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Pathophysiology of Irritable Bowel Syndrome

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Pathophysiology of Irritable Bowel Syndrome ` Pathophysiology of Irritable Bowel Syndrome Rastita Widyasari, Iswan Abbas Nusi, Poernomo Boedi Setiawan, Herry Purbayu, Titong Sugihartono, Ummi Maimunah, Ulfa Kholili, Budi Widodo, Amie Vidyani, Muhammad Miftahussurur, Husin Thamrin 1 Department of Internal Disease, Faculty of Medicine Universitas Airlangga, Dr. Soetomo General Hospital, Jl. Prof dr. Moestopo 47 Surabaya 60132, Indonesia [email protected] Keywords: Irritable bowel syndrome, bowel habit, barrier, genetic, brain-gut axis Abstract: Irritable bowel syndrome (IBS) is a large bowel functional disorder characterized by abdominal pain or discomfort and is associated with bowel habit changes without organic disorder. IBS is affected by many factors and is suspected of involving central and peripheral mechanisms, such as gastrointestinal dysmotility, bowel visceral/mucosal hypersensitivity, increased bowel permeability and interaction among the luminal factors including food and bowel microbiota changes, bowel epithelial barrier, mucosa immunity, genetic factor and biopsychosocial and brain gut axis which are suspected to affect IBS pathophysiology. Understanding the various factors and mechanisms underlying IBS helps in the consideration of management and repair of patients’ prognosis. 1 INTRODUCTION requires high health costs. About 2 million prescriptions are given out by doctors to IBS Irritable bowel syndrome (IBS) is a functional patients and spend approximately $742 per year abnormality of the large bowel characterized by (Owyang 2009; Sperber, 2010). abdominal pain or discomfort and is associated with The pathophysiology of IBS remains unknown bowel habit changes without organic abnormalities. for certain to date. Genetic factors, intestinal IBS patients’ various complaints and the absence of microbiota, intestinal dysmotility, particularly certain diagnostic markers make clinical lactose intolerance, visceral hypersensitivity, mild presentation crucial in establishing IBS diagnosis inflammation, and abnormalities of brain-gut (Owyang, 2009). interaction are suspected to underlie IBS complaints Worldwide, IBS occurs in 3.6% - 21.8% of the (Park et al., 2010; El-Salhy, 2012). Understanding population with an average of 11%. In the United the various factors and mechanisms underlying IBS States, the incidence of IBS reaches 15% of the helps in the consideration of the management and population, in Asia the prevalence is between 2.9% - repair of patients’ prognosis. 15.6% of the population, while in Indonesia there is no documentation of the number of IBS incidents. Women are known to have more IBS than men with 2 LARGE BOWEL ANATOMY the ratio of 3:1 (Sperber, 2010; Mearin et al., 2012; Manan, 2014). The large bowel is a part of the lower IBS can occur at various ages, but its prevalence gastrointestinal tract, with the length of about 1.5 m decreases with age. At least 50% of IBS patients and diameter of 6 - 7 cm. It consists of cecum, colon, experience early symptoms before the age of 35 and rectum, and anus. The ileocecal valve lies at the it rarely occurs at the age of above 60 years where upper limit of the cecum and prevents the return of more organic abnormalities are found (Mach, 2004). the fecal matter from the cecum into the small IBS has a high social impact in the community and intestine. The appendix is located around 2.5 cm is influential in decreasing the quality of life. In the from the ileocecal valve. The colon consists of United States, IBS is the most common digestive ascending, transverse, and descending colon. The disease with an average of 10.6 visits per year and 470 Widyasari, R., Nusi, I., Setiawan, P., Purbayu, H., Sugihartono, T., Maimunah, U., Kholili, U., Widodo, B., Thamrin, H., Vidyani, A. and Miftahussurur, M. Pathophysiology of Irritable Bowel Syndrome. In Proceedings of Surabaya International Physiology Seminar (SIPS 2017), pages 470-476 ISBN: 978-989-758-340-7 Copyright © 2018 by SCITEPRESS – Science and Technology Publications, Lda. All rights reserved ` Pathophysiology of Irritable Bowel Syndrome anal canal is between the two medial borders of the neuron activity, improving sphincter function, and levator ani muscle. The sphincter muscle is able to improving smooth muscle tone of the withstand the occurrence of incontinence. The large gastrointestinal tract. The sympathetic fibers supply bowel has two main functions serving as a reservoir the lower esophagus, the pylorus, and the internal of residual digestion products and water absorbance and external anal sphincters. Most are excitatory and electrolytes in the process of digestion (Porth, nerves, but their role in controlling sphincters is 2011). poorly understood (Porth, 2011; Wood et al., 2012). 3 ENTERIC AND AUTONOMIC 4 CONCEPT OF BOWEL NERVOUS SYSTEM PHYSIOLOGY The intramural nerves in the gastrointestinal wall There were two aspects of bowel physiology that are consist of 2 plexuses, i.e. the myenteric/Auucach most relevant to explain the functional digestive plexus and the submucosal/Meissner plexus. Both disorders, i.e. sensation and motility aspects. Bowel plexuses are connected to ganglion cells along the mobility includes myoelectric activity, contraction, gastrointestinal wall. The myenteric plexus lies tone, regularity of movement, and transit periods between the muscles of the circular and the governed by reflex mechanisms and is strongly longitudinal muscles, while the submucosal plexus is associated with intestinal sensitivity (Browning and between the mucosal layer and the circular muscles. Travagli, 2014). The activity of neurons is governed by local stimuli, inputs from the autonomic nervous system, 4.1 Bowel Sensation Aspect and transmitter fibers connecting the two plexuses. The myenteric plexus consists of a linear chain of Gastrointestinal function is controlled by the enteric connecting neurons located along the gastrointestinal nervous system located in the gastrointestinal wall tract and has the biggest role in gastrointestinal and the sympathetic-parasympathetic nerves of the motility. Meanwhile, the submucosal plexus works autonomic nervous system. The concept of sensation to regulate segmental function in the gastrointestinal in the digestive system refers to the perceptual tract by integrating signals from the mucosal lining awareness of intestinal stimuli as well as afferent to regulate intestinal motility, intestinal secretion, input on the gastrointestinal sensory pathway, both and nutrient absorption (Porth, 2011; Wood et al., related to perception and reflex response. The 2012). activation of the vagal nerve afferent is known to The gastrointestinal tract is also innervated by modulate viscera pain. The stimulus of neurons from the autonomic nervous system by both the the afferent spine fibers and received directly by the sympathetic and parasympathetic nerves. The spinal dorsal horn will be delivered to the parasympathetic nerve innervates the abdomen, supraspinal to the cortical regions where the small bowel, cecum, ascending colon, and transverse perception of consciousness is generated. In colon through the vagus nerve. The descending addition, wobble viscera is also innervated by a colon is innervated by the parasympathetic nerves group of spherical sensitive splanchnic afferent derived from the sacral segments of the spinal cord. fibers (Kellow et al., 2006). The parasympathetic preganglionic fibers will affect the intramural plexus and work directly on the 4.2 Bowel Motility Aspect intestinal smooth muscle. Most of the parasympathetic fibers are excitatory components Bowel motility functions include propulsion along (Porth, 2011). the gut, mixing bowel contents with digestive In addition, gastrointestinal sympathetic enzymes, directing the digestive product to the innervation travels through the thoracic ganglia, absorption surface area, preventing retrograde celiac, superior mesenteric, and inferior mesenteric. movement of intestinal contents, as well as Sympathetic control is largely mediated through removing the digestive residue. Motility is changes in neuronal activity in the intramural controlled by reflexes, both central and peripheral plexus. The sympathetic nervous system acts to reflexes, as well as brain-gut axis. Gastrointestinal control mucosal secretions by mucosal glands, contractions can be classified by duration, such as reducing motility by inhibiting intramural pyelid 471 ` SIPS 2017 - Surabaya International Physiology Seminar phasic contractions/short duration and tonic/continuous contractions. Phasic contractions play a role in the movement 4.4 Anus and Defecation Process of digestive products while tonic contractions are beneficial in food-storing function such as in the Under normal conditions, the anus is in a closed proximal abdomen, large bowel, and sphincter areas. position. The anal closure is governed by the Communication between the various intestinal areas Kohlrausch valve, the puborectal muscles, the is facilitated by the transmission of myogenic and internal and external anal sphincter muscles, and the neurogenic longitudinal signals throughout the gut anal vein. Both types of sphincter muscles will have (Kellow et al., 2006; Browning and Travagli, 2014). tonic contraction. The internal sphincter muscle is Motility of the gastrointestinal tract moves intrinsically stimulated by the sympathetic nerves rhythmically continuously to encourage food (L1, L2) through the adrenoceptor signal, whereas products to move in the gastrointestinal tract. The the external sphincter muscle (a striated muscle)
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