irritable%20bowel%20syndrome
IRRITABLE BOWEL SYNDROME
Irritable bowel syndrome is a common chronic gastrointestinal condition characterized by abdominal pain and bloating with altered bowel habits.
There are no identifiable physical, radiologic or lab abnormalities indicative of organic disease.
Symptoms may be exacerbated by stress, alcohol or food.

Diagnosis

  • IBS patients do not have an increased risk of organic diseases compared to individuals without IBS, therefore the routine use of extensive diagnostic tests in IBS suspected patients is not necessary
  • Accurate history collection is needed for establishing the probability of a patient having an underlying organic cause of symptoms
  • Patients who present with any of the alarm symptoms listed above may have a higher incidence of organic disease and therefore routine diagnostic tests in these patients is considered appropriate
  • There are no structural, biochemical or physiological abnormalities that are demonstrated consistently in IBS patients
  • Diagnosis is thus symptom based and therefore, accurate history of patient’s symptoms is imperative

History

  • Careful history should include factors and medications that may mimic or exacerbate IBS symptoms
    • Eg Lactose, Sorbitol, Mg-containing antacids that could cause diarrhea
    • Eg anticholinergics and Ca antagonists that could cause constipation
  • Features in history that may be indicative of IBS:
    • Symptoms started >6 months ago
    • Aggravated by stress
    • Aggravated by meals
    • Frequent visits to the clinic due to abdominal problems without clear diagnosis
    • Symptoms worsen with anxiety/depression
    • with or without nausea, dyspepsia and/or heartburn

Physical Examination

  • Should reveal no evidence of organic disease that is responsible for patient’s symptoms
Abdominal Exam
  • May reveal nonspecific tenderness in left lower abdomen over the sigmoid colon
Rectal Exam
  • Should exclude anorectal abnormalities

Laboratory Tests

  • Complete blood count (CBC)
  • Erythrocyte sedimentation rate (ESR)/C-reactive protein (CRP), fecal calprotectin
    • Testing for inflammatory markers during 1st-line investigation avoids invasive procedures, eg colonoscopy or sigmoidoscopy, in excluding inflammatory causes of symptoms
  • Stool exam (WBC, ova, parasites, occult blood)
  • Antibody testing (tissue transglutaminase [TTG], endomysial antibodies [EMA])
  • Thyroid function tests

Evaluation

Symptom-Based Criteria for Diagnosis of IBS (ROME IV Criteria)
  • Recurrent abdominal pain for at least 1 day/week in the past 3 months with >2 of the following:
    • Related to defecation
    • Associated with change in stool frequency
    • Associated with change in stool form (appearance)
  • Above criteria met for the past 3 months with symptoms starting at least 6 months prior to diagnosis
Symptoms cumulatively supporting the diagnosis of IBS
  • Bloating
  • Abnormal stool frequency (>3x/day or <3x/week)
  • Abnormal stool form (hard/lumpy or mushy/watery)
  • Abnormal stool passage (straining, urgency or feeling of incomplete evacuation)
  • Passage of mucus
Subclassification of IBS (ROME IV Criteria)
  • IBS with predominant diarrhea (IBS-D)
    • Mushy or watery stools >25% of bowel movements
    • Hard or lumpy stools <25% of bowel movements
  • IBS with predominant constipation (IBS-C)
    • Hard or lumpy stools >25% of bowel movements
    • Mushy or watery stools <25% of bowel movements
  • IBS with mixed bowel habits (IBS-M)
    • Both hard or lumpy and mushy or watery stools >25% of bowel movements
  • IBS unclassified (IBS-U)
    • Diagnostic criteria for IBS are met but bowel habits cannot be classified into 1 of the 3 groups above
    • May result from frequent changes in medications or diet or inability to discontinue medications affecting GI transit 
  • Patients commonly transition between subclasses at which diarrhea and constipation are commonly misinterpreted
    • Patients who complain of “diarrhea” may refer to the frequent passing of formed stools
    • In some patients, “constipation” may refer to complaints associated with attempts at defecation and not lesser frequency of bowel movements

Specialist Referral for Further Evaluation

Diagnostic Tests
  • Eg sigmoidoscopy, barium enema, colonoscopy, fecal occult blood tests, stool for ova and parasites, stool for culture
  • Routine colon cancer screening is recommended for all patients ≥50 years old 
    • >40 years in areas with high prevalence of gastric cancer

Assessment

Determine Severity of Symptoms
  • IBS symptoms can significantly diminish the quality of life of the patient
  • There is no data available to guide recommendations about the threshold to treat IBS
  • For some patients, it may be enough to be assured that their symptoms do not represent a life-threatening illness or cancer
  • Treatment should be offered to patients if it is felt that the symptoms are diminishing their quality of life
  • Below are general classification suggestions:
Mild
  • Infrequent symptoms
  • Little or no functional impairment or psychologic disturbance
  • Treatment should focus on establishment of physician-patient relationship, patient education, reassurance, dietary modification and fiber supplementation
Moderate
  • Disruptions of normal daily activities due to exacerbations of symptoms
  • May demonstrate psychologic distress
  • Symptom monitoring recommended to identify precipitating factors
  • Diet modifications, behavioral changes and psychotherapy may improve clinical picture
  • Pharmacologic intervention should be used to control symptom flares
Severe
  • Unrelenting pain often associated with underlying psychosocial difficulties
  • Treatment may involve behavioral modification, psychoactive drugs, and referral to a pain center
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