Irritabel tarm – hvor sitter problemene egentlig?

Jørgen ValeurGastromedisinsk avdeling, OUS Ullevål

27. OUS-symposium 8. og 9. november 2018

Prof. dr.med. Holger Ursin (1934-2016)

Agenda

• Symptomer• Patofysiologi• Håndtering

Irritabel tarm-syndrom (IBS)Kardinalsymptomer

ForstoppelseDiaré

SmerteUbehag

GassproblemerOppblåsthet

Flatulens

T R I A D E

«Negativ diagnostikk»

«Positiv diagnostikk»

<https://theromefoundation.org/>

El-Salhy (2012)

Sentralnervesystemet– Hvilken rolle spiller psykiske forstyrrelser?

Psykiske forstyrrelser kan gi symptomer fra mage-tarm-kanalen

Forstyrrelser i mage-tarm-kanalen kan gi psykiske symptomer

Psykiske forstyrrelser kan påvirke opplevelsen og tolkningen av symptomer fra mage-tarm-kanalen

Dr. William Beaumont & Alexis St. Martin

William Beaumont (1785-1853) Alexis St. Martin (1794-1880)

Brain-gut axis– ”top-down”

Gut-brain axis– ”bottom-up”

Neural axis (nerve signals)

Humoral axis (hormones)

Berntson GG et al,Eur J Neurosci 2003

NTS = nucleus tractus solitarii; reléstasjon for viscerale afferente fibre

Collins & Bercik, Gastroenterology (2009)

Modified from Drossman

«It is much more important to knowwhat sort of a patient has a disease,

than what sort of a disease a patient has»

Sir William Osler (1849-1919)

Functional gastrointestinal disordersApproach and treatment

1) Establish a therapeutic alliance2) Examinations to exclude organic diseases3) Examinations to exclude psychiatric disorders4) Explanation and reassurance. Keyword: Stress5) Life style modifications. Keyword: Regularity6) Psychotherapy, if indicated7) Drugs, if indicated

The therapeutic alliance– Is the customer always right?

• Cooperation between two ”experts”

The patient– Symptom perception cannot be questioned– The patient is best qualified

The therapist– Symptom interpretation and attribution can be questioned– The patient is not necessarily best qualified

• Together, the two ”experts” should explorethe most realistic and useful explanations

Examinations to exclude organic diseases

Always necessary to a certain extent– Therapeutic aspect (reassurance)

Unnecessary and inappropriate investigationscan be harmful (i.e. Ulysses syndrome)– May reinforce anxiety (anxiety is contagious!)

Explanation and reassurance

Life style modifications...

Tarmen liker regelmessighet

«Alt som er hyggelig er godt for maven»Mummipappa

www.lmfnorge.no

http://www.helse-bergen.no/no/OmOss/Avdelinger/mage-tarmsykdommer/Sider/default.aspx

Noen (forholdsvis ukontroversielle) kostholdsråd

• Avslapping før og under måltid

• Små og hyppige måltider – regelmessig

• Forsiktighet med– Sterkt krydder, kaffe, te, tobakk– Fett? Kan gi gassretensjon– Mat som gir stor gassdannelse, i.e. FODMAP

• Fiber?– Vannuløselig: Gjør ofte vondt verre…– Vannløselig: Havregrøt!

Giuseppe Arcimboldo (1527-1593):Vertumnus (ca. 1590)

Lav FODMAP-diett sammenliknet med tradisjonell IBS-diettLena Bøhn, dr.avhandling, Gøteborg 2015

Probiotics?

McFarland & Dublin. WJG (2008)

McFarland & Dublin. WJG (2008)

Publisert 02.11.2017, kl. 07:27

Psychotherapy?

• If a psychiatric disorder is present– Specific treatment, often combined with drugs

• If psychological factors are predominant(dysfunctional thinking patterns)– Cognitive behavioral therapy (CBT)

(help to cope with the impact of the disorder)

Drugs?

Fra Magnus Simrén

Berstad & Valeur. NGF-nytt 2012; nr. 4: 10-12 (www.gastroenterologen.no)

Havre

Patrick Murray, 5th Lord Elibank (1703–1778), parerte:"Yes, and where else will you see such horses and such men?"

Samuel Johnson (1709-1784), definerte havre slik:"A grain, which in England is generally given to horses, but in Scotland supports the people“

Organisk Funksjonell

Lykke til!

”Keep an open mind– but not so open that your brain falls out!”

Richard Feynman