Diagnosis Dan Tatalaksana: Nyoman Purwadi

“IRRITABLE BOWEL
SYNDROME”
(IBS)
Diagnosis dan Tatalaksana
Nyoman Purwadi
Div. Gastro-Entero-Hepatology
Bagian Penyakit Dalam
FK Unud/ RS Sanglah
Denpasar Bali
Apakah IBS ?
Ggn Fungsi tanpa kelainan struktural dan

kelainan biokimia
Bukan Radang, infeksi atau keganasan
Keluhan bisa dicetuskan oleh : bahan

makanan tertentu dan stres
Sangat mempengaruhi kwalitas hidup
Drossman DA et al. Gastroenterology 1997;112:2120-37;

Drossman DA et al. The Functional Gastrointestinal Disorders, 2000 p366.
Perubahan Fungsi Usus pada IBS
Perubahan fs. Usus
Perubahan
Perubahan Straining
frekuensi Urgensi
konsistensi
dan gerakan usus
feses
Bloating Babf Feses bercampur

(fullness/swelling) tidak lampias mukus
IBS
 20% pdd. USA dilaporkan memiliki keluhan yang
1
sesuai dengan IBS
 Diagnosis tersering pada gastroenterologist di
1
USA
 Satu diantara 10 alasan untuk tidak masuk kerja
 Terbanyak mengenai wanita (~70% ) 4
 “functional bowel disorder” tersering

1. Camilleri and Choi. Aliment Pharmacol Ther. 1997;11:13–15
2. Everhart and Renault. Gastroenterology. April 1991;100:998–1005
3. Physician Drug & Diagnosis Audit (PDDA), April 1999, Scott–Levin
4. Sandler. Gastroenterology. August 1990;99:409–415
5. Thompson et al. Gastroenterol Int. 1992;5:75–91
IBS : Patofisiologi
 Kelainan pada “enteric nervous system”

merupakan “hallmark” keluhan IBS
1
 Visceral hypersensitivity
• Meningkatnya respon aferen terhadap
rangsangan
• Mediators : 5-HT, bradykinin, tachykinins, CGRP,
and neurotropins
2
 Gangguan motilitas pada GI tract
• di perantarai oleh : 5-HT, acetylcholine, ATP,
motilin, nitric oxide, somatostatin, substance P,
and VIP
1. Bueno et al. Gastroenterology. May 1997;112:1714–1743

2. Goyal and Hirano. N Engl J Med. April 1996;334:1106–1115
Distribusi Normal 5-HT
CNS – 5%
GI tract – 95%
– enterochromaffin cells
– neuronal
Gershon. Aliment Pharmacol Ther 1999;13(suppl 2):15–30

Patogenesis IBS:
Factors Pencetus
Makanan dan zat yg dikandung
Obat obatan
Problems psikis /stress
Hormones (siklus menstruasi)
Perubahan musim
Faktor Psikis yang mempengaruhi
Fungsi Saluran Cerna
Ansietas, panik, depresi
“Unexplained bodily symptoms”
Fisikal, sexual atau emosional abuse
Alkohol atau penyalah guna obat
Gangguan makan
IBS: Understanding the condition
Early life
Genetics,
environment
Psychosocial CNS
factors Physiology
Life stress, Motility, sensation
ENS
psychological state,
coping, social support
IBS
Symptom
experience,
behaviour
Outcome
Medications, physician
visits, daily function,
Drossman, 1997; 1999
quality of life
Diagnosis
“Irritable Bowel Syndrome”
(IBS)
Perkembangan Diagnosis IBS
1950s – Meningkatnya “gut motility”

1970s – Petanda kusus motilitas usus
1980 to 1999 – kriteria khusus
• Manning criteria
• Rome criteria
1999 – kriteris Rome II
1. Drossman. Aliment Pharmacol Ther. 1999;13(suppl 2):3–14

2. Thompson et al. Gut. 1999;45(suppl 2):1143–1147
The Manning Criteria (1978)
Four symptoms significantly more common in IBS:
Pain relieved by defecation

More frequent stools at the onset of pain
Looser stools at the onset of pain
Visible abdominal distention
A strong trend for the following:

Passage of mucus
Sensation of incomplete bowel emptying
Manning AP et al. Br Med J 1978;2:653–4

The Rome Criteria (1992)
3 months continuous/recurrent symptoms:
1. Abdominal pain or discomfort that is
• Relieved with defecation
• Associated with a change in frequency of stool and/or
• Associated with a change in consistency of stool; and
2. Two or more of the following at least on one quarter

of the time
• Altered stool frequency (>3 / day or <3 / week)
• Altered stool form (lumpy/hard or loose/watery stool)
• Altered stool passage (straining, urgency)
• Passage of mucus
• Bloating or feeling of abdominal distention
Thompson WG et al. Gastroenterol Int 1992;5:75–91
Rome II Criteria
 At least 12 weeks, which need not be consecutive,

in the preceding 12 months, of abdominal discomfort
or pain that has 2 of 3 features:
• Relieved with defecation
• Onset associated with a change in frequency of

stool
• Onset associated with a change in form

(appearance) of stool
Thompson et al. Gut. 1999;45(suppl 2):1143–1147

1 2
Rome I Criteria Rome II Criteria
1. At least 3 months of continuous or 1. At least 12 weeks, which need not be
recurrent symptoms of abdominal consecutive, in the past 12 months of
pain or discomfort that is: abdominal discomfort or pain that has
• Relieved by defecation and/or 2 of 3 features:
• Associated with a change in • Relieved by defecation; and/or
frequency of stool; and/or • Onset associated with a change in
• Associated with a change in frequency of stool; and/or
consistency of stool • Onset associated with a change in form
(appearance) of stool
2. 2 or more of the following at least
25% of the time:
• Altered stool frequency
• Altered stool form
• Altered stool passage (straining,
urgency, feeling of incomplete evacuation)
• Passage of mucous; and/or
• Bloating or feeling of abdominal
distension 1Thompson WG et al. Gastroentrol Int 1992;5:75–91;
2Thompson WG et al. Gut 1999;45(Suppl II):II43–II47.
Rome III criteria for IBS if your symptoms
began at least 6 months ago, you have had
abdominal (belly) pain or discomfort at least
3 days each month in the last 3 months, and
at least two of the following statements are
true: 1
The pain is relieved by having a bowel
movement.
The pain is linked to a change in how often
you have a bowel movement.
The pain is linked to a change in the
appearance or consistency of your stool.
Perubahan Motilitas Usus
Hipomotilitas Hipermotilitas
Gerakan
Usus
C-IBS D-IBS
Subtipe IBS (~Rome)
C-IBS: D-IBS:
Rome II Rome II
$1 of A + none of B $1 of B + none of A
$ 2 of A + 1 of B $ 2 of B + 1 of A
A - <3 bowel movements / week

- hard lumpy stool
- straining during bowel movements
B - >3 bowel movements / week

- loose or watery stool
- urgency of bowel movements
Evaluasi IBS
Pemeriksaan Darah
Pemeriksaan feses
Pemeriksaan Radiologi
Sigmoidoskopi
Drossman, 1997; 1999

Differential Diagnosis
Malabsorpsi
“Food Intolerance”
Infeksi
“Inflammatory bowel disease” (IBD)
Kelainan Psikis
Gangguan ginekologis
1. Drossman. Aliment Pharmacol Ther. 1999;13(suppl 2):3–14

2. Moore et al. Br J Obstet Gynaecol. December 1998;105:1322–1325
Defining IBS: by exclusion of disease
Infection
IBD
Dietary Factors Giardia lamblia UC
Lactose Bacterial CD
Coffeine Ameba
Alcohol
Fat Psychologic
Gas-producing Differential Anxiety/panic
foods
Diagnosis Depression
Somatization
Malabsorption Miscellaneous
Post-gastrectomy
Intestinal Endometriosis
Pancreatic Endocrine tumours
AIDS
‘Red Flags’ May Suggest an
Alternative or Coexisting Diagnosis
Additional diagnostic screening needed for atypical
presentations such as
 Anemia  Nocturnal symptoms of

pain and abnormal bowel
 Fever function
 Persistent diarrhea  Family history of GI cancer,
 Rectal bleeding inflammatory bowel disease,
or celiac disease
 Severe constipation
 New onset of symptoms in
 Weight loss patients 50+ years of age
Paterson et al. Can Med Assoc J. July 1999;161:154–160

Tatalaksana
Irritable Bowel Syndrome
(IBS)
Tatalaksana Umum
 Hubungan dokter - Pasien yang baik
= Lakukan anamnesa yang baik dan teliti
= Identifikasi “Patient’s concern”
= Jelaskan : ini penyakit medis
Diet dan stres : pencetus
 Singkirkan penyakit organik
 Ongoing review
 Atasi Stres dan modifikasi gaya hidup
 Obat obat
Terapi IBS
Screening for Organic Diseases
Symptomatic subgroups
Constipation Diarrhoea Pain / gas
Fiber/Laxative Loperamide Antispasmodic

Prokinetic Diphenoxylate Antiflatulence
Tegaserod

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“IRRITABLE BOWEL

Ggn Fungsi tanpa kelainan struktural dan

Bukan Radang, infeksi atau keganasan

Keluhan bisa dicetuskan oleh : bahan

Sangat mempengaruhi kwalitas hidup

Drossman DA et al. Gastroenterology 1997;112:2120-37;

Perubahan fs. Usus

Bloating Babf Feses bercampur

 “functional bowel disorder” tersering

 Kelainan pada “enteric nervous system”

1. Bueno et al. Gastroenterology. May 1997;112:1714–1743

Gershon. Aliment Pharmacol Ther 1999;13(suppl 2):15–30

Problems psikis /stress

Hormones (siklus menstruasi)

Ansietas, panik, depresi

“Unexplained bodily symptoms”

Fisikal, sexual atau emosional abuse

Alkohol atau penyalah guna obat

1950s – Meningkatnya “gut motility”

1999 – kriteris Rome II

1. Drossman. Aliment Pharmacol Ther. 1999;13(suppl 2):3–14

Pain relieved by defecation

A strong trend for the following:

Manning AP et al. Br Med J 1978;2:653–4

2. Two or more of the following at least on one quarter

 At least 12 weeks, which need not be consecutive,

• Relieved with defecation

• Onset associated with a change in frequency of

• Onset associated with a change in form

Thompson et al. Gut. 1999;45(suppl 2):1143–1147

A - <3 bowel movements / week

B - >3 bowel movements / week

Drossman, 1997; 1999

1. Drossman. Aliment Pharmacol Ther. 1999;13(suppl 2):3–14

 Anemia  Nocturnal symptoms of

Paterson et al. Can Med Assoc J. July 1999;161:154–160

Screening for Organic Diseases

Constipation Diarrhoea Pain / gas

Fiber/Laxative Loperamide Antispasmodic

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