36 DIARRHEA,CONSTIPATION, D AN
wel SY
AKURRITABLE BO NDROME
William J. Spruill dan William E.
Wade
KONSEP
UTAMA
4 Bismuth
subsalisilat dipasarkan untuk gangguan
1 Diare
disebabkan oleh banyak organisme virus dan
pencernaan, mengetahui kembali kram perut, dan
bakteri. Paling sering adalah ketidaknyamanan kecil, tidak
mengendalikan diare, termasuk diare pada pelancong,
mengancam jiwa, dan tetapi mengandung banyak komponen yang mungkin
biasanya terbatas. beracun jika diberikan secara berlebihan.
3 Penatalaksanaan
diare berfokus pada
6 Dasar
perawatan sembelit adalah serat makanan atau
pencegahanberlebihan kehilangan air dan elektrolit yang,
pencahar pembentuk massal yang menyediakan 10 hingga
perawatan makanan, menghilangkan gejala,
mengobati
penyebab yang dapat disembuhkan, dan mengobati 15 g / harimentah
gangguan sekunder. sera
t. beberapa budaya Timur seperti di Afrika, menghasilkan tinja
dengan berat lebih dari 300 g / hari.
Diare dapat dikaitkan dengan penyakit spesifik pada testis
7 Irritable bowel syndrome adalah salah satugas-paling
atau sekunder dari penyakit di luar usus. Misalnya, disentri basiler
umum gangguanusus yang, dan ditandai denganlebih secara langsung memengaruhi usus, sedangkan diabetes mellitus
menyebabkan episode diare neuropatik. Selain itu, diare dapat
rendah nyeri
perut yang, buang air besar yang terganggu,
dianggap sebagai penyakit akut atau kronis. Diare infeksius sering
dan kembung. Banyak manifestasi nongastrointestinal juga akut; diare diabetes kronis. Apakah akut atau kronis, diare memiliki
ada dengan IBS. Studi terbaru telah menemukan bahwa penyebab patofisiologis yang sama yang membantu identifikasi
hipersensitivitas visceral adalah penyebab utama dalam perawatan tertentu.
patofisiologi penyakit.
EPIDEMIOLOGI
8 IBS
yang dominan diare harus dikelola dengandiet
Epidemiologi diare bervariasi di negara maju dan negara
modifikasidan obat-obatan seperti loperamide ketikadiet berkembang.1-3 Di Amerika Serikat, penyakit diare biasanya tidak
perubahansaja tidak cukup untuk mengendalikan dilaporkan ke Centers for Disease Control and Prevention (CDC)
gejala. yang tidak terkait dengan wabah atau organisme atau kondisi yang
tidak biasa. Misalnya, sindrom defisiensi imun yang didapat
9 Beberapa
kelas obat yang terlibat dalam pengobatan (AIDS) telah diidentifikasi dengan penyakit diare yang
berkepanjangan. Diare adalah masalah utama
rasa sakit yangterkait dengan IBS, termasuk senyawa
trisiklik dan
usus-selektif calcium channel
blockers.
aret 2005 22:45
DIARE
Karakteristik feses penting dalam menilai etiologi diare. Deskripsi rotavirus. Pengujian serologis
gastrointestinal, r khususnya
frekuensi, volume, konsistensi, dan warna memberikan petunjuk
diagnostik. Misalnya, diare yang dimulai di usus kecil antibodi menunjukkan peningkatan titer selama3 hingga 6 hari rr
menghasilkan feses yang banyak, encer atau berlemak (berminyak), periode, tetapi tes ini tidak praktis dan tidak spesifik.
dan berbau busuk; mengandung partikel makanan yang tidak
Kadang-kadang, total volume tinja harian juga ditentukan.
tercerna; dan biasanya bebas dari darah kotor. Diare kolon muncul
sebagai gerakan kecil, pucat, dan terkadang berdarah atau berlendir. Langsung visualisasi endoskopi dan biopsi dari usus besar dapat
Tenesmus rektal dengan flatus menyertai diare usus besar.
dilakukan untuk menilai adanya kondisi seperti kolitis atau r.
GB109-36 2 Maret 2005 22:45 kanker Studi radiografi sangat membantu dalamneoplastik dan
inflamasi
kondisi.
BAB 36 DIARRHEA, KONSTIPASI, DAN SISTEM BOWEL YANG TIDAK DIRITRIT 679
PRESENTASI KLINIS
TABEL 36-1. Presentasi Klinis Diare
Tabel 36-1 menguraikan presentasi klinis diare sementara Tabel
TABEL 36-2. Obat-obatan yang
36-2 menunjukkan penyebab diare yang diinduksi oleh obat. Obat
Menyebabkan Diare
pencahar Antasida yang
mengandung magnesium
Umum r Biasanya, episode diare akut mereda dalam 72 jam setelah Antineoplastik Auranofin
(garam emas) Antibiotik
onset,
Klindamisin Tetrasiklin
sedangkan diare kronis sering melibatkan serangan selama periode
Sulfonamida Antibiotik
waktu yang lama. Tanda r dan gejala timbulnya mendadak mual, spektrum luas Antihipertensi
Reserpine
muntah, sakit perut, sakit kepala, demam, r, menggigil
dan malaise. Guanethidine
Methyldopa
Buang air besar yang sering dan tidak pernah berdarah, dan diare Guanabenz
jam. Intermiten periumbilikalis atau lebih rendah Cholinergik
berlangsung r 12-60
Bethanechol Neostigmine Agen
nyeri kuadran kanan dengan kram kardiak Quinidineobat-obatan.
Penyakit diare virus akut sering terjadi di pusat penitipan anak dan
rumah perawatan. Karena kontak orang-ke-orang adalah
■ MANAJEMEN NONFARMAKOLOGI
mekanisme penyebaran penyakit virus, teknik isolasi harus dimulai.
Untuk infeksi bakteri, parasit, dan protozoa, penanganan makanan Manajemen
yang ketat, sanitasi, air, dan praktik kebersihan lingkungan lainnya
dapat mencegah transmisi. Jika diare adalah sekunder dari penyakit
lain, mengendalikan kondisi primer diperlukan. Antibiotik dan diet adalah prioritas pertama dalam pengobatan diare. Kebanyakan
bismuth subsalisilat dianjurkan untuk mencegah diare, bersamaan dokter merekomendasikan untuk menghentikan konsumsi makanan
dengan pengobatan air minum dan kehati-hatian dengan konsumsi padat dan produk susu selama 24 jam. Namun, puasa adalah nilai
sayuran segar. yang patut dipertanyakan, karena modalitas perawatan ini belum
secara luas dihentikan. Pada diare osmotik, manuver ini
mengendalikan masalah. Jika mekanismenya keluar, diare tetap
■ HASIL YANG ada. Untuk pasien yang mengalami
DIINGINKAN
Gunakanantibiotik yang tepat penipisan ume, cairan oral atau parenteral / elektrolit, terapi simtomatik dan agen tidiarrheal (lihat Tabel
36-4), dan diet .
Berlangsung> 14 hari
Diagnosis
a. Obati penyebab spesifik
Demam atau gejala sistemik
Terapi simtomatik a. Penggantian cairan / elektrolit b. Loperamide,
diphenoxylate, atau absorbent c. Diet
mual dan / atau muntah, diet rendah residu yang ringan dan mudah dicerna harus diberikan selama 24 jam. Jika muntah hadir dan
diare kronis kronis
dengan antiemetik (lihat Bab 35 tentang mual dan muntah), tidak ada yang diminum. Saat buang air besar berkurang, diet hambar
dimulai. Pemberian makan harus dilanjutkan pada anak-anak dengan diare bakteri akut. Anak-anak yang diberi makan memiliki
lebih sedikit morbiditas dan mortalitas, terlepas apakah mereka menerima cairan rehidrasi oral atau tidak. Studi tidak tersedia di
lansia atau dalam kelompok berisiko tinggi lainnya untuk menentukan nilai pemberian makanan berkelanjutan pada diare bakteri.
■ AIR DAN
ELEKTROLIT Rehidrasi dan pemeliharaan air dan elektrolit adalah tujuan perawatan utama sampai episode diare berakhir. Jika
volume pasien habis, rehidrasi harus diarahkan untuk mengganti air dan elektrolit ke komposisi tubuh normal. Kemudian
komposisi air dan elektrolit dipertahankan dengan mengganti kehilangan. Banyak pasien tidak akan mengalami penurunan
volume dan oleh karena itu hanya akan memerlukan cairan perawatan dan terapi elektrolit. Parenteral dan enteral
Tidak ada diagnosis,
rute dapat digunakan untuk memasok air dan elektrolit. Jika muntah terapi simtomatik
dan dehidrasi tidak parah, pemberian makan enteral adalah metode yang lebih murah dan disukai. Di Amerika Serikat, banyak
persiapan rehalasi oral komersial tersedia (Tabel 36-3).
Karena kekhawatiran tentang hipernatremia, dokter terus dirawat di rumah sakit dan memperbaiki defisit cairan dan elektrolit
secara intravena pada dehidrasi parah. Solusi oral sangat dianjurkan.5,6 Di negara-negara berkembang, Solusi Reformasi Mulut
Organisasi Kesehatan Dunia (WHO-ORS) menyelamatkan kehidupan jutaan anak setiap tahun.
Selama diare, usus kecil mempertahankan kemampuannya untuk secara aktif mengangkut monosakarida seperti glukosa. Glukosa
secara aktif membawa natrium dengan air dan elektrolit lainnya. Karena WHO-ORS memiliki konsentrasi natrium yang tinggi,
dokter AS enggan menggunakannya pada anak-anak yang bergizi baik. Namun studi komparatif terkontrol menggambarkan hasil
yang lebih baik dengan WHO-ORS daripada dengan cairan parenteral.7 Asam amino meningkatkan transportasi natrium dan
bertindak sebagai penyebab yang mungkin:
a. Infeksi usus b. Penyakit radang usus
c. Malabsorpsi d.hormon sekretoris
Tumore. Narkoba, tiruan f. Gangguan motilitas
Pilih studi diagnostik yang tepat Misalnya, a. Biakan tinja / ovum /
parasit / WBC / RBC / lemak b. Sigmoidoskopi c. Biopsi usus
a. Hidrasi penuh b. Menghentikanberpotensi menyebabkan
obat yangc. Sesuaikan diet d. Loperamide atau
absorben
GAMBAR 36–2. Rekomendasi untuk mengobati diare kronis. Ikuti langkah-langkah ini: (1) Lakukan anamnesis dan pemeriksaan
fisik yang cermat. (2) Banyak kemungkinan penyebab diare kronis. Ini dapat diklasifikasikan ke dalam infeksi usus (bakteri atau
protozoa), penyakit radang (penyakit Crohn atau kolitis ulserativa), malabsorpsi (intoleransi laktosa), tumor hormon sekretorik (tumor
karsinoid usus atau VIPoma), obat (antasid), tiruan (pencahar), faktual (pencahar) penyalahgunaan), atau gangguan gerak (diabetes
mellitus, sindrom iritasi usus, atau hipertiroidisme). (3) Jika diagnosisnya tidak pasti, beberapa studi diagnostik yang sesuai harus
dipesan. (4) Setelah didiagnosis, pengobatan direncanakan untuk penyebab yang mendasari dengan terapi antidiare simtomatik. (5)
Jika tidak ada penyebab spesifik yang dapat diidentifikasi, terapi simtomatik ditentukan.
Sejarah dan pemeriksaan fisik
a b b b
WHO-ORS Pedialyte (Ross) Rehydralyte (Ross) Infalyte (Mead Johnson) Resolusi (Wyeth)
b c
Osmolalitas (mOsm / L) 333 249 304 200 269 Karbohidrat (g / L) 20 25 25 30 20 Kalori (kal / L) 85 100 100 126 80 Elektrolit (mEq / L)
Sodium 90 45 75 50 50 Kalium 20 20 20 25 20 Klorida 80 35 65 45 50 Sitrat - 30 30 34 34 Bikarbonat 30 - - - - Kalsium - - - - 4
Magnesium - - - - 4 Sulfat - - - - - Fosfat - - - - 5
Organisasi
Kesehatan Dunia Rehidrasi Oral Solution.
b
Karbohidrat adalah glukosa. c Padatan sirup beras
consisting mainly of
highly refined foods r GI disorders r Metabolic and endocrine disorders r Pregnancy r Neurogenic r Psychogenic r Drug-Induced r
Laxative abusers Symptoms seen with chronic constipation r Fluid and electrolyte imbalances (hypokalemia) r Protein-losing
gastroenteropathy with hypoalbuminemia r Syndromes resembling colitis Select appropriate diagnostic studies r P
rotoscopy r
■ DRUG REGIMENS OF
function 3 to 5 days after beginning a high-fiber diet, but some
patients may require a considerably longer period of time. Patients CHOICE
should be cautioned that abdominal distention and flatus may be
particularly troublesome in the first few weeks of fiber therapy, Treatment and prevention of constipation should consist of bulk-
particularly with high bran consumption. In most cases these forming agents in addition to dietary modifications that increase di-
problems resolve with continued use. etary fiber.23 A variety of products are available that provide
Bulk-forming laxatives have few adverse effects. The adequate bulk. Whichever agent is chosen, it should be used daily
only major caution in the use of bulk-forming laxatives is that and continued indefinitely in most patients, particularly those with
obstruction of the esophagus, stomach, small intestine, and colon chronic consti- pation. Bulk-forming agents available in
has been reported when the agents have been consumed without combination with diphenyl- methane or anthraquinone derivatives
sufficient fluid or in patients with intestinal stenosis. should not be used on a routine basis.For most persons with acute
■ DRUG
CLASSES
UBRICANTS
The traditional classification system for laxatives and cathartics by
suspected mode of action is not very useful, as this is not clearly ineral oil is the only lubricant laxative in routine use. This agent,
understood for many agents. In general, most of these products in- btained from petroleum refining, acts by coating stool and
duce bowel evacuation by one or more of the mechanisms lowing for easier passage. It inhibits colonic absorption of water,
ereby
associated with the etiology of diarrhea, including active electrolyte increasing stool weight and decreasing stool transit time.
secretion, decreased water and electrolyte absorption, increased ineral oil may be given orally or rectally in a dose of 15 to 45
intraluminal osmolarity, and increased hydrostatic pressure in the L. Generally, the effect on bowel function is noted after 2 or 3
gut. Laxatives convert the intestine from primarily an organ that ays of use.
absorbs water and electrolytes to an organ that secretes these Mineral oil is helpful in situations similar to those
substances. ggested for docusates: to maintain a soft stool and to avoid
raining for relatively short periods of time (a few days to 2
The various classes of laxatives are discussed in this section.
eeks); however, it possesses a much greater potential for adverse
These agents are divided into three general classifications: (a) those
causing softening of feces in 1 to 3 days (bulk-forming laxatives, fects and its routine use should be discouraged. Mineral oil may
do- cusates, and lactulose); (b) those that result in soft or semifluidabsorbed systemically and can cause a foreign-body reaction in
stool in 6 to 12 hours (diphenylmethane derivatives and mphoid tissue. Also, in debilitated or recumbent patients, mineral
anthraquinone deriva- tives); and (c) those causing water l may be aspirated, causing lipoid pneumonia.21 Mineral oil may
crease the absorption of fat-soluble vitamins (A, D, E, and K)
evacuation in 1 to 6 hours (saline cathartics, castor oil, and
polyethylene glycol-electrolyte lavage solution). ith chronic use by causing retention in the GI tract. Finally, even
hen given orally, mineral oil may leak from the anal sphincter,
using pruritus and soiling of clothing.
■ EMOLLIENT
LAXATIVES
LACTULOSE AND
Emollient laxatives are surfactant agents, docusate in its various
ORBITOL
salts, which work by facilitating mixing of aqueous and fatty
materials within the intestinal tract. They may increase water and
actulose is a disaccharide that is used orally or rectally. It is
electrolyte secretion in the small and large bowel. These products
etabo- lized by colonic bacteria to low-molecular-weight acids,
are generally given orally, although docusate potassium has alsosulting in an osmotic effect whereby fluid is retained in the
been used rectally. These products result in a softening of stools 22
lon. The fluid retained in the colon lowers the pH and increases
within 1 to 3 days of therapy.
lonic peristalsis. Lactulose is generally not recommended as a
first-line agent for the treatment of constipation because it is costly reversible after anthraquinones have been discontinued for 3 to 6
and not necessarily more effective than such agents as sorbitol or months.
milk of magnesia. It may be justified as an alternative for acute
constipation, and has been particu- larly useful in elderly patients.
Occasionally, the use of lactulose may result in flatulence, cramps, ■ SALINE
diarrhea, and electrolyte imbalances.27 Sorbitol, a monosaccharide, CATHARTICS
exerts its effect by osmotic action and has been recommended as a
primary agent in the treatment of func- tional constipation in Saline cathartics are composed of relatively poorly absorbed ions
cognitively intact patients.19 It is as effective as lactulose and much such as magnesium, sulfate, phosphate, and citrate, which produce
less expensive. their effects primarily by osmotic action in retaining fluid in the GI
tract. Magnesium stimulates the secretion of cholecystokinin, a
hormone that causes stimulation of bowel motility and fluid
secretion. These agents may be given orally or rectally. A bowel
■ DIPHENYLMETHANE
movement may result within a few hours after oral doses and in 1
DERIVATIVES hour or less after rectal administration.
These agents should be used primarily for acute evacuation
The two commonly used diphenylmethane derivatives are bisacodyl
of the bowel, which may be necessary before diagnostic
and phenolphthalein. Bisacodyl exerts its therapeutic effect by stim-
examinations, after poisonings, and in conjunction with some
ulating the mucosal nerve plexus of the colon. Phenolphthalein is
anthelmintics to eliminate parasites. Such agents as milk of
thought to inhibit active glucose and sodium absorption, resulting in
magnesia (an 8% suspension of magnesium hydroxide) may be used
fluid accumulation in the colon by osmotic action. With both of
occasionally (every few weeks) to treat constipation in otherwise
these agents, significant interpatient variability exists with dosing.
healthy adults. Saline cathartics should not be used on a routine
A dose that causes no effect in one patient may result in excessive
basis. The enema formulations of these agents may be useful in
cramping and fluid evacuation in others. With phenolphthalein, a
fecal impactions.
small portion of the dose undergoes enterohepatic recirculation,
which may result in a prolonged laxative action. As with most laxatives, these agents may cause fluid and
elec- trolyte depletion. Also, magnesium or sodium accumulation
These agents are not recommended for regular daily
may occur when magnesium-containing cathartics are used in
use. Their use is acceptable intermittently (every few weeks) to
patients with renal dysfunction or when sodium phosphate is used in
treat constipa- tion or as a bowel preparation before diagnostic
patients with congestive heart failure.
procedures in which cleansing of the colon is necessary. These
agents may sometimes cause severe abdominal cramping as well as
significant fluid and electrolyte imbalances with chronic use. They
■ CASTOR
should not be used for patients in whom appendicitis is a possibility
(perforation of the appendix may result) or during pregnancy or OIL
lactation. Finally, pa- tients using phenolphthalein-containing
laxatives should be cautioned that their urine might turn pink. Castor oil is metabolized in the GI tract to an active compound, ri-
cinoleic acid, which stimulates secretory processes, decreases glu-
■ ANTHRAQUINONE
cose absorption, and promotes intestinal motility, primarily in the
DERIVATIVES
small intestine. Castor oil usually results in a bowel movement
within 1 to 3 hours of administration. Because the agent has such a
Anthraquinone derivatives include cascara sagrada, sennosides, and
strong purgative action, it should not be used for the routine
casanthrol. Gut bacteria metabolizes these agents to their active
treatment of constipation.
com- pounds, but the exact mechanisms of action are not
understood. Effects are limited to the colon, and stimulation of
Auerbach's plexus may be involved. Recommendations for the use
■
of these agents are similar to those for the diphenylmethane
derivatives. In most cases, intermittent use is acceptable; daily use
GLYCERIN
should be strongly discouraged.
Glycerin is usually administered as a 3-g suppository and exerts its
Most of the concerns with the use of diphenylmethane
effect by osmotic action in the rectum. As with most agents given as
derivatives apply to the anthraquinone derivatives. In addition, the
suppositories, the onset of action is usually less than 30 minutes.
anthraquinone derivatives may cause melanosis coli, an
Glycerin is considered a very safe laxative, although it may occa-
accumulation of dark pig- ment, mainly in the cecum and rectum,
sionally cause rectal irritation. Its use is acceptable on an
that is evident after 4 to 13 months of use. A pathologic effect of
intermittent basis for constipation, particularly in children.
melanosis coli has not been demonstrated, and it appears to be
of these agents is without adverse consequences. Abuse of laxatives
GB109-36 March 2, 2005 22:45 has occurred tradi- tionally in persons trying to maintain daily
bowel function, but more recently has extended to others who use
laxatives for the purpose of controlling weight. In either case, the
consistent abuse of strong laxatives and cathartics may lead to
serious illness.
Laxative abuse AND
CHAPTER 36 DIARRHEA, CONSTIPATION, for the purpose BOWEL
IRRITABLE of maintaining
SYNDROMEdaily
689 bowel func- tion begins with misconceptions about the frequency,
quantity, or consistency of stools. With the use of strong purgatives,
the colon may be so thoroughly cleansed that a bowel movement
■ POLYETHYLENE may not oc- cur normally until a few days later. This delay
GLYCOL-ELECTROLYTE LAVAGE reinforces the need for more purgatives and the cycle of laxative
SOLUTION dependence is begun. Eventually the patient may require daily
in a bowel movement within 30 minutes. Soap-suds enemas are nolaxatives to maintain bowel function.
longer recommended as their use may result in proctitis or colitis. The laxative abuser may present with contradictory
findings of diarrhea and weight loss. In addition, long-term abusers
Whole-bowel irrigation with polyethylene glycol-electrolyte lavage of laxatives tend to have vomiting, abdominal pain, lassitude,
solution (PEG-ELS) has become popular for colon cleansing before weakness, thirst, edema, and bone pain (caused by osteomalacia).
diagnostic procedures or colorectal operations. With prolonged use of laxatives a number of serious illnesses may
Four liters of this solution is administered over 3 hours to arise. These include fluid and electrolyte imbalances (including
obtain complete evacuation of the GI tract. The solution is not acid-base imbalances and hypokalemia), protein-losing
recommended for the routine treatment of constipation and its use gastroenteropathy with hypoalbumin- emia, and syndromes
should be avoided in patients with intestinal obstruction. resembling colitis.
The determination of laxative abuse syndrome can be
difficult because many laxative abusers vigorously deny laxative
■ OTHER
use. Middle- aged women tend to be the most common laxative
AGENTS abusers. The chronic laxative abuse problem should be addressed
by a combination of measures, including psychiatric evaluation,
Tap-water enemas may be used to treat simple constipation. The ad- dietary modification with reliance on bulk-forming laxatives, and
ministration of 200 mL of tap water by enema to an adult often specific guidelines to the patient for the withdrawal of stimulant
results laxatives.
■ A variation of laxative abuse is seen in persons who use
PREVENTIO them as a means of weight loss. It appears from the medical
N literature and daily news sources that this type of abuse is on the
increase. Treatment of patients who abuse laxatives in this way has
proven very difficult.
For certain groups of patients, such as those recovering from
myocardial infarction or rectal surgery, straining at defecation is to
be avoided. The basis of preventive therapy in these patients should EVALUATION OF THERAPEUTIC
be bulk-forming laxatives. Additionally, the use of docusate is OUTCOMES
popular, although its effectiveness is debated. In pregnant patients,
constipation may result because of alterations in anatomy or iron The ultimate goal of treatment for constipation is alteration of
supplementation. As described earlier, bulk-forming laxatives and lifestyle (particularly diet) to prevent further episodes of
docusates should be the first line of prevention. constipation. Short-
term goals include alleviation of acute constipation with relief from
symptoms. For patients with chronic constipation, the goals are
more long-term and include use of proper diet and decreased
LAXATIVE ABUSE reliance on laxatives. Effective treatment of constipation requires
SYNDROME the patient to become more knowledgeable about the causes of
constipation, proper diet, and appropriate use of laxatives.
Misconceptions about normal bowel patterns and the effect of laxa-
tives have contributed to a syndrome of laxative abuse that is
relatively common in the United States. The availability of
laxatives as choco- lates or gums conveys to the public that the use IRRITABLE BOWEL
SYNDROME
gns rrrrrr and
symptoms Lower abdominal pain Abdominal
Irritable bowel syndrome (IBS) is one of the most common
gastroin- testinal disorders encountered in clinical practice, oating and distention Diarrhea symptoms, >3 stools/day
affecting as many as 20% of adults, and is more common in
xtreme urgency Mucus passage Constipation symptoms, <3
women. This latter point is probably a consequence of women
ools/wk, straining, incomplete r evacuation
being more likely than men to report their symptoms to the medical
Psychological
community. Although a benign disorder, IBS is chronic and
mptoms such as depression and anxiety
recurring in nature.
ongastrointestinal rrr symptoms Urinary symptoms
■ GENERAL APPROACH TO
TREATMENT ■ CONSTIPATION-PREDOMINANT
DISEASE
recep- tors on the neurons in the gastrointestinal tract, increasing GI motility and decreasing visceral sensations. It is approved as
2-mg or 6-mg doses given twice daily 30 minutes prior to a meal with water for up to 12 weeks.29 Stimulation of the 5-HT4
■ DRUG CLASSES CURRENTLY UNDER INVESTIGATION FOR THE TREATMENT OF IBS resulting in
drug discontinuation in 1.6% of study subjects.
Numerous agents are currently undergoing investigation for the man-
■ DIARRHEA-PREDOMINANT DISEASE
agement of IBS.33 Selective blockade of the muscarinic M3 receptors as
well as β3-adrenoceptor agonists have been shown to alter
For patients in whom diarrhea is the primary
gut motility without affecting the cardiovascular system.34 However, two 8
complaint, avoid-
ance of certain food products may be necessary. Caffeine, al-
Add serotonin-3 antagonists (eg, alosetron)
recently tested compounds, zamifenacin and darifenacin have shown limited efficacy to date.35 cohol, and artificial sweeteners
(sorbitol, fructose, and mannitol)
Other compounds being evaluated include neurokinin 1 and are known to irritate the gut and produce a laxative effect. Lactose
neurokinin 3 receptor antagonists, gut-selective calcium channel
blockers, cholecystokinin A receptor antagonists, and agents capa- ble of stimulating motilin receptors (motilinomimetics).36
IBS is usually classified as constipation-predominant, diarrhea- predominant, or IBS with abdominal pain and bloating. Therapeutic goals
in IBS should focus on the patient's primary complaint. Dietary and drug therapy goals should focus on end-organ treatment to relieve
abdominal pain (antispasmodic drugs) or disturbed bowel habits (an- tidiarrheals and bulk-forming agents). Additionally, severe symptoms
from central nervous system dysregulation should be treated with an- tidepressants, psychotherapy, relaxation/stress management, cogni-
tive behavior treatment, and/or hypnosis aimed at specific affective disorders.36 Lastly, the serotonin receptor agonists and antagonists can
be used in carefully selected patients whose symptoms are not ade- quately controlled with other agents. The American Gastroenterology
Association recommends that patients with severe IBS consider psy- chological treatments such as psychotherapy, relaxation/stress man-
agement, and/or cognitive behavior treatment.
ABBREVIATIONS
HT: serotonin IBS: irritable bowel syndrome ORS: oral rehydration solution PEG-ELS: polyethylene glycol-electrolyte lavage
solution PHM: peptide histidine methionine VIP: vasoactive intestinal peptide
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