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Gastroenterology
Table 3
Pharmacologic Therapy
Purpose When to use Class Examples Indication
Pain Control
First line
(mild symptoms)
Second line (mild to
moderate symptoms)
Antispasmodics
Tricyclic antidepressants,
SSRIs*
Dicyclomine, hyoscyamine,
encapsulated peppermint oil
Amitriptyline, fluoxetine*
Reduce spasms and pain
Reduce pain and diarrhea
Constipation First line Bulking agents Psyllium Restore stool motility
Chloride-channel activator Lubiprostone Severe, refractory constipation
Diarrhea First line Antidiarrheal Loperamide Reduce stool
Second line Serotonin-3 antagonist Alosetron Severe, refractory diarrhea
*few placebo controlled trials to support
against gliadin, a glycoprotein found in gluten-containing
cereals. Often, these disorders occur in patients carrying the
same human leukocyte antigen (HLA) genotypes associated
with celiac disease, DQ2 and DQ8.
This immunopathology was found earliest in family members
of people with celiac disease who, despite not having villous
atrophy, had evidence of immune responsiveness to gluten
(i.e., diarrhea after gluten ingestion). 15 This finding supports
the emerging consensus that gluten sensitivity is an abnormal
immune response to gluten that can occur without the intestinal
damage seen in celiac disease. However, some patients who are
sensitive to gluten but have negative biopsies and serology may
eventually develop mucosal damage. 16 No therapeutic guidelines
for gluten sensitivity have been published.
Lactose intolerance also causes IBS symptoms of diarrhea,
abdominal pain, flatulence and bloating. The prevalence of
lactose intolerance is unknown, 17 but it affects many racial and
ethnic groups in the United States. Symptoms are caused by
malabsorption of lactose due to a deficiency in lactase, which
is required to digest lactose. Lactase metabolizes lactose into
two simpler sugars, glucose and galactose, which are readily
absorbed into the bloodstream. This enzyme is produced by
expression of the lactase-phlorizin hydrolase gene in the cells
lining the small intestine. 17
Infants normally produce lactase and digest lactose in human
milk or infant formulas. After weaning, most children are
genetically programmed to produce less lactase. The symptoms
of lactose intolerance are caused by bacterial fermentation of
undigested lactose in the colon. 17
The demonstration of lactose malabsorption does not necessarily
indicate that a patient will be symptomatic. Many variables
determine whether a person develops symptoms, including
the amount of lactose ingested, the residual intestinal lactase
activity, the ingestion of food along with lactose, the ability of
the colonic flora to ferment lactose, and individual sensitivity
to the products of lactose fermentation. 17
Diagnosis
Functional GI disorders are diagnosed clinically. IBS is a
chronic, relapsing gastrointestinal syndrome diagnosed using
current Rome criteria. 3 Behavioral features of IBS that can help
diagnose it are: symptoms for more than 6 months; “frequent
flyer” visits for non-GI symptoms; prior medically unexplained
symptoms; and intensification of symptoms with stress.
Red flags for more significant or life-threatening diagnoses
(i.e., age older than 50, recent symptom onset, weight loss,
nighttime NP010603-0008 symptoms, Calmosep.qxd male gender, 11/24/03 family history 5:12 of colon PM Page 1
cancer, anemia, rectal bleeding and recent antibiotic use) warrant
thorough consideration. In the presence of these factors,
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