This issue of eMedRef provides information to clinicians on the pathophysiology, diagnosis, and therapeutics of irritable bowel syndrome

Dhaliwal, Khushi A.

Maroon, Michael

Monteleone, Guy

Shannon, Claude K.

Sperry, Jeannie A.

English

University of Missouri: MOspace

Irritable Bowel Syndrome Page 1 of 6    2.20.12 IRRITABLE BOWEL SYNDROME  Background 1. Definition o Chronic non-inflammatory bowel condition with no known structural or biochemical abnormalities1 2. General Information o Abdominal pain or discomfort that occurs in association with altered bowel habits for at least 3 months1 o Categorized by predominant bowel habit, based on stool frequency and consistency2  Constipation (IBS-C)  Diarrhea (IBS-D)  Mixed pattern (IBS-M) o Less than one-quarter with symptoms may be diagnosed3  Pathophysiology 1. Pathology of Disease o Uncertain o Possible primary mechanisms of symptom development4  Motility  Visceral hypersensitivity  Psychosocial factors  Infection/inflammation of enteric mucosa  Neurotransmitter imbalance  Altered perception of visceral stimuli 2. Incidence, Prevalence o Prevalence reported to range from 3% to 22% in Western countries3 o 1.5:1 female to male ratio1 o Consume >50% more health care resources than matched controls1 3. Risk Factor o Increased risk for other, non-GI functional disorders, including5  Fibromyalgia  Gastroesophageal reflux  Migraine  Asthma  Temporomandibular joint disorder  Dysmennorhea  Chronic fatigue syndrome  Psychologic disorders 4. Morbidity/Mortality o Significant direct and indirect costs of care1 o May have reduced quality of life6  Diagnostics 1. History o Individual symptoms have limited accuracy for diagnosing IBS, and therefore the disorder should be considered as a symptom complex1 Irritable Bowel Syndrome Page 2 of 6    2.20.12 o A variety of criteria have been developed to identify a combination of symptoms to diagnose IBS1  ACG Task Force criteria incorporated key features of previous diagnostic criteria for a pragmatic definition of IBS1  Abdominal pain or discomfort  Altered bowel function  Recurrence of symptoms over an extended period of time at least 3 months  There is no consistent difference in sensitivity or specificity between Manning, Rome1 and Rome II. Tests of Rome III criteria are needed12  The Manning Criteria1:  Onset of pain linked to more frequent bowel movements  Looser stools associated with onset of pain  Pain relieved by passage of stool  Noticeable abdominal bloating  Sensation of incomplete evacuation more than 25% of the time  Diarrhea with mucus more than 25% of the time  Rome I criteria1  Abdominal pain or discomfort relieved with defecation or associated with a change in stool frequency or consistency, PLUS two or more of the following on at least 25% of the occasions or days for 3 months:  Altered stool frequency  Altered stool form  Altered stool passage  Passage of mucus  Bloating or distension  Rome II criteria1:  Abdominal pain or discomfort that has 2 of 3 features for 12 weeks need not be consecutive in the last 1 year:  Relieved with defecation  Onset associated with a change in frequency of stool  Onset associated with a change in form of stool  Rome III criteria1:  Recurrent abdominal pain or discomfort** at least 3 days/month in the last 3 months associated with two or more of the following: o Improvement with defecation o Onset associated with a change in frequency of stool o Onset associated with a change in form (appearance) of stool  Criterion fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis Irritable Bowel Syndrome Page 3 of 6    2.20.12  ** “Discomfort” means an uncomfortable sensation not described as pain.  In pathophysiology research and clinical trials, a pain/discomfort frequency of at least 2 days a week during screening evaluation is recommended for subject eligibility. 2. Physical Examination o A general physical examination to rule out signs of systemic disease11 o Usually normal o May present with sigmoid tenderness 3. Diagnostic Testing  o Once a positive diagnosis is made using clinical criteria for diagnosis, one should look for alarm warning symptoms * or signs, and should categorize the type of bowel habit13 o Limited or no workup for those <50 y/o and no alarm symptoms (SOR:C)1 o Workup if patient > 50 y/o or has alarm symptoms, emphasizes colonic imaging (SOR:C)1 o Alarm symptoms *1  Anemia  Weight loss  Family history of colorectal cancer, inflammatory bowel disease or celiac sprue o Routine serologic testing for celiac sprue recommended for diarrhea or mixed type IBS (SOR:B)1 o Lactose breath testing should be considered when lactose maldigestion remains a concern despite dietary modification (SOR:B)1  Differential Diagnoses 1. Inflammatory Bowel Disease o Crohn’s disease o Ulcerative colitis 2. Medications o Laxatives o Constipating medications 3. Infections o Parasitic o Viral o Bacterial o Opportunistic 4. Malabsorption Syndromes o Celiac disease o Pancreatic insufficiency 5. Endocrine disorders o Hypothyroidism o Hyperthyroidism o Diabetes mellitus o Addison’s disease 6. Endocrine tumors o Gastrinoma o carcinoid Irritable Bowel Syndrome Page 4 of 6    2.20.12 7. Colorectal carcinoma o Adenocarcinoma o Villous adenoma 8. Intestinal pseudo-obstruction o Diabetes mellitus o Scleroderma 9. Lactose intolerance 10. Psychiatric disorders o Depression o Anxiety o Somatization disorder 11. Chronic diarrhea   Therapeutics 1. The current treatment approach often requires multiple trials of various medications because of diverse constellation of symptoms which may change over time14 2. Evidence is weak or moderate and inconsistent for any therapy. 3. The treatments below have the best evidence of effect. o Bulking agent psyllium may be effective in preventing constipation (SOR:B)1,7 o Probiotic preparations containing bifidobacteria promote symptom improvement (SOR:B)1,7  It has been shown to reduce pain, bloating, and defecatory difficulty, regardless of predominant bowel habit11 o Lubiprostone therapy promotes global symptom relief in constipation-predominant IBS (SOR:B)1,7 o Antispasmodic agents may provide short relief of abdominal pain/discomfort of IBS (SOR:C)1,11 Evidence of long term efficacy, safety and tolerability is limited (SOR:B)1,11 o Antidiarrheal agent like loperamide is no more effective than placebo at reducing global symptoms of IBS, but is effective for treatment of diarrhea (SOR:C)1,11 o The dose of laxative and antimotility agent should be titrated according to stool consistency with the aim of achieving soft, well formed stool10 o Short term course of non absorbable antibiotic like rifaximin is more effective than placebo for global improvement of IBS. No data supporting long term efficacy1,14 o Selective serotonin reuptake inhibitor (SSRI) therapy promotes global symptom relief and decreased abdominal pain (SOR:B)1,7 o Tricyclic antidepressant (TCA) therapy promotes global symptom relief and decreased abdominal pain (SOR:B)1,7 o Psychotherapy is suggested as superior to usual care for global IBS symptom improvement (SOR:B)1,7 o Cognitive behavioral therapy is suggested as superior to usual care for global IBS symptom improvement (SOR:B)1,7,8     Irritable Bowel Syndrome Page 5 of 6    2.20.12 Follow-Up 1. In mild cases, there is generally no medical  need for follow up consultations in the long term, unless: o Symptoms persist, with considerable inconvenience or dysfunction o The patient is seriously worried about the condition o Diarrhea >2 weeks o Constipation persists and does not respond to therapy o Warning signs/ alarm symptoms* for serious gastrointestinal disease develop o Beware of eating disorders developing from dietary manipulation  Prognosis 1. For most patients with IBS symptoms are likely to persist, but not worsen. A smaller proportion will deteriorate, and some will completely recover11 2. Factors that may negatively affect  prognosis: o Avoidance behavior related to IBS symptoms o Anxiety about certain medical conditions o Impaired function as a result of symptoms o Along history of IBS symptoms o Chronic ongoing life stress o Psychiatric comorbidity 3. Approaches that positively affect treatment outcome: o Acknowledging the disease o Educating the patient about IBS o Reassuring the patient  Patient Education2 1. Medline Plus: www.nlm.nih.gov/medlineplus/tutorials/irritablebowelsyndrome/htm/index.htm 2. National Digestive Diseases Information Clearinghouse: www.digestive.niddk.nih.gov/dduseases/pubs/ibs/ 3. International Foundation for Functional Gastrointestinal Disorders, Inc.: www.AboutIBS.org 4. WebMD: www.Webmd.com/ibs  References 1. American College of Gastroenterology Task Force on IBS. An evidence-based systematic review on the management of irritable bowel syndrome. Am J Gastroenterol. 2009; 104 (supple 1):S1-S35. 2. Davis RH. Overcoming barriers in irritable below syndrome with constipation (IBS-C). J Fam Prac. 58(5): S3-S20, 2009. 3. Hungin AP, Chang L, Locke GR, Dennis EH, Barghout V. Irritable bowel syndrome in the United States: prevalence, symptom patterns and impact. Aliment Pharmacol Ther. 2005;21:1365-1375. 4. Schwetz I, Bradesi S, Mayer EA. Current insights into the pathophysiology of irritable bowel syndrome. Curr Gastroenterol Report 2003;5:331-336. 5. Chey WD. The evidence-based diagnosis of irritable bowel syndrome with constipation.  J Fam Pract (suppl) 2009; 58(5):S8-S12. Irritable Bowel Syndrome Page 6 of 6    2.20.12 6. Gralnek IM, Hays RD, Kilbourne A, Naliboff B, Mayer EA. The impact of irritable bowel syndrome on health-related quality of life. Gastroenterol 2000; 119:654-660. 7. Heitkemper MM. Evidence-based treatments for irritable bowel syndrome with constipation. J Fam Pract. 58(5):S13-S20. 8. Lackner JM, Jaccard J, Krasner SS, Katz LA, Gudleski GD, Blanchard EB. How does cognitive behavior therapy for IBS work?: A meditational analysis of a randomized clinical trial. Gastroenterology 2007; 133(2):433-444. 9. Ruepert L, Quartero AO, de Wit NJ, van der Heijden GJ, Rubin G, Muris JWM 10. Bulking agents, antispasmodics and antidepressants for the treatment of irritable bowel syndrome, Cochrane 2011, Issue 11 11. Irritable bowel syndrome in adults: diagnosis and management of irritable bowel   syndrome in primary care, NICE clinical guideline 61,2008 Feb 12. Irritable bowel syndrome: a global perspective ,World Gastroenterology Organisation Global Guideline , April 20, 2009 13. Validation of symptom-based diagnostic criteria for irritable bowel syndrome: a critical review. Am J Gastroenterol 2010 Apr;105(4):814-20 14. Diagnosing irritable bowel syndrome: a changing clinical paradigm. South Med J 2011 Mar;104(3):195-9. 15. Trinkley, K. E. and Nahata, M. C. (2011), Treatment of irritable bowel syndrome. Journal of Clinical Pharmacy and Therapeutics, 36: 275–282   Authors:  Claude K. Shannon, MD; Khushi A. Dhaliwal, MD; Jeannie A. Sperry, Ph.D.; Michael Maroon, DO; & Guy Monteleone, MD,  West Virginia SOM Department of FM  Editor:  Robert Marshall, MD, MPH, MISM, CMIO,  Madigan Army Medical Center, Tacoma, WA   

Irritable bowel syndrome

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Irritable bowel syndrome

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