GI Disorders in Women: Pearls for the Practitioner

Educational Objectives

The goal of this program is to improve the management of various gastrointestinal (GI) disorders in women. After hearing and assimilating this program, the clinicians will be able to:

1. Differentiate between the symptoms of irritable bowel syndrome (IBS) and other GI conditions.
2. Recommend dietary, pharmacologic, and nonpharmacologic interventions for the management of IBS.
3. Devise an effective management plan for constipation and pelvic floor dysfunction.

Summary

Diagnosing irritable bowel syndrome (IBS): IBS is currently defined by the ROME IV criteria; the primary indicator is recurrent abdominal pain ≤1 day/wk, along with related symptoms; earlier guidelines included pain and discomfort but have since narrowed down criteria to pain alone; pain should be related to defecation and associated with changes in stool frequency and form; symptoms should persist for ≥3 mo, with symptom onset ≥6 mo before the diagnosis is made

Testing for suspected IBS: recommendations based on the 2021 guidelines of the American College of Gastroenterology — celiac serology is recommended; celiac disease affects ≈1% of the US population; assess immunoglobulins (Ig) A and G vs tissue transglutaminases and total IgA levels; selective IgA deficiency is the most common form of IgA deficiency; the second recommended test is fecal calprotectin to detect bowel inflammation; if fecal calprotectin testing is unavailable, lactoferrin can be used as an alternative; the third recommended test is C-reactive protein (CRP) to rule out inflammatory bowel disease; British guidelines support adding complete blood cell count (CBC) to enhance diagnostic accuracy, increasing the pretest probability from 87% to 95%; a comprehensive approach that includes celiac serologies, fecal calprotectin/lactoferrin, CRP, CBC, and clinical assessment can achieve 95% accuracy

Unnecessary tests for IBS: for individuals <45 yr of age without alarm symptoms, colonoscopy is not required; stool testing for pathogens is unnecessary unless there is a high risk for giardiasis; testing for food allergies using at-home kits is not recommended as they may not provide accurate results; the key to management is a positive diagnostic strategy based on a thorough history and limited diagnostic testing; this approach provides patient reassurance, timely treatment, improved patient education, and cost-effectiveness; IBS is not curable but can be managed

Diet: many individuals with IBS link their symptoms to food; fiber can impact gastrointestinal (GI) motility and the gut microbiome, leading to changes in gut transit speed and bacterial composition; dietary changes can reliably shift the microbiome; various diets have been explored for managing IBS, including low FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) diet, National Institute of Clinical Excellence (NICE) diet, and gluten-free and dairy-free diets; these diets aim to address dysregulated gut-brain axis which contributes to IBS symptoms through different mechanisms; implementing a restricted diet (eg, low FODMAP) causes a shift in the gut microbiome, with certain bacteria being elevated and others reduced; a meta-analysis (Black et al [2022]) showed that low FODMAP has the highest efficacy as an alternative diet and is the most likely diet to improve IBS

Low-FODMAP and NICE diets: FODMAP components can cause gas production and irritation in susceptible individuals; by reducing FODMAP intake, gut inflammation, fermentation, and gas production can be decreased, providing relief for many IBS symptoms; however, the diet is restrictive, eliminating commonly consumed foods like onions, garlic, and apples, which makes it difficult to maintain long-term; the low FODMAP diet is designed for short-term use; prolonged adherence may decrease gut biodiversity and potentially have a pro-oncogenic effect; the top-down approach eliminates all high-FODMAP foods for 6 wk, followed by gradual reintroduction to assess their impact on symptoms; another approach eliminates high-FODMAP foods one at a time; working with a dietitian is highly recommended; mobile apps and websites can be useful when dietitian support is not readily available; the NICE diet is easier to manage, offering more parental-like advice for patients; guidelines include eating regular meals, avoiding skipping meals or long gaps between eating, drinking ≥8 cups of fluid, limiting caffeine to 3 cups/day, and reducing alcohol and carbonated beverage intake

Potential risks with restrictive diets: these diets may trigger maladaptive responses and eating disorders in predisposed individuals; some may excessively restrict beyond the recommended duration or refuse reintroduction, leading to deficiencies or weight loss; avoidant restrictive food intake disorder (ARFID; recently added in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition) involves dietary restrictions related to negative consequences of eating; diagnosis of ARFID requires interference with nutrition or energy intake, significant weight loss, nutritional deficiency, dependence on enteral feeding or oral supplements, marked interference with psychosocial function, and no identified explanatory external factor, eg, perceptions of body image; awareness of eating disorders when using a restrictive diet is essential; herbal therapy is another IBS management tool; an open and informed conversation about potential benefits and limitations is necessary; while diet may offer relief to some, efficacy and safety can vary

Digital therapeutics for IBS: cognitive behavioral therapy (CBT) has long been recognized as beneficial for managing IBS; however, the challenge has been finding enough GI psychologists and specialists who can provide CBT; some digital therapeutics (eg, Mahana IBS, Regulora) are prescription-based and offer CBT and gut-directed hypnotherapy; early data suggest that these can provide durable benefits after 3 mo of use; subscription-based digital therapeutics (eg, Zemedy, Nerva) are not approved by the US Food and Drug Administration

Peppermint oil for IBS: peppermint oil has an antispasmodic effect and analgesic properties; has shown benefits in reducing IBS symptoms, with a number-needed-to-treat of 4 for global response and 7 for pain; has a low side-effect profile; can be used in small-bowel release formulations; immediate-release formulations may work better for functional dyspepsia or more proximal conditions, but for IBS, delayed-release formulations are preferred; peppermint oil relaxes the lower esophageal sphincter, which may cause heartburn or dyspepsia in some individuals

IBS in women vs men: IBS affects women more frequently than men, with a ratio of ≈2:1; hormones may play a role in IBS symptoms, particularly during menses; drop in hormone levels during menstruation can lead to increased bowel motility and diarrhea; unlike women without IBS, women with IBS tend to have heightened rectal sensitivity and increased nausea during their menstrual cycle; estrogen has pain and motility-modulating effects on the bowel through direct estrogenic receptors; progesterone relaxes smooth muscles; constipation is more common during progesterone-rich times of the cycle; prostaglandins increase motility and are also increased during menses, contributing to increased bowel motility, which leads to diarrhea

Constipation: medications, including those over-the-counter (OTC), are among the leading causes of constipation; symptoms may resolve with a change from constipating to nonconstipating medication; more common in women; there is a hormonal effect on motility; there is a higher rate of pelvic floor dysfunction (PFD) in women, even higher in those with history of child-bearing; women have a longer colon than men (≤1 ft) and a higher rate of pelvic surgery; slow transit constipation — characterized by infrequent bowel movements, ie, once per week or less frequently; patients do not feel the urge to pass stool regularly; accounts for 12% to 15% of cases; normal transit constipation — accounts for ≤50% of cases; patients have normal frequency of bowel movements but may experience other issues, eg, feeling of incomplete evacuation or straining; PFD — straining is always a component; failure of the pelvic floor to relax results in difficulty in passing stool and a sense of incomplete evacuation; may have Bristol stool scale type 1 or 2 stools, indicative of hard and lumpy stools; stool sits in the rectal vault for a prolonged period and becomes desiccated; patients may use facilitating maneuvers, eg, leaning on one side (“toilet Yoga”) or pushing on the perineum to aid in passing the stool; without treatment, PFD, which is treatable, can progress to slow transit constipation (more difficult to treat); recognizing PFD is critical

Mechanism of PFD: at rest, the angle at the rectum helps to maintain continence; with normal defecation, coordinated contraction and relaxation of various muscles facilitates passing of stool; with PFD, there is dyssynergic defecation with failure of relaxation or paradoxical contraction

Identifying PFD: a proper rectal examination can yield a specificity of 87%; inspect for lumps and hemorrhoids; perform a sensory examination, test the reflex, and palpate to assess for lumps; instruct the patient to squeeze the inserted finger as if trying to prevent stool from passing (more useful for incontinence), then instruct the patient to simulate defecation by pushing against the finger as if trying to push out stool; assess contraction of the abdominal muscles, relaxation of the anal musculature, and descent of the pelvic floor (optimally 1 cm)

Treatment of PFD: pelvic floor physical therapy is the primary treatment; ensure adequate fiber intake, good toileting habits, and heeding the urge to pass stool; timed voiding is beneficial

Nonmedicinal treatment of chronic constipation: defecation postural modification devices — change the angle of the hips while sitting on the toilet; provides a more squat-like position; helpful in ≈20% of individuals; kiwis — have been shown to improve straining, stool form, and complete spontaneous bowel movements with no increase in diarrhea; kiwis contain actinidin, which has a pro-motility effect; vibrating colon capsule — involves swallowing a vibrating capsule; initial research shows promising response rates of 41% and 64% in 2 trials; abdominal massage — improves number of bowel movements, abdominal pain, and abdominal distension, and decreases flatulence; should be avoided in people with IBS, recent abdominal surgery, or unstable spinal injuries

Fiber: recommended intake for women is 20 to 25 g/day; whole wheat starches, unrefined cereals, fruits, and vegetables are good sources; start incorporating fiber slowly to avoid bloating; ensure adequate hydration for optimal results; prune juice can help soften hard stools without increasing diarrhea; psyllium (useful for decreasing straining and improving stool frequency) and pectin are effective supplementary fibers

Pharmacotherapy: polyethylene glycol is a safe and effective option for managing chronic constipation and is suitable for all ages; magnesium oxide can also be used but requires careful titration to prevent diarrhea; if initial treatments are ineffective, OTC options (eg, senna, sodium picosulfate) can be considered as rescue therapy; prescription medications (eg, linaclotide, plecanatide, prucalopride) are effective for chronic constipation, especially in patients with pain or gastroparesis; start with low doses to manage side effects effectively

Readings

Bai T, Xia J, Jiang Y, et al. Comparison of the Rome IV and Rome III criteria for IBS diagnosis: A cross-sectional survey. J Gastroenterol Hepatol. 2017;32:1018-1025; Black CJ. Review article: Diagnosis and investigation of irritable bowel syndrome. Aliment Pharmacol Ther. 2021;54 Suppl 1:S33-S43. doi:10.1111/apt.16597; Black CJ, Staudacher HM, Ford AC. Efficacy of a low FODMAP diet in irritable bowel syndrome: systematic review and network meta-analysis. Gut. 2022;71:1117-1126; Daniali M, Nikfar S, Abdollahi M. An overview of interventions for constipation in adults. Expert Rev Gastroenterol Hepatol. 2020;14:721-732; Eswaran SL, Chey WD, Han-Markey T, et al. A randomized controlled trial comparing the low FODMAP diet vs. modified NICE guidelines in US adults with IBS-D. J Am Coll Gastroenterol. 2016;111:1824-1832; Kim YS, Kim N. Sex-gender differences in irritable bowel syndrome. J Neurogastroenterol Motil. 2018;24:544-558; Lacy BE, O'Shana T. Clinical pearls for irritable bowel syndrome: Management of the diarrhea-predominant subtype. Gastroenterol Nurs. 2014;37:392-405; Liedl B, Inoue H, Sekiguchi Y, et al. Update of the integral theory and system for management of pelvic floor dysfunction in females. Eur Urol Suppl. 2018;17:100-108; Werlang ME, Palmer WC, Lacy BE. Irritable bowel syndrome and dietary interventions. Gastroenterol Hepatol. 2019;15:16-26; Whelan K, Martin LD, Staudacher HM, et al. The low FODMAP diet in the management of irritable bowel syndrome: an evidence-based review of FODMAP restriction, reintroduction and personalisation in clinical practice. J Human Nutr Diet. 2018;31:239-255.

Disclosures

For this program, the following relevant financial relationships were disclosed and mitigated to ensure that no commercial bias has been inserted into this content: Dr. Young is a consultant for Elements Endoscopy. Members of the planning committee reported nothing relevant to disclose. Dr. Young’s lecture includes information related to the off-label or investigational use of a therapy, product, or device.

Acknowledgements

Dr. Young was recorded at Health of Women, 2023, held May 18-19, 2023, in Richmond, VA, and presented by Virginia Commonwealth University. For more information about upcoming CME activities from this presenter, please visit https://vcu.cloud-cme.com/. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 1.50 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 1.50 CE contact hours.

Lecture ID:

IM703601

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.