REBOOT: #334 IBS, Functional Dyspepsia, and Cyclic Vomiting: Disorders of Gut Brain Interaction (DGBI)
Jan 1, 2024
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Dr. Xiao Jing (Iris) Wang from Mayo Clinic joins to discuss disorders of the Gut-Brain Interaction (DGBI), including IBS, functional dyspepsia, and cyclic vomiting. Topics include diagnostic criteria and treatments for functional dyspepsia, testing algorithms and treatments for irritable bowel disease, and diagnosis and management of cyclic vomiting syndrome and cannabis hyperemesis syndrome.
Minimal testing is needed to diagnose IBS, but additional testing may be warranted in post-infectious cases or for ruling out other conditions.
Explaining the pathophysiology of IBS to patients can help alleviate anxiety and improve treatment adherence.
Treatment for gut-brain axis disorders should be tailored to address specific symptoms, and collaboration with a multidisciplinary team is important for comprehensive care.
Deep dives
Post-infectious IBS and diagnostic workup
Post-infectious IBS is a possible diagnosis for Ms. Cruz, given her history of gastritis and recurrent loose bowel movements with abdominal pain. When it comes to diagnosing IBS, minimal testing is needed. Testing for celiac disease with serologies, ruling out inflammatory bowel disease with fecal calprotectin or CRP, and testing for pathogens like C. diff or Giardia may be warranted, especially in post-infectious cases. Known risk factors for bacterial overgrowth should also be considered for testing. While additional testing for slow transit constipation or SIBO may be necessary in certain cases, a positive diagnosis of IBS based on clinical presentation can still guide treatment even without extensive testing.
Explaining the Pathophysiology to Patients
When explaining the pathophysiology of IBS to patients, it is important to address the interaction between the enteric and central nervous systems, highlighting their embryological connection and shared response to neurotransmitters. For patients with visceral hypersensitivity, it can be helpful to compare their heightened sensation to a malfunctioning fire alarm. Patients may also benefit from analogies that illustrate the impact of factors like microbiome dysbiosis or central sensitization, and how these contribute to their symptoms. Empathy, positive diagnoses, and clear explanations are key to alleviating patient anxiety and ensuring they understand the rationale behind their treatment plans.
Treatment Approaches for IBS
Treatment for IBS can vary depending on subtype (IBS-D, IBS-C, or mixed type) and predominant symptoms. For patients with pain-related symptoms, medications that target nerve hypersensitivity, such as TCAs or SSRIs, may be prescribed. Antispasmodics like buspirone can be used to relax the muscles of the digestive system. Non-pharmacological approaches include dietary modifications (e.g., smaller meals, avoiding high-fat and high-fiber foods) and measures to relieve stress and improve overall well-being. It is important to have ongoing communication with patients, addressing concerns and adjusting treatment plans as needed.
Key Points about Treating Gut-Brain Axis Disorders
When encountering patients with gut-brain axis disorders, it's important to approach them with an open mind and avoid dismissing their symptoms as psychosomatic. Providing a positive diagnosis and explaining the rationale behind it can greatly enhance patient buy-in and the effectiveness of treatment. These disorders are heterogeneous, so tailoring the treatment to address specific symptoms is crucial. Collaborating with a multidisciplinary team, including psychologists and dietitians, can provide comprehensive care. Additionally, resources such as the Rome Psychogastroenterology section and ash.net can help in locating appropriate providers and training opportunities.
Action Plan and Treatment Strategies for Cyclic Vomiting Syndrome
For patients with cyclic vomiting syndrome (CVS), it is important to develop an action plan that addresses the different phases of the condition. Migraine prophylaxis, such as amitriptyline, propranolol, and cyproheptadine, can be used in the inter-episode phase to prevent episodes. Medications like lorazepam, analgesics, and triptans are used during the prodromal phase to abort an episode. In the episode phase, medications like IV ondansetron, lorazepam, quetiapine, and diphenhydramine can be used. The recovery phase can involve IV proton pump inhibitors, IV fluids, and other supportive measures. Non-pharmacologic interventions, including CBT and gut-directed hypnotherapy, can also be beneficial in managing CVS.
Approaches to Treating Gut-Brain Axis Disorders Involving Cannabis
When addressing gut-brain axis disorders associated with cannabis use, it is necessary to strike a balance between addressing the underlying condition and managing the use of cannabis as a potential exacerbating factor. Gradual reduction of cannabis use is advised, approaching it with empathy and providing patients with alternatives. Medications like haloperidol and those used to address cyclic vomiting syndrome can assist during this process. Holistic treatment plans encompassing psychological, dietary, and medical interventions are crucial for successful outcomes. Accessing resources like the Rome Psychogastroenterology section and ash.net can help in facilitating comprehensive care for patients with gut-brain axis disorders involving cannabis.
Discover DGBI! Learn its pathophysiology, evaluation and individualized treatments so you can leave the fear of managing DGBI behind. We’re joined again by the great Dr. Xiao Jing (Iris) Wang, (@IrisWangMD, Mayo Clinic)
