresinin fazla olduğunu belirtiyor Sırt ağrısı, kas ağrıları ve gerginliği olduğunu söylüyor Baş ağrısı ve baş dönmesi oluyor İdrar sorunları var, dizürisi yok FM: sol alt kadran hassaslığı dışında N USG: Kolelithiazis Slide 128 Factors Associated with a Better Clinical Outcome Several studies have indicated certain prognostic factors that may help determine who will have a better clinical outcome or response to treatment. These include: a) the presence of diarrhea rather than constipation, b) a post-infectious etiology, c) anxiety, d) a short history of symptoms, f) no prior abdominal surgery, g) a positive physician-patient relationship and h) male gender. Drossman DA, Camilleri M, Mayer EA, et. al., AGA Technical Review on Irritable Bowel Syndrome. Gastroenterology 2002 2

3 Soru 1: Hastadan aşağıdaki testlerden hangisini istersiniz ?
1) Gaita mikroskobisi ve parazit 2) Fleksible sigmoidoskopi 3) CBC ve ESR 4) Tiroid fonksiyon testleri 5) Hiçbir test istemem tedaviye başlarım Slide 128 Factors Associated with a Better Clinical Outcome Several studies have indicated certain prognostic factors that may help determine who will have a better clinical outcome or response to treatment. These include: a) the presence of diarrhea rather than constipation, b) a post-infectious etiology, c) anxiety, d) a short history of symptoms, f) no prior abdominal surgery, g) a positive physician-patient relationship and h) male gender. Drossman DA, Camilleri M, Mayer EA, et. al., AGA Technical Review on Irritable Bowel Syndrome. Gastroenterology 2002 3

4 Tetkik sonuçları 1) Gaita mikroskobisi ve parazit : Normal
2) Fleksible sigmoidoskopi : Normal 3) CBC ve ESR : Normal 4) Tiroid fonksiyon testleri : Normal Slide 128 Factors Associated with a Better Clinical Outcome Several studies have indicated certain prognostic factors that may help determine who will have a better clinical outcome or response to treatment. These include: a) the presence of diarrhea rather than constipation, b) a post-infectious etiology, c) anxiety, d) a short history of symptoms, f) no prior abdominal surgery, g) a positive physician-patient relationship and h) male gender. Drossman DA, Camilleri M, Mayer EA, et. al., AGA Technical Review on Irritable Bowel Syndrome. Gastroenterology 2002 4

5 Soru 2: Bir önceki tetkikler normal hastadan aşağıdaki testlerden hangisini istersiniz ?
1) Fleksible sigmoidoskopi ve rektal biyopsi 2) Çölyak testleri 3) Kolon grafisi 4) Üst endoskopi 4) Hiçbir test istemem tedaviye başlarım Slide 128 Factors Associated with a Better Clinical Outcome Several studies have indicated certain prognostic factors that may help determine who will have a better clinical outcome or response to treatment. These include: a) the presence of diarrhea rather than constipation, b) a post-infectious etiology, c) anxiety, d) a short history of symptoms, f) no prior abdominal surgery, g) a positive physician-patient relationship and h) male gender. Drossman DA, Camilleri M, Mayer EA, et. al., AGA Technical Review on Irritable Bowel Syndrome. Gastroenterology 2002 5

6 Tetkik sonuçları 1) Fleksible sigmoidoskopi ve rektal biyopsi : Normal
2) Çölyak testleri : (+) 3) Kolon grafisi : Normal 4) Üst endoskopi : Normal Slide 128 Factors Associated with a Better Clinical Outcome Several studies have indicated certain prognostic factors that may help determine who will have a better clinical outcome or response to treatment. These include: a) the presence of diarrhea rather than constipation, b) a post-infectious etiology, c) anxiety, d) a short history of symptoms, f) no prior abdominal surgery, g) a positive physician-patient relationship and h) male gender. Drossman DA, Camilleri M, Mayer EA, et. al., AGA Technical Review on Irritable Bowel Syndrome. Gastroenterology 2002 6

7 Çölyak Taraması İçin İstenen Testler ?
1) Antigliadinler 2) Endomisyum antikoru 3) Transglutaminaz IgA 4) Serum IgA Slide 128 Factors Associated with a Better Clinical Outcome Several studies have indicated certain prognostic factors that may help determine who will have a better clinical outcome or response to treatment. These include: a) the presence of diarrhea rather than constipation, b) a post-infectious etiology, c) anxiety, d) a short history of symptoms, f) no prior abdominal surgery, g) a positive physician-patient relationship and h) male gender. Drossman DA, Camilleri M, Mayer EA, et. al., AGA Technical Review on Irritable Bowel Syndrome. Gastroenterology 2002 7

8 Soru 3: Bu aşamada hastadan aşağıdaki testlerden hangisini istersiniz ?
1) Üst endoskopi ve duodenal biyopsi 2) Kolonoskopi+biyopsi 3) Kapsül endoskopi 4) Hiçbir test istemem tedaviye başlarım Slide 128 Factors Associated with a Better Clinical Outcome Several studies have indicated certain prognostic factors that may help determine who will have a better clinical outcome or response to treatment. These include: a) the presence of diarrhea rather than constipation, b) a post-infectious etiology, c) anxiety, d) a short history of symptoms, f) no prior abdominal surgery, g) a positive physician-patient relationship and h) male gender. Drossman DA, Camilleri M, Mayer EA, et. al., AGA Technical Review on Irritable Bowel Syndrome. Gastroenterology 2002 8

9 Tetkik sonuçları 1) Üst endoskopi ve duodenal biyopsi : Vülluslarda düzleşme 2) Kolonoskopi+biyopsi 3) Kapsül endoskopi 4) Hiçbir test istemem tedaviye başlarım Slide 128 Factors Associated with a Better Clinical Outcome Several studies have indicated certain prognostic factors that may help determine who will have a better clinical outcome or response to treatment. These include: a) the presence of diarrhea rather than constipation, b) a post-infectious etiology, c) anxiety, d) a short history of symptoms, f) no prior abdominal surgery, g) a positive physician-patient relationship and h) male gender. Drossman DA, Camilleri M, Mayer EA, et. al., AGA Technical Review on Irritable Bowel Syndrome. Gastroenterology 2002 9

10 Soru 4: Bu hastada tedavi planınız nedir ?
1) Glutenden fakir diyet 2) Kemik dansimetresi 3) Hb, ferritin Slide 128 Factors Associated with a Better Clinical Outcome Several studies have indicated certain prognostic factors that may help determine who will have a better clinical outcome or response to treatment. These include: a) the presence of diarrhea rather than constipation, b) a post-infectious etiology, c) anxiety, d) a short history of symptoms, f) no prior abdominal surgery, g) a positive physician-patient relationship and h) male gender. Drossman DA, Camilleri M, Mayer EA, et. al., AGA Technical Review on Irritable Bowel Syndrome. Gastroenterology 2002 10

11 Soru 4: Bu hastada tedavi planınız nedir ?
1) Stresi için psikiatri konsültasyonu 2) Baş ağrıları için nöroloji konsültasyonu 3) Sırt ağrıları için romatoloji konsültasyonu 4) İdrar sorunları için üroloji konsültasyonu 5) Hiçbir konsültasyon istemem tedaviye başlarım Slide 128 Factors Associated with a Better Clinical Outcome Several studies have indicated certain prognostic factors that may help determine who will have a better clinical outcome or response to treatment. These include: a) the presence of diarrhea rather than constipation, b) a post-infectious etiology, c) anxiety, d) a short history of symptoms, f) no prior abdominal surgery, g) a positive physician-patient relationship and h) male gender. Drossman DA, Camilleri M, Mayer EA, et. al., AGA Technical Review on Irritable Bowel Syndrome. Gastroenterology 2002 11

12 Soru 4: Safra Taşı Tedavisi ?
1) Hemen kolesistektomi 2) Elektif kolesistektomi 3) Kolesistektomi önermem izlerim Slide 128 Factors Associated with a Better Clinical Outcome Several studies have indicated certain prognostic factors that may help determine who will have a better clinical outcome or response to treatment. These include: a) the presence of diarrhea rather than constipation, b) a post-infectious etiology, c) anxiety, d) a short history of symptoms, f) no prior abdominal surgery, g) a positive physician-patient relationship and h) male gender. Drossman DA, Camilleri M, Mayer EA, et. al., AGA Technical Review on Irritable Bowel Syndrome. Gastroenterology 2002 12

13 Karın Ağrısı Kramp hissi ile olur
Alt kadranlarda sık, en sık sol alt kadran Stres ve yemek ağrıyı ↑ Defekasyonla ağrı ↓ Ağrıda ne zaman organik neden aranır ? anoreksi, kilo kaybı, malnutrisyon progressif, uykudan uyandıran, uyutmayan Videlock EJ at al, Gastroenterol Clin Am 2007;36:

14 Diyare Gündüz saatlerinde sıklıkla sabah veya yemek sonrası
Diyare öncesinde ağrı sonrasında tam boşalamama hissi % 50 sinde diyare mukusludur Diyarede ne zaman organik neden aranır ? Kanlı, büyük volümlü, yağlı diyare uykudan uyandıran diyare Videlock EJ at al, Gastroenterol Clin Am 2007;36:

15 Başlangıç Tanısal Testler
Rutin lab: CBC, biyokimya Diyarede; parazit malabs/sekretuar/ozmotik: 24 h dışkı analizi gluten testleri Fleks.sigmoidoskop+biyopsi: rutinde yararı yok diyaresi olan gençlerde İBD ekarte eder Kolonoskopi: >50 Y, KRK ekarte eder diyare varsa Bx. (İBD, miroskobik, kollagenez) Videlock EJ at al, Gastroenterol Clin Am 2007;36:

16 İBS; Ayırıcı Tanı Diyet Parazit Bakteriyel infeksiyon İnflamasyon
Laktoz Yağ Alkol Kafein… Parazit Bakteriyel infeksiyon İnflamasyon IBD Mikroskobik kollejenaz Malabsorbsiyon Pankreas İnce bağırsak Psikolojik Durum Anksiyete Depresyon Somatizasy. Diğer Endometriyozis AİDS Tümör (VİP) Drosman DA, Ann Intern Med 1995;123:688

17 İBS; Tanısal Yaklaşım Organik Gİ hastalık İBS hastaları
(Pretest ihtimal) Genel populasyon (Prevelans) Kolit/İBH %0,51-0,98 %0,3-1,2 Kolorektal kanser %0-0,51 %4-6 Gİ infeksiyon %0-1,7 Pratik değil Tiroid disfoksiyonu %6 %5-9 Laktoz malabsorbsiyonu %22-26 %26 Çölyak hastalığı %3,3-11,4 %0,2-0,3

18 Diğer Gastrointestinal Semptomlar
GER Dispepsi Erken açlık İntemittan disfaji Bulantı Non-kardiyak göğüs ağrısı Videlock EJ at al, Gastroenterol Clin Am 2007;36:

19 Motilite Bozukluklarında Komorbidite ve Semptomların Çakışması
Diyare Geğirme Karın ağrısı Dispepsi IBS Göğüs ağrısı şişkinlik Many GI motility disorders share common symptoms, such as bloating, belching, constipation, discomfort, abdominal pain, heartburn, and regurgitation. Many patients also suffer from comorbid GI motility disorders. For example, of patients with dyspepsia, 23% to 50% have irritable bowel syndrome (IBS), 29% have functional constipation, and 22% to 50% have gastroesophageal reflux disease (GERD). Likewise, 75% of patients with functional chest pain have a coexisting functional GI disorder. For instance, 31% have IBS. Symptoms of GI dysmotility may fluctuate over time and can change from symptoms associated with one disorder to those associated with another disorder. It has, therefore, been hypothesized that GI motility disorders share a common pathway. __________ Corazziari E. Best Pract Res Clin Gastroenterol. 2004;18: Mudipalli RS, et al. Gastroenterology. 2002;T1700. Talley NJ, et al. Am J Gastroenterol. 2003;98: GÖRH Rahatsızlık kabızlık Regürgitasyon

20 Gastrointestinal Sistem Dışı Semptomlar
Letarji Sırt ağrısı Baş ağrısı Baş dönmesi İdrar yolu semptomları Dispareunia Seksüel fonksiyon bozukluğu Dismenore Depresyon, anksiyete, somatizasyon Hipertansiyon, romatolojik semptomlar (fibromyalji) Videlock EJ at al, Gastroenterol Clin N Am 2007;36:

21 IBS; Cerrahi Operasyon Sıklığı Artar
Karın ağrısı/rahatsızlığı Histerektomi1,7× Kolesistektomi3× Apendektomi2× Longstreth GF, 2004.

22 İBS; Tanısal Yaklaşım ‘’ İBS de gastrointestinal sistem dışı semptomlarında İBS ye bağlı olabileceği dikkate alınmalı ve gereksiz konsültasyonlardan kaçınılmalıdır…’’

23 Olgu 2 Slide 128 Factors Associated with a Better Clinical Outcome
Several studies have indicated certain prognostic factors that may help determine who will have a better clinical outcome or response to treatment. These include: a) the presence of diarrhea rather than constipation, b) a post-infectious etiology, c) anxiety, d) a short history of symptoms, f) no prior abdominal surgery, g) a positive physician-patient relationship and h) male gender. Drossman DA, Camilleri M, Mayer EA, et. al., AGA Technical Review on Irritable Bowel Syndrome. Gastroenterology 2002 Olgu 2

24 Olgu 2 55 Y Erkek 20 yaşından beri karında gaz ve şişkinliği var dışkılama ile semptomlar azalıyor. Haftada 2-3 kez tuvalete gidermiş Tuvalette uzun oturuyor, tam boşalmama hissi var Dışkıda kan görmemiş Stresinin fazla olduğunu belirtiyor FM: normal Slide 128 Factors Associated with a Better Clinical Outcome Several studies have indicated certain prognostic factors that may help determine who will have a better clinical outcome or response to treatment. These include: a) the presence of diarrhea rather than constipation, b) a post-infectious etiology, c) anxiety, d) a short history of symptoms, f) no prior abdominal surgery, g) a positive physician-patient relationship and h) male gender. Drossman DA, Camilleri M, Mayer EA, et. al., AGA Technical Review on Irritable Bowel Syndrome. Gastroenterology 2002 24

25 Soru 1: Hastadan aşağıdaki testlerden hangisini istersiniz ?
1) Tiroid fonksiyon testleri 2) Fleksible sigmoidoskopi 3) CBC ve ESR 4) Hiçbir test istemem tedaviye başlarım Slide 128 Factors Associated with a Better Clinical Outcome Several studies have indicated certain prognostic factors that may help determine who will have a better clinical outcome or response to treatment. These include: a) the presence of diarrhea rather than constipation, b) a post-infectious etiology, c) anxiety, d) a short history of symptoms, f) no prior abdominal surgery, g) a positive physician-patient relationship and h) male gender. Drossman DA, Camilleri M, Mayer EA, et. al., AGA Technical Review on Irritable Bowel Syndrome. Gastroenterology 2002 25

26 Tetkik sonuçları 1) Tiroid fonksiyon testleri : Normal
2) Fleksible sigmoidoskopi : Normal 3) CBC ve ESR : Normal 4) Hiçbir test istemem laksatif veririm Slide 128 Factors Associated with a Better Clinical Outcome Several studies have indicated certain prognostic factors that may help determine who will have a better clinical outcome or response to treatment. These include: a) the presence of diarrhea rather than constipation, b) a post-infectious etiology, c) anxiety, d) a short history of symptoms, f) no prior abdominal surgery, g) a positive physician-patient relationship and h) male gender. Drossman DA, Camilleri M, Mayer EA, et. al., AGA Technical Review on Irritable Bowel Syndrome. Gastroenterology 2002 26

27 Hastaya bekunis ve pursennid öneriliyor kabızlığı kısmen düzeliyor
Slide 128 Factors Associated with a Better Clinical Outcome Several studies have indicated certain prognostic factors that may help determine who will have a better clinical outcome or response to treatment. These include: a) the presence of diarrhea rather than constipation, b) a post-infectious etiology, c) anxiety, d) a short history of symptoms, f) no prior abdominal surgery, g) a positive physician-patient relationship and h) male gender. Drossman DA, Camilleri M, Mayer EA, et. al., AGA Technical Review on Irritable Bowel Syndrome. Gastroenterology 2002 27

28 Soru 2: Bir önceki tetkikler normal hastadan aşağıdaki testlerden hangisini istersiniz ?
1) Kolonoskopi 2) Çölyak testleri 3) Kolon grafisi 4) Üst endoskopi 4) Hiçbir test istemem tedaviye başlarım Slide 128 Factors Associated with a Better Clinical Outcome Several studies have indicated certain prognostic factors that may help determine who will have a better clinical outcome or response to treatment. These include: a) the presence of diarrhea rather than constipation, b) a post-infectious etiology, c) anxiety, d) a short history of symptoms, f) no prior abdominal surgery, g) a positive physician-patient relationship and h) male gender. Drossman DA, Camilleri M, Mayer EA, et. al., AGA Technical Review on Irritable Bowel Syndrome. Gastroenterology 2002 28

29 Tetkik sonuçları 1) Kolonoskopi : İstenmemiş
2) Çölyak testleri : Normal 3) Kolon grafisi : Normal 4) Üst endoskopi : İstenmemiş Slide 128 Factors Associated with a Better Clinical Outcome Several studies have indicated certain prognostic factors that may help determine who will have a better clinical outcome or response to treatment. These include: a) the presence of diarrhea rather than constipation, b) a post-infectious etiology, c) anxiety, d) a short history of symptoms, f) no prior abdominal surgery, g) a positive physician-patient relationship and h) male gender. Drossman DA, Camilleri M, Mayer EA, et. al., AGA Technical Review on Irritable Bowel Syndrome. Gastroenterology 2002 29

30 Soru 4: Bu hastada tedavi planınız nedir ?
1) Bitkisel çaylar 2) Pursennid 3) Duphalac solüsyon 4) Magnezi kalsine toz Slide 128 Factors Associated with a Better Clinical Outcome Several studies have indicated certain prognostic factors that may help determine who will have a better clinical outcome or response to treatment. These include: a) the presence of diarrhea rather than constipation, b) a post-infectious etiology, c) anxiety, d) a short history of symptoms, f) no prior abdominal surgery, g) a positive physician-patient relationship and h) male gender. Drossman DA, Camilleri M, Mayer EA, et. al., AGA Technical Review on Irritable Bowel Syndrome. Gastroenterology 2002 30

31 Kabızlık Dışkılama öncesinde ağrı sonrasında tam boşalamama hissi tuvalette çok kalır laksatif / lavman kullanır Videlock EJ at al, Gastroenterol Clin Am 2007;36:

32 Kabızlık Nedenleri Borum ML. Prim Care. 2001;28:577.
It is also important, as shown in the next slide, to consider potential secondary causes of constipation, especially in elderly individuals. Malignancy and mechanical obstruction are on this list and generally the ones that prompt our diagnostic evaluations, at least endoscopic imaging evaluations. Also consider such things as endocrine disorders, neurologic disorders, metabolic disorders, and cardiovascular disease. We generally will screen for those with blood testing when appropriate. Pregnancy also can be associated with constipation, as can medications. Borum ML. Prim Care. 2001;28:577. Schuffler MD. In: Sleisenger and Fordtran’s Gastrointestinal and Liver Disease. 7th ed. 2002:2140.

33 Alarm Semptomları Semptom başlangıcı >50 yaş
Kilo kaybı (> 5 kgr.) Hematokezya Kronik ağır diyare Gece Semptomları Ailede KRK öyküsü Anormal FM ; Ateş, Artrit, LAP, kitle, deri lezyonları Anormal Lab.: Anemi, BK ↑, ESR ↑, CRP Videlock EJ at al, Gastroenterol Clin Am 2007;36:

34 Alarm Semptomları ???? Spiller R . Lancet 2007;369:

35 ABD Cinsiyete Göre Mortalite Oranları 1995-1999
Kolorektal Kanser: ABD Cinsiyete Göre Mortalite Oranları Insidans Erkek Insidans Kadın MortaliteKadın Mortalite Erkek These are incidence and mortality curves for colorectal cancer by gender. They are from SEER, the National Cancer Institute’s (NCI) Surveillance, Epidemiology and End Results Program. This program monitors cancer incidence throughout the country. These curves show incidence and mortality rates for men and women. In both men and women, the incidence of colorectal cancer begins to rise around age 40 and then takes off at age 50; 92% of colorectal cancers are diagnosed in people aged 50 years and older. The mortality follows the incidence, rising with age in a similar fashion. Yaş Kaynak: SEER Cancer Statistics Review,

36 Tanısal Testler; Genel
İBS tanısı sadece organik nedenleri ekarte etmekle konulmamalıdır Manning ve Roma kriterlerini kullanarak tanı maliyetini azaltabiliriz ACG alarm semptomları olmayanlara Fleks, BE, kolonoskopi, GGK, TFT, dışkı analizi önermez Alarm semptomları varsa gereken araştırmaları yapmalıyız Videlock EJ at al, Gastroenterol Clin Am 2007;36:

37 İBS; Tanısal Yaklaşım Semtoma dayalı tanı Baskın semptomu sapta
Diğer klinik faktörleri dikkate al Tanısal testleri yap Tedaviye başla 3-6 hafta sonra değerlendir

38 - + Cash BD, 2005.

39 İBS Tanı Birinci basamak hekimi Gastroenterolog
Roma III kriterleri veya ağrı+Manning s. Yaş >50, alarm semptom var Yaş<50, alarm semptom yok Evet Yanıtsız, hasta kaygısı tedavi Hayır

40 Sonuçlar İBS tanısı semptoma dayalı olması nedeniyle bazı belirsizlikler içerir İBS, hastaların yaşam kalitesini bozmakta ve sağlık sistemi üzerine önemli bir yük oluşturmaktadır Tipik semptomları olan İBS hastalarına özellikle birinci basamak sağlık kuruluşlarında tanı konulup tedavi edilebilmesi, gereksiz cerrahi girişimleri ve sağlık kaynaklarının israfını önlenleyecektir

41 TEŞEKKÜRLER…………….. Slide 128
Factors Associated with a Better Clinical Outcome Several studies have indicated certain prognostic factors that may help determine who will have a better clinical outcome or response to treatment. These include: a) the presence of diarrhea rather than constipation, b) a post-infectious etiology, c) anxiety, d) a short history of symptoms, f) no prior abdominal surgery, g) a positive physician-patient relationship and h) male gender. Drossman DA, Camilleri M, Mayer EA, et. al., AGA Technical Review on Irritable Bowel Syndrome. Gastroenterology 2002 TEŞEKKÜRLER……………..

42 Roma III Tanı Kriterleri
3/6 ay Karın ağrısı/rahatsızlığı 3 gün/ay, son 3 ay + 2/3 Defekasyon ile karın ağrısının rahatlaması Gaita sıklığında değişiklik Gaita şeklinde (görünüşünde) değişiklik Tanıyı destekleyici semptomlar: Haftada <3 veya günde >3 gaita sıklığı Anormal gaita (Sert, keçi pisliği gibi veya gevşek, sulu) Mukuslu gaita Barsak gazı veya abdominal distansiyon Tam boşalmama hissi