Irritabel tarm – hvor sitter problemene egentlig?
Jørgen Valeur
Gastromedisinsk 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
Forstoppelse
Diaré Smerte
Ubehag
Gassproblemer Oppblåsthet
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 know what sort of a patient has a disease, than what sort of a disease a patient has»
Sir William Osler (1849-1919)
Functional gastrointestinal disorders
Approach and treatment
1) Establish a therapeutic alliance
2) Examinations to exclude organic diseases
3) Examinations to exclude psychiatric disorders 4) Explanation and reassurance. Keyword: Stress 5) Life style modifications. Keyword: Regularity 6) Psychotherapy, if indicated
7) 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 explore the most realistic and useful explanations
Examinations to exclude organic diseases
Always necessary to a certain extent – Therapeutic aspect (reassurance)
Unnecessary and inappropriate investigations can 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-diett
Lena 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