Article: IBS, SSRI's & Colon Ischemia

[MightyMouse]

On the Relationship Between Colon Ischemia, Irritable Bowel Syndrome, and Serotonergic Therapy of Irritable Bowel Syndrome

Posted 09/24/2004

Lawrence J. Brandt, MD

Introduction and Context

The Problem

Colon ischemia and irritable bowel syndrome (IBS) are 2 common gastroenterologic disorders that, until recently, were thought to occur independently in very different populations. We know now, however, that there is a complex association between the 2: (1) colon ischemia appears to be more common in the IBS patient than was recognized previously; and (2) there is concern that the newly developed serotonin receptor agonists or antagonists may increase the risk of colon ischemia, and serotonergic signaling may be abnormal in patients with colitis. This review highlights some of the relationships between colon ischemia, IBS, and therapy for IBS.

IBS -- Pathophysiology and Clinical Presentation

IBS is a disorder that is diagnosed by various symptom-based criteria, such as the Manning, Rome, and Rome II criteria. IBS lacks any biologic, physiologic, structural, or serologic marker, and so diagnosis is symptom-based. Symptoms typically include abdominal discomfort or pain, bloating, diarrhea, fecal urgency, and constipation. Symptoms may change with time, and patients who have diarrhea or constipation as a major part of their illness may evolve to the opposite bowel habit or develop a pattern in which they alternate between the 2. IBS must never be considered as the explanation for rectal bleeding, bloody diarrhea, weight loss, fever, constitutional symptoms, or anemia, and in the presence of these "alarm" symptoms or signs, organic disease must be excluded using conventional stool tests, endoscopic, and radiologic examinations. For the IBS patient without alarm symptoms, the routine use of these tests is not recommended, although for patients with IBS and diarrhea, serologic testing for celiac sprue may be appropriate and cost-effective.[1,2] Of course, screening tests for colon cancer are recommended for all patients 50 years of age or older, including those with IBS.

Colon Ischemia -- Pathophysiology and Clinical Presentation

Colon ischemia generally presents in individuals older than 55 years, a population considerably older than that typically affected by IBS. The known causes of colon ischemia are many, but in the usual case, no definitive cause is found; most episodes of colon ischemia are thought to be caused by brief periods of localized nonocclusive ischemia. The acute onset of mild, lower abdominal pain accompanied or followed by diarrhea, rectal bleeding, or bloody diarrhea is typical. Most patients with colon ischemia have spontaneous resolution of symptoms within several days. Computed tomography of the abdomen usually shows segmental thickening of the colon, although this is not a specific finding. Colonoscopy, if performed within the first 24-48 hours, usually will show submucosal hemorrhage or edema in a segmental pattern (ischemic colopathy). If the examination is repeated within a few days after the onset of symptoms, it will show the disease process to have evolved into a segmental (ischemic) colitis pattern with ulceration and even pseudopolyp formation, an appearance that may mimic inflammatory bowel disease or infectious colitis; biopsy usually is nonspecific, with only infarction and ghost cells pathognomonic of ischemic injury. In general, mesenteric angiography is not used to evaluate patients suspected of having colon ischemia, because by the time of presentation, colonic blood flow usually has normalized.

It is important for primary care practitioners to be aware of colon ischemia because it is a common cause of bloody diarrhea in the elderly and can be seen in patients of all ages, especially those who have a coagulation disorder, systemic illness associated with vasculitis, or those with IBS. Moreover, colon ischemia can mimic or be mimicked by infectious colitis or inflammatory bowel disease. Most patients who develop colon ischemia do well with conservative management. For the patient who continues to have symptoms for more than 2 weeks, referral to a gastroenterologist is recommended because it is likely that these individuals will have a complicated course.

Lawrence J. Brandt, MD, Chief of Gastroenterology, Montefiore Medical Center, Bronx, New York; Professor of Medicine and Surgery, Albert Einstein College of Medicine, Bronx, New York

Disclosure: Lawrence J. Brandt, MD, has served as an advisor or consultant for Novartis, GlaxoSmithKline, Solvay, and TAP. He has also disclosed he is on the speakers bureau for AstraZeneca.

Medscape Gastroenterology 6(2), 2004. ? 2004 Medscape

[DancingLight]

thanks nina,

i am especially interested in all this b/c i am trying to figure out the cause of my gi pain and whether it is worth investigating or i should just chalk it up to POTS.

emily

[Merrill]

Emily, I should probably just email you, but maybe others are curious too ... Did the pyridium work for you in relieving the bladder discomfort? (Or not, which is why you went for that gallbladder test?)

Anyway, thanks, Nina, for posting the article, and Emily, I hope you're feeling OK.

m

[Guest Julia59]

Very interesting. I wonder if that is what is affecting my old neighbor whom i've known for over 35 years. Now his daughter is my sister in law almost for 25 years. She has also been one of my dearest friends for over 35 years----she was 7 and I was 8 when we met. Anyway he has suffered a lot of bleeding recently, and they are tying to figure out what's wrong.

I tried the zelnorm for my IBS------and the side affects are too much, and when I stopped things got much worse. Now I can barely go at all. It all gets stuck in the middle somehow----I get though A & B----but the digestion process doesn't seem to want to get to C.......UGGGGGG............

I have been a bear to say the least...............................

Julie :0)

[justin]

extremely interesting, as i have IBS (have had it for 10+ years) and about two weeks ago had an abnormal bleeding episode. i do have rectal bleeding sometimes but it's almost always on the paper only and it happens WITH bowel movements. this time it happened without a BM, and was heavy enough that it stained my underwear and turned the toilet bowl water red. (i apologize if this is TMI for some )

anyway, the bleeing stopped shortly after, but since then i've been having much worse bloating, gas, constipation and nausea than is usual for my IBS. and also very abnormal BM's.

on the other hand, from reading the article (i don't know anything about colon ischaemia apart from what i've just read there) it seems that this generally affects people over 55 and not 'young, "healthy" male(s)' as doctors always seem to refer to me.

[MightyMouse]

I think there were additional pages to the article that I am now unable to access on Medscape... those pages, I believe, were where they outlined the increased risk of ischemia with SSRI treatment.

Bleeding with BM's is usually hemoroidal if the blood is still red/pink--I've had the same thing Justin. Dark or black is typically blood that's come from farther up along the GI tract, such as bleeding from the colon (often described as "tarry").

yeah, sorry if TMI, but it's important info to know! We've had a few of these Too Much Info threads this week better to know that to have complications that could be prevented or treated early.

Nina

Edited October 7, 2004 by MightyMouse

[Guest Julia59]

It's nice to have a place to go----THE FORUM ----to talk about such things as IBS---slow gut motility----and all the ugly things that can happen to our bodies.

All these accessories that are spawned from our dysautonomia--(ANS dysfunction) are no fun to deal with, and without this forum I don't know how I would deal with these daily struggles.

I don't find it TMI for me at all-------- Like you said Nina, this is very valued information that educates us, and helps us to cope with these undesirable accesories---

Thanks again for the information!

Julie

[Merrill]

Maybe not even hemmoroids--blood on paper only can be caused by "anal fissures" (small tears) and it's not serious; goes away on its own..though there's probably some nasty kind of treatment if it's causing a problem or is excessive or whatever.