- Relapsing abdominal pain with bloating, flatulence and change in bowel habits (alternating diarrhea and constipation) that improves with defecation, seen in middle aged women.
- This condition is a diagnosis of exclusion
Etiology and association
- Unknown etiology, mostly women with history of childhood abuse.
- Unknown cause of increase in frequency of normal peristalsis and segmentation contraction of bowel.
- Can be diarrhea predominant, Constipation predominant or both (alternate consti-diarrhea).
Symptoms and Clinical Presentation:
- Abdominal pain/cramping with change in bowel movements that gets better post defecation
- 20% constipation only, some diarrhea alone only, rest switch between diarrhea and constipation
- All have abdominal pain/bloat/gas/flatulence.
- No Bleeding, No Weight loss, No fever, No nocturnal Symptoms. No GI Pathology appreciated
- Get better with Fiber rich foot or go away with bowel movements
- (Rome criteria) – (at least 3 months; 3 days per month) 2/3 below.
- Change in Form and Appearance of Stool
- Diarrhea alternating with constipation [ie change in frequency]
- Pain relived by BM or by change in bowel habit (when you diarrhea, pain gone)
- Colonoscopy – normal mucosa
- Stool guaic negative, No WBC, Culture/Ova all negative, Abdominal CT negative
Treatment and Management
- Best initial: High fiber diet and increase the bulk of the stool (help relief pain, if not use medication)
- Medication for pain of IBD
- Pain (antispasmotics) – Hyoscyamine, Dicyclomine, Belladonna alkaloid [relax bowel]
- Relax muscle wall contracture hence diminish pain – Can worsen GERD!
- If refractory pain can use TCA (anti HAM) can relax bowel and treat depression since many have depression anyways (amitriptyline is anticholinergic, relive neuropathic pain, antidepressant)
- Medication for Diarrhea-Constipation predominant;
- Diarrhea predominant
- Rifaximine: non-absrobed Abx
- Loperamide, Diphenoxylate,
- Alosetron (arrest stool via 5HT)
- EluxadolineL mu-opioid receptor agonist for diarrhea, relieves pain/slows bowel.
- Constipation predominant
- Always Fiber
- Polyethylene glycol (PEG): non-absorbed bowel lubricant. If don’t work use below 2: lubipristone, Linaclotide
- Lubiprostone (Cl channel activator that increase BM frequency)
- Linaclotide (guanylate cyclase agonist) also like lubirpistone used if PEG not work.
- Tegaserod (Side effects include diarrhea. This drug manipulate 5HT),