Irritable Syndrome Syndrome


Article Author:
Nicolas Patel


Article Editor:
Karen Shackelford


Editors In Chief:
Dustin Constant
Donald Kushner


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
1/9/2019 12:34:33 PM

Introduction

Irritable bowel syndrome (IBS) is one of the most commonly diagnosed gastrointestinal diseases. IBS, in the absence of any other causative disease, is defined as the presence of abdominal pain or discomfort with altered bowel habits. Diagnosis of IBS has evolved since its first discovery, and today the Rome III diagnostic criteria are used to diagnose IBS. Depending on the subclass of IBS, symptoms can be managed by a variety of medications and nonpharmaceutical agents. Nonetheless, IBS treatment should be individualized, and a significant factor in management remains a strong patient-physician relationship.[1]

Etiology

The etiology of IBS is broad and not clearly understood. However, as below in the pathophysiology section, motility, visceral sensation, brain-gut interaction, and psychosocial distress can all play a role in the development of IBS.

Epidemiology

Nearly 12 percent of patients seek medical care in primary care practices for IBS related complaints.[1][2] Studies have demonstrated that the prevalence of IBS ranges between ten and fifteen percent, however, the majority of these patients do not seek medical care.[1] IBS is most prevalent in South America at approximately 21 percent and least prevalent in Southeast Asia at 7 percent.[3][4] In the United States, Canada, and Isreal, IBS symptoms are 1.5 to 2 times more prevalent among women than men.[5] Moreover, women are more likely to report abdominal pain and constipation whereas men are more likely to report diarrhea.[5] The prevalence of IBS also decreases with age.[3] IBS can also be broken down into more specific diagnosis which includes IBS with diarrhea (IBS-D), IBS with constipation (IBS-C), and IBS with mixed bowel pattern (IBS-M). The prevalence of these three diagnoses differs in the United States versus Europe. In the United States, there is an equal distribution of these diagnoses whereas in Europe IBS-C or IBS-M can be more prevalent.[6]

Pathophysiology

The pathophysiology of IBS is broad and includes abnormalities involving motility, visceral sensation, brain-gut interaction, and psychosocial distress.[3] One of these can usually be demonstrated in the majority of IBS patients however not all symptoms can be attributed to them.[3] Recent studies have also shown altered gut immune activation, and intestinal and colonic microbiome are associated with IBS[3][7][8]. Environmental contributors to IBS include early life stressors, food intolerance, antibiotics, and enteric infections.[3] Patients often complain that IBS symptoms are related to food intake. However, a true food allergen has a limited contribution to IBS.[3][9]

Histopathology

Histopathology examination of the intestinal mucosa in those with IBS can show chronic inflammatory cells, mast cells, enteroendocrine cells, and enteric nerves.[10]. IBS-D is typically associated with a greater increase in mucosal T-lymphocytes than IBS-C.[10][11] Moreover, there can be an increased number of nerve fibers that stain positive for neuron-specific enolase, substance P and 5-HT.[10][12] There also appears to be a significantly increased density of nerve fibers around mast cells.[10][12]

History and Physical

IBS typically consists of abdominal pain or discomfort, altered bowel habits along with either constipation, diarrhea or both. Other complaints in patients with IBS include bloating, distention, symptoms brought on by food intake, and a change in pain location, and stool pattern with time.[3]. Concerning features would include onset after age 50 years old, severe or progressive symptoms, unexplained weight loss, nocturnal diarrhea, rectal bleeding, iron deficiency anemia, or a family history of organic gastrointestinal diseases such as colon cancer, celiac disease, or inflammatory bowel disease.[3] Additional history that would be important would include travel and social history.

The Rome III criteria is used to diagnose IBD, which requires at least 3 days a month in the last 3 months associated with 2 or more of the following: improvement in abdominal pain or discomfort with defecation, onset associated with a change in frequency of stool, and/or an onset accompanied by a change in form or appearance of stool[3].

Evaluation

If no alarm findings exist (weight loss, hematochezia, iron deficiency), routine diagnostic testing is not recommended.[1] If symptoms are not typical of IBS or alarm symptoms are present then a complete blood cell count, comprehensive metabolic panel, inflammatory markers such as erythrocyte sedimentation rate or C-reactive protein, and thyroid stimulating hormone level should be checked.[1] If diarrhea is predominant, fecal leukocytes and stool tests for Clostridium difficile, Giardia, and Cryptosporidium when appropriate should be ordered.[1] Testing for celiac disease may be needed as well, and a tissue transglutaminase or TTG-IgA can be obtained.[1] A colonoscopy may be beneficial when there is a family history of inflammatory bowel disease, colon cancer, or alarm symptoms.[1] If the patient has diarrhea, random biopsies should be done on colonoscopy.[1]

Treatment / Management

One of the most important goals in the management of IBS patients is to develop a trusting patient-physician relationship by actively listening, showing empathy, and setting a realistic expectation for treatment.[3][13] IBS is a symptom-based disorder, and thus treatment goals are aimed at resolving symptoms such as pain, bloating, cramping, and diarrhea or constipation.[3] For constipation, fiber supplements and laxatives can be helpful whereas, in those with diarrhea, medications such as loperamide or probiotics can be helpful.[3] Moreover, increased physical activity can increase colonic transit time and improve symptoms.[3][14] Patients also often associate food intake with IBS symptoms. Foods such as wheat products, onions, fruits, vegetables, sorbitol, and some dairy can include short chain, poorly absorbed, highly fermentable carbohydrates, which are known as FODMAPs. FODMAPs have been associated with increased gastrointestinal symptoms in IBS patients.[3] For patients with constant and chronic abdominal symptoms, oftentimes they can have a response to low dose tricyclic antidepressants (TCAs), or serotonin reuptake inhibitors (SSRIs)[1]

Differential Diagnosis

The differential diagnosis of IBS is broad and ultimately depends on whether the patient has predominant diarrhea or constipation.  If a patient has IBS with diarrhea, the differentials includes lactose intolerance, caffeine intake, alcohol intake, gastrointestinal infections (Giardia, Amoeba, HIV), inflammatory bowel disease, medication-induced diarrhea (antibiotic use, proton pump inhibitor, nonsteroidal anti-inflammatory drugs, ACE inhibitor, chemotherapy), celiac disease, malignancies, colorectal cancer, hyperthyroidism, VIPoma, and ischemic colitis.[15] If constipation is the predominant symptoms, then the differentials can include inadequate fiber intake, immobility, Parkinson's disease, multiple sclerosis, spinal injury, diabetes, hypothyroidism, hypercalcemia, medication-induced (opiates, calcium-channel blockers, antidepressants, clonidine), malignancies, bowel obstruction, endometriosis, and diverticular disease. If a patient's history indicates one of these diseases, then appropriate lab testing should be pursued.[15]

Prognosis

IBS has a good prognosis, and the diagnosis is unlikely to change on follow-up.[16] The use of ambulatory health services by IBS patients can be reduced if a positive physician-patient interaction if developed.[16]

Consultations

Important consults include a gastroenterologist and a nutritionist. Gastroenterologists often sub-specialize in IBS care and are invaluable members of the treatment team. A gastroenterologist can tailor treatment plans for the patient and are also likely to be more aware of advancements in the field of IBS. Given that patients often believe certain food intake is associated with their symptoms, and the findings of FODMAPs association with IBS, nutritionists are vital to providing dietary recommendations for the patient.

Deterrence and Patient Education

If a patient has concerns about abdominal pain, bloating, cramping, and changes in bowel habits, a visit to a primary care physician is advised. If IBS is diagnosed, a gastroenterology consultation will be needed as they can guide management and treatment.

Pearls and Other Issues

IBS can be sub-classified into IBS-C, IBS-D, or IBS-M. Although some treatments are the same between the groups, each subclassification is unique and have different treatments focused on the different symptomatologies. 

Enhancing Healthcare Team Outcomes

IBS can be a very disabling syndrome for patients, and it has been shown to be a very common reason for seeking medical attention. It is vital that there is a multidisciplinary approach when it comes to the care of these patients as it can improve the quality of life, reduce medications needed, and manage the symptoms of IBS much better.[17][Level V]


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Irritable Syndrome Syndrome - Questions

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Which is a typical feature of irritable bowel syndrome?



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Which of the following is not a feature of irritable bowel syndrome?



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Which of the following is part of the criteria to help make a diagnosis of irritable bowel syndrome?



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Which of the following, in theory, is not widely regarded as a cause of irritable bowel syndrome?



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Which of the following antibiotics have been shown to relieve symptoms in some patients with irritable bowel syndrome?



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Which of the following is not a feature of irritable bowel syndrome?



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Which of the following dietary modifications does help some people with irritable bowel syndrome?



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Which of the following has not been associated with irritable bowel syndrome?



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A female with no past medical history presents complaining of a long history of intermittent abdominal pain and alternating diarrhea and constipation who denies weight loss or dark, tarry stool. She has a normal physical exam except for mild, left lower quadrant tenderness. Her lab values are normal. What is the most appropriate next step in the management of this patient?



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What causes irritable bowel syndrome?



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A 38 year old female presents with a long history of intermittent abdominal pain and alternating diarrhea and constipation. She denies weight loss or dark, tarry stools. Physical exam is normal except for mild left lower quadrant tenderness. Lab values are normal. What is the next best step?



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Irritable bowel syndrome (IBS) may be diagnosed clinically based on abdominal pain that is present for at least 12 weeks (not necessarily consecutive) in the prior 12 months. Which of the following is not characteristic of the pain?



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Which of the following is the most appropriate pharmacotherapy for irritable bowel syndrome?



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A 31-year-old female has an extensive evaluation and is diagnosed with irritable bowel syndrome. Which of the following is not likely to be an additional finding?



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A 28-year-old female takes triptans for migraine headaches twice a month with good relief. She has a history of depression on a SSRI. The patient presents with recurrent abdominal pain that can occur after eating or episodically. It is relieved after urgent diarrhea. She also has episodic constipation. What is the most likely cause of her gastrointestinal symptoms?



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A patient is seen by a physical therapist for a home exercise program for bilateral knee pain. The patient has a history of irritable bowel syndrome (IBS). Select the best advice for the patient about the exercise.



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Which of the following may alleviate the symptoms of irritable bowel syndrome (IBS)?



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Which is not a typical presentation of a patient with irritable bowel syndrome (IBS)?



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Which treatment has been shown to have the most success in treating irritable bowel syndrome (IBS)?



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What mental disorder affects the vast majority of individuals who suffer from irritable bowel syndrome (IBS)?



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Which condition benefits from a diet low in fermentable oligosaccharide, disaccharide monosaccharide, and polyols?



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A young female with a new diagnosis of irritable bowel syndrome wants you to recommend a diet to her because she has been having severe bouts of diarrhea and constipation. You recommend that she eat low FODMAPS foods. Which of the following is a low FODMAP food?



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A young female with a new diagnosis of irritable bowel syndrome wants you to recommend a diet to her because she has been having severe bouts of diarrhea and constipation. You recommend that she eat low FODMAPS foods. She responds very well to a diet of blueberries and citrus foods. She now presents again for a second visit and wants to know if she should continue with the same diet. What should she be told?



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A client in a medical-surgical unit is diagnosed with irritable bowel syndrome (IBS). What symptoms usually are associated with IBS? Select all that apply.



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Irritable Syndrome Syndrome - References

References

Occhipinti K,Smith JW, Irritable bowel syndrome: a review and update. Clinics in colon and rectal surgery. 2012 Mar     [PubMed]
Drossman DA,Camilleri M,Mayer EA,Whitehead WE, AGA technical review on irritable bowel syndrome. Gastroenterology. 2002 Dec     [PubMed]
Chey WD,Kurlander J,Eswaran S, Irritable bowel syndrome: a clinical review. JAMA. 2015 Mar 3     [PubMed]
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Lovell RM,Ford AC, Effect of gender on prevalence of irritable bowel syndrome in the community: systematic review and meta-analysis. The American journal of gastroenterology. 2012 Jul     [PubMed]
Guilera M,Balboa A,Mearin F, Bowel habit subtypes and temporal patterns in irritable bowel syndrome: systematic review. The American journal of gastroenterology. 2005 May     [PubMed]
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Dupont HL, Review article: evidence for the role of gut microbiota in irritable bowel syndrome and its potential influence on therapeutic targets. Alimentary pharmacology     [PubMed]
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Drossman DA, 2012 David Sun lecture: helping your patient by helping yourself--how to improve the patient-physician relationship by optimizing communication skills. The American journal of gastroenterology. 2013 Apr     [PubMed]
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Lucak S, Diagnosing irritable bowel syndrome: what's too much, what's enough? MedGenMed : Medscape general medicine. 2004 Mar 12     [PubMed]
Kirsch R,Riddell RH, Histopathological alterations in irritable bowel syndrome. Modern pathology : an official journal of the United States and Canadian Academy of Pathology, Inc. 2006 Dec     [PubMed]
Chadwick VS,Chen W,Shu D,Paulus B,Bethwaite P,Tie A,Wilson I, Activation of the mucosal immune system in irritable bowel syndrome. Gastroenterology. 2002 Jun     [PubMed]
Wang LH,Fang XC,Pan GZ, Bacillary dysentery as a causative factor of irritable bowel syndrome and its pathogenesis. Gut. 2004 Aug     [PubMed]
Owens DM,Nelson DK,Talley NJ, The irritable bowel syndrome: long-term prognosis and the physician-patient interaction. Annals of internal medicine. 1995 Jan 15     [PubMed]
Shani-Zur D,Wolkomir K, [Irritable Bowel Syndrome treatment: a multidisciplinary approach]. Harefuah. 2015 Jan     [PubMed]

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