Consenso Latinoamericano sobre Síndrome de Intestino Irritable

IBS in Mexico and Latin-America:
Epidemiology and Sociocultural Issues
Max Schmulson
Professor of Medicine
Laboratorio de Hígado, Páncreas y Motilidad (HIPAM)-Department of Experimental
Medicine, Faculty of Medicina
Universidad Nacional Autónoma de México-UNAM
Hospital General de México
IBS prevalence
in
Latin-America
35.5%
16.0%
13.2%
19.9%
14.8%
10.7%
24.7%
22.1%
13.5%
26.2%
24.0%
11.7%
10.9%
Population:
10.9-26.2%
10.7-35.5%
Community-based
Volunteers
Not reported
Prevalence of IBS subtypes in Latin America
90
85.7
80
70
60
57.7
50
50
%
40
30
40
41.2
48.6
43.8
43
43
35.7
32.1
27.9
30
27.9
25.5
19.819
20
20
34
23
15
9.9
10
5.6
0
Mexico Cty
Rome II
(n=324/115)
Tlaxcala-Mex Veracruz-Mex
Rome II
Rome II
(n=500/80)
(n=459/78)
IBS-C
Schmulson M, et al. Dig.Dis. 2006;24:342-7.
López-Colombo A, et al. Gastroenterology. 2006;130(Suppl.2):A508.
Valerio-Ureña J, et al. Rev Gastroenterol Méx. 2010;75:36-41.
2.8
9.5
4.8
4.5
Mexico-Natl
ColombiaBrazil-Natl
Rome III
Bucara. Rome
Rome III
(n=1677)
III (558/111)
(N=1510/373)
IBS-D
IBS-A/M
Peru-Lima
Rome II
(N=197/21)
Argentina-13
Areas Rome II
(N=831/100)
IBS-U
Francisconi CF, et al. Gut 2007;56:A196.
Prochazka R, et al. Am J Gastroenterol. 2006;101(Supl.):S476.
Olmos JA, et al. Gut 2010;59(Suppl.III):A361.
“Bloating”: A difficult symptom to investigate in
Spanish
Bloating in IBS patients in Mexico
100
100
p<0.001
99
• There is not a Spanish word for
“Bloating”.
• Patients usually refer to it as “feeling
pregnant”, “swelling”, “inflammation”,
“fullness” or even “distension”.
• In research questionnaires we ask for
the presence of: the “sensation of
distension” or “swelling”.
• The intensity is significantly higher
among patients in the 30-50 years
old-age group.
98
97
97.7
96.8
96.6
96
95.5
95
94
93
All
IBS-C
(N=1687) (n=725)
IBS-D
(N=95)
IBS-M
(N=819)
IBS-U
(n=48)
Bloating/Abdominal Distension
Schmulson M et al. Rev Gastroenterol Mex. 2010;75:427-38.
Remes JM et al. Am.J.Gastroenterol. 2003;98(Suppl.):S268.
Psychosocial factors that have been related to IBS in
Western Nicaragua
Epidemiological Surveillance System: 11000 homes (200000 inhabitants)
Intimate Partner Violence (IPV)
•
•
•
•
Traumatic War Experiences
965 Women, Age (mean): 37
Stable relationship:
55%
Education (<6th grade):
40%
Moderate-Extreme Poverty: 31%
(Sandinista Revolution 1975-79)
• N: 1012, W: 64%, Age: 29-65
• War experience: 19% (M: 35%, W: 9%)
• IBS: 15% (W: 17%, M: 12%)
IBS significant associations
IBS and IPV
N
Physical
(%)
Sexual
(%)
IBS-Rome II
151
24
9
Controls
300
13
3
2.1(1.3-3.5)
3.4(1.4-8.2)
OR (95%CI)
Becker-Dreps S, et al. Gastroenterology 2008;134(Suppl.1):A417.
Women
Witnessing
an
execution
Relative
killed/
injured
Physical/
psychol.
abuse
++
+
+
+
+
+
+
+
+
Men
Older (>43)
+
Multiple
traumas
Wurzelman D, et al.Gastroenterology 2008;134(Suppl.1):A112.
Factors associated with IBS in Latin America:
GI Infections, Diet and Living Conditions
Mexico:
–
First manifestations of IBS-Rome I patients in a
tertiary referral center, was related to1:
•
•
•
•
•
–
Nicaragua:
Surgeries:
Emotional factors:
Organic diseases:
Infections:
None identified:
–
•
26%
22%
15%
6%
31%
•
–
Foods triggering/exacerbating symptoms in IBSRome III patients in GI-private clinics nationwide2:
•
•
•
•
Fatty foods
Spicy/highly seasoned
Legumes
No relationship with artificial sweeteners
•
IBS-Rome II (phone survey- 223 cities) was
related to5:
•
•
•
clinics3
Past history of parasitic infections: 49%
–
–
–
–
E. histolytica:
Giardia:
Tenia, Ascaris, Trichuris:
Combinations:
30%
3%
3%
5%
Lower educational level
Younger age
No impact of socieconomical status
Chile:
–
IBS-Rome II (5 areas)6:
•
1. Ortíz OM, et al. Rev.Gastroenterol.Méx. 2003;68(Supl.2):98-99.
2. Schmulson M, et al. Rev Gastroenterol Méx. 2010;75:427-38.
3. Bufanda L, et al. An Med Intern (Madrid). 2002;19:179-82.
Presence of water system
Indoor sanitation
Severe poverty
Brazil:
Guatemala:
IBS-Rome I patients consulting to GI
No difference in parasite burden in IBS vs.
Controls: 17 vs. 15% (IBS patients: 6%)
No difference in risk for IBS with pathogens or
commensals
Socieconomic factors did not affect the risk for
IBS-Rome II4:
•
•
•
–
–
Stool exams, IBS-Rome II (N=163) vs. Controls
(N=194)4:
No difference according to educational level
4. Benshoff M, et al. Gastroenterology. 2008;134(Suppl.1):A-104.
5. Francisconi C, et al. Gut 2007;56(Suppl III):A533.
6. Madrid AM y col Gastroenterología Latinoamericana 2005; 16:392.
Reasons for medical consultations in IBS-Rome I
patients in Mexico
Factors/Reasons
Freq.
(%)
Overall
Intensity
(VAS)
Self
reported
importance
(VAS)
Anxiety
(HAD)
Depression
(HAD)
HRQOL
(SF-36)
Abdominal pain/
discomfort
78
11.7±0.7
10.4±0.7
+
+
No differences
Symptom
stressfulness
60
11.5±0.8
9.6±1.0
++
++
< GH**, VT**, MH*
Impairment in daily
function
33
12.5±1.1
7.2±0.8
+
+++
< PF**, RP*, GH**,
VT**, MCS**
Fear of cancer
11
12.8±2.9
6.3±1.1
+
+
< MH*
NS
<0.05
0.008
0.009/
0.002
*<0.01, **<0.05
p
Age: 41±2, F: 84%, College education: 48%, Average lenght of IBS: 6±1 years, IBS-C: 62%.
One factor: 35%, Two: 40%, Three: 17%, Four: 6%.
Schmulson M et al. J Psychosom Res. 2006;61:461-7.
Consultation to different health care providers in subjects
with IBS-Rome III vs. controls in Colombia
Medical Specialty
OR
95%(CI)
General
Practitioner
5.09
3.20-8.10
Specialists
2.94
1.65-5.17
Alternative
Medicine Providers
2.34
1.08-4.84
Gómez Alvarez DF y cols. Gastrenterol Hepatol. 2009;32:395-400.
Satisfaction with pharmacological treatments and
use of CAM in IBS in Mexico
Previous treatment for IBS
CAM
60
60
55
51
50
50
51
40
40
33
29
% 30
20
20
% 30
20
15
10
10
8
4
0
0
Previous
Treatment
Quite
Moderately
Not at all
Effectiveness/Satisfaction
Schmulson M, et al. Rev Gastroenterol Méx. 2010;75:427-38.
Relative
MD
CAM
Friend
Other/Media
Treatment
Source of Recommendation
Carmona-Sánchez R et al. Rev Gastroenterol Méx. 2005;70:393-8.
Excesssive work-up/
investigations in patients
with IBS in Mexico
IBS-Rome I (N)
98
Gender (F %)
71
Diagnostic test
N (median/year)
2.8 years
CBC
1.97
Sedimentation rate
0.35
Stools for ova and parasites
1.44
Occult blood tests
1.08
Blood chemistry
3.41
Flex Sig
0.54
Barium Enema
0.72
Colonoscopy
0.18
Age (Years: mean)
41
Urinalysis
2.6
IBS diagnosis during first visit (%)
87
Urine culture
1.25
Lipids
3.24
Electrolytes
1.08
Coagulation
0.72
Thyroid tests
0.89
Malabsorption/Celiac Disease
1.08
Upper GI Series
0.72
Upper Endoscopy
0.54
Small Bowel Follow Through
0.18
Abdominal US
0.54
EKG
0.72
Chest Rx
1.08
Diagnostic tests (%)
Number of diagnostic tests
Mean (range)
-Previous to DX
-Post Dx
Schmulson M. Rev. Gastroenterol. Mex. 1998;63:6-10.
98
22 (1-82)
5 (1-11)
17 (1-18)
The value of a limited diagnostic work-up in patients
fulfilling Rome II criteria for IBS in Mexico
Diagnostic Test
Abnormalities (%)
Organic Diagnosis
Frequency (%)
At least one abnormal (N=310)
64.0
At least one N(%)
88 (28.0)
CBC
4.0
Hypothyroidism
17 (5.5)
Sedimentation rate
15.0
Giardia
55 (17.8)
Stools ova/parasytes
46.0
Ascaris
2 (0.6)
Blood/stools
6.0
Amoeba
2 (0.6)
TSH
8.0
Oxyurus (Pinworm)
1 (0.3)
Visualize Colon (>45 yo)
6.5
Lymphocitic Colitis
2 (0.3)
-
Esinophilic Colitis
1 (0.3)
Uterine Myomas
2 (0.6)
-Flex Sig
(N=19)
-Barium enema (N=85)
3.9
-Colonoscopies (N=50)
2.6
IBS-A: 49%, IBS-D: 45%, IBS-C: 29%, p<0.01
N=1565
Carmona-Sánchez R et al. Rev Gastroenterol Méx. 2004;69:18-23.
Traits anxiety and depression are related to the number
of days with abdominal pain/discomfort in IBS patients
in Mexico
Trait Anxiety: 70.3%, Depression: 45.9%, Both: 40.5%
Patients (%)
50
45
P=0.03
45
40
40
35
35
30
30
25
25
20
20
15
15
10
10
5
5
0
P=0.006
1-2
3-4
Anxiety
5-6
Without
7
Days/Week
Abdominal
pain/discom.
0
1-2
3-4
Depression
5-6
7
Without
Days/Week
Abdominal
pain/disc.
Reséndiz-Figueroa FE, et al. Rev Gastroenterol Mex. 2008;73:3-10.
Conclusions
•
In Latin America, IBS has a prevalence that ranges between 11 and 26% in the community
and IBS-C is the most common subtype.
•
Although there is not a word for bloating, this symptom is very commonly reported
among patients with IBS.
•
IBS has been related to previous war experiences, intimate partner violence, and spicy
and fatty foods but not to educational/socio-economical level.
•
Although it has not been related to parasitic infections, it is necessary to rule these out
before diagnosing IBS.
•
Abdominal pain/discomfort and symptom stressfullness are the factors most commonly
driving medical consultations in these patients. General practitioners are the most
commonly visited physicians for IBS while gastroenterologists are the least common
ones.
•
Consultation to providers of alternative medicine and CAM is most frequently used by
patients with IBS than controls.
•
IBS produces a high use of medical resources such as an excessive number of clinical
investigations, work absenteeism and has a negative impact on work productivity and
HRQOL.