# Diagnosing IBS



## eric

I want to lay down some information on diagnosing IBS. I think this will help some of the confusion in postings that IBS is a bacterial infection, celiac disease, food allergies, candida, altered gut flora ect..Hopefully also it will help when talking to your doctor.NEVER self diagnose. The leading cause of misdiagnoses is self diagnoses. Some conditions that mimick some IBS symptoms are also very serious and even potentially deadly. First though is the change in diagnosing IBS that has been made."In the past two decades, medical opinion has changed regarding how to diagnose IBS. The older view emphasized that IBS should be regarded primarily as a "diagnosis of exclusion;" that is, diagnosed only after diagnostic testing excludes many disorders that could possibly cause the symptoms. Because many medical disorders can produce the cardinal IBS features of abdominal discomfort or pain and disturbed bowel habit as well as other symptoms caused by IBS, this approach often led to extensive diagnostic testing in many patients. Since the era when such thinking about IBS was common, laboratory, motility, radiologic, and endoscopic tests have proliferated. Although each of these tests is useful in evaluating certain problems, their routine or indiscriminate use can cause unnecessary inconvenience and cost for patients, and complications even occur infrequently from some of the tests. Fortunately, physicians can now diagnose IBS in most patients by recognizing certain symptom details, performing a physical examination, and undertaking limited diagnostic testing. This simpler approach is grounded on recent knowledge of the typical symptoms of IBS, and it leads to a reliable diagnosis in most cases. Extensive testing is usually reserved for special situations."http://www.aboutibs.org/Publications/diagnosis.html


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## Mary:::)))

Hi Eric.....I read the article.....I have been diagnosed with UC after having a colonoscopy......I see a lot of the symptoms in the article mimic my own....If I had IBS on top of the UC would that show up in a colonoscopy? Mary::







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## eric

Mary a lot of symptoms m from GI disorders are somewhat the same because the gut only has a limitied number of ways to signal there is a problem, which I will also post about.You can have UC and IBS, I can't diagnose you though and you would have to ask a docotr.Having IBS doesn't show up in a colonoscopy, but rules other conditions out.I will be posting more for you on all this so you know.


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## eric

I am going to jump ahead here a little bit for you Mary since you asked that question.There maybe a couple new tests to tell if there is inflammation in the gi tract.This is a very good article in medscapeACG 2006 - Evaluation and Treatment of IBS and Chronic Constipation IntroductionThousands of physicians, scientists, researchers, and allied healthcare professionals attended the 2006 meeting of the American College of Gastroenterology (ACG). A myriad of topics related to functional gastrointestinal disorders were once again center stage. Many of the clinical trials focused on the evaluation and treatment of functional bowel disorders, including the 2 most common of these disorders to affect the lower gastrointestinal tract: irritable bowel syndrome (IBS) and chronic constipation. This report reviews some of the most relevant of these data as presented during ACG 2006, with a focus on implications for clinical practice."(Note) there is interesting to info on opioid bowel induced constipation. Another reason they don't use narcotics in treating IBS, except for very special circumstances.Diagnosis, Mechanisms, and UnderstandingThe utility of performing a colonoscopy in patients with constipation is frequently debated. Healthcare providers express the concern that constipation could reflect an underlying malignancy, especially in an older patient. Nagri and colleagues[8] performed a retrospective analysis of 678 consecutive colonoscopies performed in patients aged 65 years and older (72% female) referred for the predominant complaint of constipation. The most common findings included hemorrhoids (65%), diverticulosis (61%), and adenomatous polyps (30%). However, only 1% of patients were found to have colon cancer. This study points out that age-appropriate colon cancer screening is important, although the onset of constipation in an older patient is unlikely to represent underlying colon cancer.*Patients treated with opioids often develop constipation due to delayed colonic transit and reduced gastrointestinal tract secretions.* New findings from Coates and colleagues[9] showed that the serotonin (5-hydroxytryptamine [HT]) signaling system may also play a role in opioid-induced constipation, *which represents a pharmacologically induced functional disorder. * Serotonin is secreted from enterochromaffin cells, and is an important activator of reflexes in the bowel. Rectal mucosal biopsies from patients with opioid-induced constipation (n = 14; 50% women) were compared with those from healthy controls (n = 14; 50% women). Enterochromaffin cells were identified by immunohistochemistry, serotonin content was identified by enzyme-linked immunosorbent assay, and levels of the selective-serotonin reuptake transporter (SERT) were measured by mRNA levels. The authors found that SERT levels were significantly lower in patients with opioid-induced constipation compared with controls (P < .05), whereas there was no difference in serotonin levels and enterochromaffin cell numbers between the 2 groups. Although the mechanism of opiate-associated changes in SERT levels was not addressed, this study suggests that agents that stimulate the serotonin pathway may prove useful in opioid-induced constipation.Knowledge and AttitudesTwo groups of investigators reported on different techniques to assess the concerns of IBS patients. Halpert and colleagues[23] encouraged patients to write a narrative describing their thoughts and feelings about having IBS. The narratives were reviewed and coded by 2 separate investigators with respect to themes, insight, and coping style. Eighty-two percent of the 23 narratives were written by women and the mean age of subjects was 42 years. The most frequent themes expressed were those of frustration (65%), social isolation (40%), and interference with intimacy (22%). Weiser and colleagues[24] developed a 54-question survey that was prospectively validated using standardized techniques. The questionnaire was mailed to appropriate patients, and a second identical questionnaire was mailed 4 weeks later; 119 patients completed both surveys, and the questions were found to be reliable and valid. The study authors reported that this questionnaire could be easily used in clinic to assess the knowledge base, fears, and concerns of IBS patients. The use of a questionnaire that could be easily administered may prove to be helpful in treatment programs, because many patients with IBS have inappropriate fears and concerns about IBS that interfere with and prevent successful therapy.EtiologyThe etiology of IBS is unknown, but is likely multifactorial.[25] Previous studies have shown that dysfunctional family relationships may increase the likelihood of IBS developing in children. Langer and colleagues[26] prospectively evaluated the effects of family size on IBS symptoms; 450 mothers (46% of whom had IBS; mean age = 42.9 years) rated the severity of their child's abdominal pain over a 2-week period. Overall, 631 children were evaluated (51% female; mean age = 11.9 years). The study authors found that mothers with IBS were more likely to report the presence of abdominal pain in their children than non-IBS mothers. In addition, IBS mothers reported more pain when the child had no siblings or only 1 sibling. *These findings are intriguing because they support previous findings that family dynamics can play a significant role in the generation of IBS symptoms.*Diagnosis*Patients with IBS can be confidently and correctly diagnosed using the Rome criteria in conjunction with a complete history and thorough physical examination (reviewed by Lacy and De Lee* The utility of routine laboratory testing is widely debated, however, especially in those presumed IBS patients with diarrhea predominance, because of concern regarding the possibility of missing the diagnosis of celiac disease or inflammatory bowel disease (IBD). During ACG 2006, studies were presented that evaluated the utility of tests commonly ordered in the evaluation of some IBS patients. Two separate studies[27,28] reported on the diagnostic accuracy of serologic markers for celiac disease and IBD in a prospective, multicenter, observational trial involving 323 patients with IBS symptoms (mean age = 39 years; 68% women) and 241 controls referred for routine colon cancer screening (mean age = 54 years; 43% women). Routine laboratory tests (complete blood count, thyroid-stimulating hormone, and electrolytes), testing for specialized IBD serologic markers (antineutrophil cytoplasmic antibodies, IgA, and IgG anti-Saccharomyces cerevisae antibodies, and anti-OmpC antibodies [outer membrane porin to Escherichia coli]), serologic tests for celiac disease (anti-gliadin, anti-endomysial, anti-tissue transglutaminase antibodies), and colonoscopy were performed in all patients. Patients with serologic evidence of celiac disease also underwent upper endoscopy with biopsies of the small intestine. *In this large group of subjects, only 2 patients with IBS symptoms were diagnosed with IBD. * In fact, IBD serologic markers had a false-positive rate of 30%, and this finding was similar in both control and IBS patients. *Tests for celiac disease were more frequently positive in IBS patients (7.4%) than in controls (2.9%); however, biopsies confirmed the diagnosis of celiac disease in just 1.24% of IBS patients and 0.8% of controls.* No single antibody test for celiac disease identified all patients with biopsy-proven celiac disease. *This large, ongoing prospective study demonstrates that celiac disease is uncommon in patients with IBS, that no single antibody test can accurately diagnose all patients with celiac disease, and that serologic tests for IBD have a high false-positive rate. Testing for these disorders should thus be limited to those IBS patients with persistent symptoms who fail to respond to standard therapy and should not be routinely performed in all IBS patients.*Two other studies presented during this meeting that discussed testing in IBS patients warrant mention. In the first of these studies, Whitlock and colleagues[29]* measured lactoferrin, a marker of activated neutrophils, in stool specimens from 94 IBD patients, 22 IBS patients, and 27 healthy controls (mean age, race, and sex breakdown not provided). Although raw data were not included, the study authors reported that fecal lactoferrin differentiated active IBD from IBS patients and healthy controls with 100% sensitivity and specificity. In addition, the test appeared to be highly accurate in differentiating active IBD patients from inactive IBD patients.* These preliminary results are very interesting and warrant confirmation in a multicenter, prospective trial. In the second study, http://www.medscape.com/viewarticle/547772Celiac disease is one of the conditions they are looking at in regards to a misdiagnoses. However Celiac is NOT IBS and it has symptoms such as weight loss and other symptoms that can differentiate for IBS, but a knowledeable doctor.Celiac does not always cause pain either. It is estimated in about 1 % percent of the population and is still some what underdiagnoseed. It also has a close genetic relationship, so if family members have it is could be a very good idea to be screened.If your looking for very accurate Celiac information this is one of the Doctors.Dr Green is the Director of The Celiac Disease Center at Columbia Universityhttp://www.celiacdiseasecenter.columbia.ed...3-StaffBios.htmAlsoIrritable Bowel Syndrome: How far do you go in the Workup?http://www.romecriteria.org/reading1.html


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## eric

To the moederators I know this is all long, but I can't post small amounts really to it all. Please forgive me.







Next the Rome criteria."The Rome CriteriaThe third process involves an international effort to characterize and to classify the functional gastrointestinal disorders using a symptom-based classification system, now called the Rome criteria (13, 14). The rationale for such a classification scheme is based on the premise that patients with functional GI complaints consistently report symptoms that "breed true" in their clinical features, yet they cannot be classified by any existing structural, physiological, or biochemical substrate. A symptom-based approach has its precedent with classification systems in psychiatry and rheumatology, and is in common use around the world. So, in the absence of laboratory markers, persons with anorexia nervosa, panic disorder, or fibromyalgia, as examples, are recognized by their symptoms or behaviors; these features define clinical populations that can be reliably investigated and that are amenable to specific treatments. For IBS and the other functional GI disorders, the use of a symptom-based diagnostic approach is supported by epidemiological data that show agreement in the frequency of certain symptom groups across populations (15). In addition, factor analytic studies consistently identify symptom clusters similar to those developed through empirically derived clinical studies. For example, using factor analysis of 500 nonclinical subjects, Whitehead et al. (16) identified an IBS factor (abdominal pain relieved by defecation and associated with a change in the frequency and consistency of stool). This was similar to the original Manning criteria developed from discriminant function analysis of gastroenterology patients (17), thereby providing concurrent validity. These and other studies are the basis for the IBS Rome criteria. The decision to develop diagnostic criteria by international consensus was introduced by Professor Aldo Torsoli for the International Congress of Gastroenterology held in Rome in 1988 (Roma '88). As part of a larger effort to address issues within gastroenterology that are not easily resolved by the usual scientific inquiry or review of the literature, the approach was to have working committees solve problems using the "Delphi" method of consensus (18). One of the committees, chaired by W. Grant Thompson of Canada, was charged to develop diagnostic guidelines for IBS. The committee built upon the Manning criteria published 10 yr earlier (17) and other epidemiological studies to produce a document that defined and characterized the IBS, recommended a diagnostic approach that included symptom-based criteria, and provided recommendations for treatment (19). The following year, a new Working Team Committee went on to develop a complete classification system with diagnostic and treatment guidelines for all of the functional GI disorders (20). Over the next 4 yr, several subcommittees published details on the epidemiology, physiology, diagnostic evaluation, and treatments of these newly classified disorders, and also produced documents on the design of treatment trials and on the psychosocial aspects of the functional GI disorders. From 1992 to 1994, seven articles appeared in Gastroenterology International; these were compiled, updated, and expanded in a book published in 1994 (Rome I) (13). Limitations to the Rome Criteria.A symptom-based classification system has potential limitations. The first limitation is that the criteria are developed by consensus rather than by an external diagnostic ("gold") standard. Even "expert" clinicians and investigators have different training, experience, and personal biases. Furthermore, consensus, when achieved, can only provide face validity. Therefore, additional validation studies are needed to support clinical impressions. Second, symptoms alone are not specific enough for a diagnosis, and the high frequency of functional GI disorders in clinical practice also assures their coexistence with other diseases. So, it is still necessary to exclude other medical disorders having similar clinical presentations (e.g., Crohn's disease) that will respond to different treatments. This raises the question as to whether this classification scheme might help to reduce the number of unneeded diagnostic studies, thereby increasing physician and patient satisfaction and reducing costs. Finally, there is the risk that the acceptance of these criteria in research and clinical practice might become a self-fulfilling prophecy. The published definitions and criteria for IBS and other functional GI disorders may become so familiar that, as new scientific data emerge, the capability to change them might be impaired (21).The first two of these limitations were addressed by Vanner et al. in the Journal (22). The authors tested the ability of the Rome I criteria to predict IBS using the gastroenterologists' evaluation as the "gold standard." Using both retrospective and prospective designs, they determined the degree to which referred patients who met Rome Criteria in the absence of "red flags" (weight loss, nocturnal symptoms, blood in the stools, abnormal physical examination, family history of colon cancer, recent antibiotic use) were successfully diagnosed by gastroenterology consultants to have IBS. Patients were followed-up for 2 yr. In the retrospective study, use of the Rome criteria, and the absence of "red flags" yielded a sensitivity of 63% and a specificity of 100%, with a positive predictive value (PPV) of 100%. In the prospective study the PPV was 98% (one patient was found to have proctitis and the other was hyperthyroid), which is greater than the PPV of studies evaluating the Manning (17) and Kruis (23) criteria (22). Because the high PPV might result from the use of "red flags" that exclude obvious disease, the authors performed further analyses. They found that adding the Rome criteria to the "red flags" more than doubled the PPV.It is noteworthy that the false negative rate was 16% (i.e., 16% of patients not meeting criteria were diagnosed as having IBS by the gastroenterologists) and the negative predictive value was 76%. The sensitivity of the Rome criteria tend to be lower than the Manning and Kruis criteria, in part because the Rome Criteria were originally designed for clinical trials and tend to be more restrictive. However, it is also possible that, if physicians are not adequately trained in the diagnosis of IBS, they might mislabel other functional GI disorders (e.g., painless diarrhea or chronic functional abdominal pain) as IBS.Overall, the data help to validate the Rome criteria. They provide preliminary evidence that the Rome Criteria, along with a good physical examination and a few ("red flag") clinical questions, can diagnosis IBS for clinical practice and research and may reduce unneeded diagnostic studies. Finally, because the criteria are more restrictive, some clinicians may still diagnose IBS in patients who do not meet the criteria."http://www.romecriteria.org/editorials.htmlThey are now into Rome lllGastroenterology April 2006 Issue:Rome III http://www.romecriteria.org/GastroIssue.htmWhile a lot might not be understandable to most with a limited background on it all, its worth looking it over.It can help for example to understand upper gi disorder and like functional dyspepsia and lowers functional disorders like IBS.I would also like to add while IBS is considered a functional disorder, the research is moving fast and now structural problems have been found and there are sub groups of IBS for example c predominate or d or d/c as well as PI IBS and others.


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## eric

This is part of this all as well. A change in medicine from dualism to Holism.History of Functional Disordershttp://216.109.125.130/search/cache?p=hist...&icp=1&.intl=us


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## eric

Gastrointestinal functional and motility disordershttp://www.iffgd.org/GIDisorders/GImain.htmlDifferent adult functional disordershttp://www.iffgd.org/GIDisorders/GIAdults.html


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## Mary:::)))

Wow Eric....that certainly was a lot of reading! Thanks for that...although sometimes all the technical language really confuses me....Mary::







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## eric

I know Mary it can be complicated and there are unfamilar terms, but the more you read the stuff, the eaiser it can get somewhat.







Here is a glossary also for some of the terms.http://www.iffgd.org/GIDisorders/glossary.html


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## Mary:::)))

You have everything all planned out don't you Eric LOL....I'm impressed! I will check out the glossary....I hope it helps my ignorantness ....tee heeMary::







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## eric

Mary I have had IBS for over thirty five years and while I am doing way better, basically remission at about 80-85 percent, when I joined here years ago I was in really bad shape, suicidal even. So I spent a lot of time, actually about three years almost 8 hours a day studying and looking things up and help from people here. I figured since I had it and its complicated I might as well try to learn everything I can about it. I have also had a lot of off the bb help from a lot of different doctors. It really helped to even learn some basics. I also love science.


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## Mary:::)))

I love Science too Eric....I can tell you have done your homework...and after only 3 mos of diagnosis for me...I think I am following in your footsteps somehow......yes...I will do as much research as I can but sometimes it overwhelms me....but I think it's because I haven't been around this that long....I really did and do appreciate all the information ...especially the glossary...I did save it to my favorites....I know it will help me to understand the terminology a lot better....I am really glad you are healing...I think all the information I can get can only make me better...I have already right away begun the elimination diet....OppOnn suggested....I gave up coffee....drinking herbal tea....no more of Mary's Famous Roasted Chicken for me awwwwwwww....unless I want to suffer....and Eric I am about 70% better than I was 3 months ago......my H and I hate to say this is vertually gone (weird since I had it for 3 years so I hope I don't make it come back)....I really appreciate your input anytime and know I don't know it all and am willing to read all and anything I can get my hands on even if I don't understand most of it I am trying......Thank you!Mary::







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## eric

Mary, I am happy to hear your feeling better.







I am glad the information helps.Have you ever registered to medscape? Its free and has an excellent IBS resource center."From Medscape General Medicineâ„¢Gastroenterology Expert ColumnDiagnosing Irritable Bowel Syndrome: What's Too Much, What's Enough?Posted 03/12/2004Susan Lucak, MD IntroductionIrritable bowel syndrome (IBS) is the most common gastrointestinal disorder diagnosed in clinical practice in the United States. Because there is no biological marker to confirm the diagnosis of IBS, it is a diagnosis that has challenged clinicians for decades. *In the past, IBS was a "waste-basket" diagnosis given to patients with unexplained gastrointestinal symptoms. It was considered to be "the diagnosis of exclusion" when extensive work-up for organic disease yielded no diagnosis.**In recent decades, it was recognized that patients with IBS experienced a constellation of specific gastrointestinal symptoms.* Manning criteria were described in 1978,[1] followed by Rome I in 1989[2] and Rome II criteria in 1999.[3] Rome I and Rome II criteria were initially developed by multinational working groups to provide a framework for the selection of patients in diagnostic and therapeutic trials. *These criteria are being continuously modified as we gain new knowledge about functional bowel disorders.*Recently published diagnostic guidelines[4,5] recommend using symptom-based criteria in making the diagnosis of IBS in clinical practice. Using these criteria in conjunction with "alarm features" allows a physician to minimize the extent of diagnostic testing needed to make the diagnosis of IBS. Furthermore, recent systematic review of the literature indicates that performing a number of diagnostic tests did not result in a significant increase in the diagnosis of organic gastrointestinal disease.[6]This column discusses novel approaches to the diagnosis of IBS."""Alarm Features"An important aspect of making the diagnosis of IBS is the absence of "red flag" or "alarm features" ( Table 2 ).[4,11,12] Unexplained weight loss may reflect disorders such as malignancy, inflammatory bowel disease (IBD), or celiac disease. Persistent diarrhea or severe constipation may be associated with an organic disease. IBS is generally an intermittent and recurrent disorder. Symptoms of IBS tend to disappear at night when the patient is asleep. Thus, nocturnal gastrointestinal symptoms warrant search for a diagnosis other than IBS. The onset of new gastrointestinal symptoms after the age of 50 should prompt the physician to look for organic disease, particularly colorectal cancer. Blood in stool may reflect IBD or an infectious process or colon cancer. Family history of IBD, celiac disease, or gastrointestinal malignancy requires evaluation for these diseases. Fever suggests the possibility of an infectious or inflammatory disorder. Anemia should alert the physician to look for IBD or colorectal cancer. Signs of bowel obstruction, malabsorption, extraintestinal signs of IBD, or thyroid dysfunction should all prompt organic disease work-up. Any laboratory test abnormalities should be pursued appropriately. Absence of these "alarm features" serves to support, not establish, the diagnosis of IBS."Summary and ConclusionsWhat's too much when we think about diagnosing IBS is to do exhaustive and duplicate testing. In a retrospective, community-based study in Olmsted County, Minnesota, two thirds of patients who consulted for gastrointestinal symptoms had to wait at least 2 years to have their IBS diagnosed, despite averaging nearly 5 healthcare visits per year.[20] Such an approach is not only costly and inefficient, but it delays treatment and fosters frustration on the part of the patient and the physician.What's enough is to use symptom-based criteria, "alarm features," and guidelines proposed by the ACG IBS Task Force and the AGA Technical Review on IBS in making a more timely diagnosis of IBS. Although additional studies are necessary to validate Rome II criteria and to assess diagnostic testing in prospective studies, the expert guidelines allow the diagnosis of IBS to be made with greater efficiency, certainty, and confidence. *Furthermore, once a diagnosis of IBS is made, it is retained in more than 93% of cases with a long-term follow-up.* Considering legal aspects of IBS diagnosis, symptom-based criteria and guidelines set forth by the ACG and AGA are becoming key elements in establishing standard of care. It has become clear that the diagnosis of IBS can and should be made quickly so that treatment can be initiated as soon as possible. This promotes greater patient confidence in the physician."IntroductionEpidemiologySymptom-based Criteria"Alarm Features"Physical ExaminationDiagnostic TestingDifferential Diagnosis and Durability of DiagnosisLegal Risks in Diagnosing IBSSummary and Conclusionshttp://www.medscape.com/viewarticle/465760_1Diagnosis, Pathophysiology, and Treatment of Irritable Bowel SyndromeDiagnosis of IBSSymptoms of IBS can be common to any number of gastrointestinal disorders. Abdominal pain, bloating, and diarrhea or constipation can easily generate an extensive list of potential diagnostic possibilities. To adopt an open-ended approach to diagnosis and to value all diagnostic possibilities equally has never been an effective approach in the diagnosis of IBS. However, with the development and validation of the Rome II criteria for the diagnosis of IBS, *our approach to the diagnosis of this traditionally perplexing disorder is rapidly changing.*Diagnosing the patient with IBS should include 3 steps. First, determine whether the patient at first encounter meets the Rome diagnostic criteria for IBS. Second, conduct a history and physical examination looking for so-called "alarm factors." Third, perform diagnostic testing.Diagnostic CriteriaThe latest version of the Rome diagnostic criteria (Rome II) for IBS were first published in abbreviated form in 1999[7] and in full form in 2000.[8] See the Table below. The Rome criteria have been shown to be both sensitive and specific for the diagnosis of IBS[9] and can be used advantageously in clinical practice. If a patient presents with symptoms suggestive of IBS and epidemiologically fits the profile of a patient most likely to have IBS (ie, younger than 40 years of age and with typical symptoms), the Rome criteria can be used to validate the physician's initial impression. Starting with a "positive approach" to diagnosing IBS, as opposed to adopting a diagnosis of exclusion, sets the entire physician-patient encounter off in a positive and thoughtful direction. Providing the diagnostic framework presented by the Rome criteria gives the physician an intellectual basis for making an IBS diagnosis with confidence.[10]History-TakingThe key to history-taking in a patient with suspected IBS is first and foremost to look for the presence of so-called "alarm factors." It is clear that the symptoms of IBS can be typical of many other structural disorders of the gastrointestinal tract. Diarrhea, abdominal bloating, and constipation can all represent an extraordinarily wide spectrum of gastrointestinal pathology. The challenge using the framework provided by the Rome II diagnostic criteria is to rapidly exclude the possibility of other disorders. The key is to look for symptoms in the history that are atypical of IBS and suggestive of other disorders. The list of so-called "alarm factors" can certainly be open to debate and discussion.Physical ExaminationAfter a patient history has been completed and the absence of "alarm factors" documented, a physical examination should always be performed. The physical examination should focus specifically on ruling out inflammatory bowel disease, colorectal or other gastrointestinal cancers, and malabsorption caused by luminal or pancreatic causes. Look for extraintestinal manifestations of inflammatory bowel disease, such as ophthalmic changes, Sicca syndrome, intraoral lesions (eg, aphthous ulcers), and skin or arthritic changes suggestive of inflammatory bowel disease. Likewise, signs of malabsorption, such as muscle wasting, nail or perioral changes, and weight loss should all be ruled out. Finally, the issue of colorectal cancer must be addressed. There is agreement in the functional bowel community that the best guide to help clarify this situation is to follow the colorectal cancer screening guidelines of the American Cancer Society. It is therefore recommended that patients 50 years of age or older who have never had a screening colonoscopy should have one performed as part of an IBS evaluation. Likewise, individuals 40 years of age or older who have a family history of colorectal cancer in a first-rank relative should also have a screening colonoscopy.[11] Finally, the use of sigmoidoscopy in individuals younger than 50 years old who have no family history is open to some discussion.[12]Small bowel (to rule out Giardia or small bowel malabsorption) or colonic (to rule out microscopic colitis) biopsies may be indicated, particularly for patients with loose or watery stools.[13] These studies, although they include some diagnostic testing, may be considered part of the "physical examination" and initial evaluation of the patient with suspected IBS.Diagnostic TestingThe use of diagnostic testing in IBS has become an increasingly controversial topic. Traditionally, the "diagnosis of exclusion" approach encouraged extensive diagnostic testing to evaluate patients with suspected IBS to rule out other possible causes of the disorder. Given the high prevalence of IBS , this approach has been subject to considerable scrutiny over the last 5 years.[10] Numerous studies have shown that the use of routine lactase hydrogen breath-testing for sugar malabsorption,[14] abdominal ultrasound,[15] routine computed tomography scanning, particularly in younger patients, and more esoteric tests, such as screening for acute intermittent porphyria[16] or thyroid testing for hyper- or hypothyroidism,[17] rarely yield data that change the diagnosis of IBS. Testing for bacterial overgrowth has been recently proposed by 1 group as a possible cause of IBS-like symptoms.[18] However, the article supporting the reasonableness of this approach studied a cohort of patients who were specifically referred by their treating physician to a tertiary center specializing in bacterial overgrowth. These patients were specifically referred to the tertiary center to rule out the possibility of bacterial overgrowth. However, given the selection bias in this study, the applicability of these data to the universe of IBS patients is open to some question. Based on the available literature, routine testing for bacterial overgrowth in patients with suspected IBS cannot be routinely recommended at this time.One additional issue that is rapidly evolving in the area of IBS diagnosis is the issue of celiac disease. A number of studies have recently demonstrated a higher prevalence of celiac disease in the North American population than was previously thought, as well as a possible higher prevalence among patients with IBS-like symptoms.[19] This issue is yet to be completely resolved. It would therefore seem prudent for physicians who have patients with suspected IBS who have subtle signs or symptoms of celiac disease, such as osteoporosis in a premenopausal female or male, infertility, mild anemia, or weight loss, to evaluate the patient by obtaining celiac disease markers. Endoscopy with small bowel biopsy can confirm any equivocal serologic results.Given these data, it would seem reasonable for the patient with IBS who presents absent alarm factors and who has a normal physical examination to have a complete blood count and chemistry panel and perhaps erythrocyte sedimentation rate measurement and thyroid function testing in the form of thyroid-stimulating hormone (TSH) levels. As noted above, in patients with diarrhea, additional initial investigation may be warranted, particularly investigation for the possibility of microscopic colitis and perhaps celiac disease.[17] For the majority of patients, this should end the initial evaluation. It is at this point that the physician should begin treatment and follow the patient prospectively. Failure to respond to reasonable treatment for IBS after a period of 2-4 weeks should certainly invite the physician to question the validity of IBS diagnosis and to consider additional evaluation as indicated. See the Figure below for a schematic that outlines this approach.Of course recently they have published the rome lll criteria.


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## eric

FYI"Does Bacterial Overgrowth Play a Role in IBS?Bacterial Overgrowth & IBS: Too Soon To TellBy Philip Schoenfeld, MD, MSEd, MSc (Epi)Associate Professor of Medicine, University of Michigan School of Medicine Chief, Division of Gastroenterology, VA Ann Arbor Healthcare System Irritable bowel syndrome (IBS) has been described as a â€œfunctionalâ€ disorder, which is a â€œdiagnosis of exclusion.â€ Thus, many physicians still think IBS has no demonstrable pathophysiologic defects and that it can only be diagnosed after other â€œorganicâ€ disorders have been ruled out with multiple diagnostic tests.*Recent data demonstrate the fallacy of this assumption. Irritable bowel syndrome IS characterized by multiple pathophysiologic defects:*Altered gastrointestinal motility (1-2) Visceral hypersensitivity (1-2) Abnormal IL-10/IL-12 ratios consistent with pro-inflammatory Th-1 state (3) Infiltration of lymphocytes and neuronal degeneration in the myenteric plexus (4) Defects in serotonergic signaling mechanisms in the enteric nervous system of the GI tract (5) Unfortunately, these pathophysiologic defects cannot be identified by conventional laboratory testing. Therefore, we rely on the symptom-based IBS diagnostic criteria of the ROME committee (i.e., the presence of abdominal discomfort for at least 12 weeks in the past 12 months associated with a change in the consistency/frequency of stool or relief of discomfort with passage of stool) or the American College of Gastroenterology (i.e., IBS is defined as abdominal discomfort associated with altered bowel habits) (1-2). However, the reliance on symptom-based criteria to diagnose IBS should not de-emphasize the pathophysiologic defects expressed by IBS patients."http://www.gastro.org/wmspage.cfm?parm1=1703


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## eric

FYI on inflammation"Mast cells are players in at least some IBSers, especially those that developed IBS from Post Infectious IBS.I have been looking at those cells for a while now in depth. They are also majorally conneted to the bodies stress system also and in part how stress and infection are linked. They can be activated in a lot of ways including allergies and stress as I have mentioned and they degrandulate histimine. This is macroscopic inflammation, but they degrandulate histimine onto the smooth muscle of the gut, they are more embedded in the gut walls. But this can contribute to pain, but there seems to be other problems. Also serotonin is a very important messenger for sensation from the digestive system to the brain. That is also really important in IBS and in pain. Irritable Bowel Syndrome: How far do you go in the Workup?"There is evidence that IBS is a heterogeneous disorder where different physiological subgroups contribute to the clinical expression of the syndrome. For example, there is a subgroup of patients, called "post-infectious IBS" who appear to respond to an enteric infection such as campylobactor jejuni with an increased inflammatory cell response (22). This is associated with activating enterochromaffin cells to produce 5HT, and CD3 cells to produce cytokines, which in turn leads to enhanced motility and lowered visceral sensation thresholds (22;23). *But microscopic inflammation cannot be a diagnostic marker for IBS because it does not typically produce pain in those who have it. All patients with active celiac disease have microscopic inflammation, but a large proportion do not have abdominal pain, and patients with ulcerative colitis who also have microscopic inflammation when compared to patients with IBS appear to have higher pain thresholds * (24). In individuals with these disorders, there may be central nervous system counter-regulatory measures responding to the peripheral pain/inflammatory processes that increase pain thresholds. With regard to IBS, the gut-related effects of microscopic inflammation may be only one component of a dysfunctional brain-gut system. In addition, and often in response to stress, there may be a failure to activate descending pain inhibitory systems that enable the clinical experience of pain and other symptoms that typify this disorder (25). In one prospective study of post-infectious IBS, it was found that those who retained their symptoms 3-months after an enteric infection had not only increased mucosal cellularity, but also had increased psychosocial distress at the time of the infection. *Furthermore, lowered visceral sensation thresholds and increased motility were present after the infection regardless of whether or not the patients retained their symptoms (26). Therefore, the microscopic inflammation and its physiological effects on motility and sensation contribute to, but are not always sufficient for the clinical expression of IBS pain"*http://www.romecriteria.org/reading1.html


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## Kathleen M.

Moving to the IBS News and abstracts section.That is the best place for a thread that is going to be an information-presenting thread rather than a discussion between people thread. Additionally, the posting length restrictions are not applied to the News section. I'm sorry if that hasn't been clear to anyone before, but it is in the guidelines that went up quite awhile ago that are in a sticky thread at the top of this forum.A shortcut to this thread will be on the main board for a day or two so people following this thread can find it.


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## eric

FYIAmerican Gastroenterological Association Teaching project slides IBS Originally posted on May 15, 2003 https://www.gastroslides.org/Main/browse_deck.asp?tpc=4Irritable Bowel Syndrome 2004 Update Originally posted on May 15, 2003 https://www.gastroslides.org/Main/browse_deck.asp?tpc=9


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## eric

Emerging Techniques to Evaluate and Treat Functional Gastrointestinal and Motility Disorders Moderator: Arnold Wald MD; Panel: Ravinder Mittal MD, Richard McCallum MD, Charlene Prather MD, Arnold Wald MD. http://www.iffgd.org/symposium2003techniques.html


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## eric

FYIOf course they are using Rome lll now butNew drugsâ€"and some respectâ€"for IBSRevised guidelines and targeted therapies are leading to a new view of the conditionFrom the September ACP Observer, copyright Â© 2003 by the American College of Physicians.Long disparaged as a "wastebasket disease," irritable bowel syndrome (IBS) appears to be gaining newfound respect among researchers, drug makers and gastroenterologists. The question now: Will other physicians begin to recognize IBS as a treatable condition, or will they continue to view it as a largely psychosomatic illness?Researchers have made major strides in detecting the physiologic underpinnings of IBS as well as the nature of patients' "gut-brain" interactions. At the same time, drug makers now offer treatments that specifically target a broad range of IBS symptoms.And gastroenterologists have identified the signs of IBS that can lead to a definitive diagnosis, crafting guidelines to help physicians distinguish IBS from other conditions.But as many gastroenterologists are quick to point out, much of the progress being made on IBS has been lost on general practitioners. Rapid advances have created a "very big gap between primary care and gastroenterology," said Douglas A. Drossman, FACP, co-director of the University of North Carolina Center for Functional Gastrointestinal and Motility Disorders at Chapel Hill. "Primary care doctors are not up to speed."To help close that gap, here is an overview of the latest developments in IBS research and treatment.Help with the diagnosisUntil recently, physicians lacked a clear definition of what exactly constituted an IBS diagnosis. The condition required a diagnosis of exclusion, frustrating physicians and patients alikeâ€"and generally hampering treatment.Even worse, arriving at an IBS diagnosis made many physicians fear they had missed a more dangerous condition such as colon cancer. Without any real guidance, it was difficult to feel sure that an IBS diagnosis didn't mean you were overlooking something more serious.With the advent of new guidelines, known as the "Rome criteria," however, diagnosing irritable bowel syndrome has become more straightforward. The latest version of the criteriaâ€"Rome IIâ€"was developed by international experts and published in 2000. The criteria point to IBS as a genuine, treatable disorder.The guidelines "give physicians something to hang a diagnosis on," said gastroenterologist Brian Lacy, MD, PhD, director of the Marvin M. Schuster Center for Digestive and Motility Disorders at Johns Hopkins Bayview Medical Center in Baltimore.According to the Rome II criteria, patients suffering from IBS have experienced several specific symptoms for at least 12 weeks during the previous year. The guidelines emphasize that IBS is a multifaceted condition that involves not only a faulty defecation pattern, but pain. (For more on the Rome criteria, see "The Rome II diagnostic criteria for irritable bowel syndrome," below.) "If they don't have pain, they don't have IBS," Dr. Lacy said, "even if they have diarrhea 15 times a day or go to the bathroom only once a month." While the guidelines still require physicians to rule out other conditions such as functional diarrhea or pelvic floor disorders, both of which are similar to IBS, experts say the criteria reduce much of the diagnostic uncertainty by limiting the range of other possible conditions. You don't need to run most patients through an extensive battery of tests to reach a diagnosis.Last year, both the American Gastroenterological Association and the American College of Gastroenterology (ACG) issued position statements that agree with that diagnostic approach. The organizations identified key "alarm signals" that should alert you to other potential diagnoses when working with possible IBS patients.Those signals include blood in the stool, unexplained weight loss, anemia, chronic severe diarrhea, recurring fever and a family history of colon cancer. In the absence of such red flags, however, the statements claimed that the Rome II criteria are nearly 100% specific in diagnosing IBSâ€"and that the risk of missing another disease is negligible. While you may feel compelled to list several problems like pain, bloating and constipation when treating IBS patients, Dr. Lacy said that approach is unnecessary. "These patients have one unifying diagnosisâ€"IBSâ€"that should make it easier to treat them," he explained. "You need to think about treating this whole constellation of symptoms."Performing fewer tests to make an IBS diagnosis benefits not only health plans, but patients themselves. Excessive testing can distress patients, noted gastroenterologist George F. Longstreth, MD, chief of gastroenterology at Kaiser Permanente Medical Care Program in San Diego."Too many tests sometimes create more anxiety," he said, a factor that can be a real liability when research suggests that IBS patients may have more pronounced intestinal reactions to stress than other patients. (For more on the "gut-brain" connection, see "IBS: An anatomy of what goes wrong in the body," below.) And while internists instinctively worry about missing another disease, they need to guard against making the opposite mistake: confusing IBS symptoms for those of other medical conditions. Studies have shown, for example, that IBS patients are more likely to have their gallbladders removed or to have a hysterectomy. "IBS patients shouldn't automatically have their gallbladders taken out," Dr. Longstreth said. "Their pain may be due to IBS."New breed of drugsAlong with new diagnostic guidelines, physicians can now offer new treatments. What's remarkable about the latest drugs to treat IBSâ€"alosetron and tegaserodâ€"is that they treat several IBS symptoms, not just a single complaint.Tegaserod. Tegaserod, which targets a serotonin receptor subtype in the intestines, has been shown to relieve IBS patients' bloating, abdominal discomfort and constipation significantly more than placebo. But because subjects in the studies' control groups experienced a significant placebo effect, the drug outperformed the placebo by only 10% to 15%."To say this drug is a breakthrough is an exaggeration," said Dr. Longstreth. "Some patients don't respond, and it is quite expensive."The drug costs more than $2 a pill, and patients must take it twice a day. (Dr. Drossman noted, however, that patients who regularly take laxatives can spend up to $100 a month. He also added that laxatives do not address the pain of IBS.)Tegaserod's main side effect, however, is diarrhea, which causes 1% to 2% of patients to stop taking it. Nevertheless, Dr. Drossman said he considers the drug safe enough to prescribe it even to patients with mild to moderate IBS.While Dr. Lacy agreed that he doesn't consider tegaserod a "magic bullet," he said he considers it to a good, safe drug. He added that it will likely be years until researchers develop a miracle drug for a condition like IBS. "We have been spoiled by drugs like Prilosec that give a 90% response rate," he said. "You'll never see that for IBS."One other note: Because tegaserod was tested primarily on women who suffer from an IBS-related form of constipation, the FDA approved the drug only for those patients.However, a study published in the May 2003 issue of Gut suggested that the drug can relieve symptoms in IBS patients who alternate between diarrhea and constipation. Another study published in the May 2002 American Journal of Gastroenterology found that tegaserod does not worsen diarrhea symptoms in IBS patients. And both Drs. Drossman and Lacy said they have had male patients who benefited from taking the drug.Alosetron. Alosetron has a more checkered history than tegaserod. The FDA originally approved the drug in February 2000 for women with diarrhea-predominant IBS after alosetron was shown to relieve pain and discomfort, urgency and diarrhea. When several patients taking the drug developed serious complications due to severe constipation or ischemic colitis, however, the agency pulled the drug from the market.To meet patient demand, the FDA re-approved it in June of 2002â€"with some new conditions. The agency restricted the drug to treating only women with "severe, diarrhea-predominant IBS who have failed to respond to conventional IBS therapy." The agency also cut the recommended starting dose in half. Physicians prescribing alosetron must register with the drug's manufacturer and educate patients about its risks and benefits. They must also have patients sign a consent form before using the drug.But much of the anxiety over alosetron's serious side effects is unwarranted, Dr. Drossman said. If given to the right subgroup of IBS patientsâ€"those with diarrhea but not with constipation, he explainedâ€"the drug is generally safe.Recent studies have found that alosetron used at the current recommended starting dose of 1 mg per day produced a 10% to 35% improvement in symptoms when compared to placebo. About 10% of patients, however, stop taking the drug because of constipation.Most experts recommend prescribing alosetron for women who have moderate to severe IBS and no other options. "I've had a few patients who definitely thought alosetron was the best thing they've ever tried," noted Dr. Longstreth.For most patients with milder forms of IBS, he added, physicians should "focus on the symptoms that are the biggest problem and do what they can for that." Many symptoms can be effectively treated with antidiarrheal agents such as loperamide. If constipation is the main complaint, fiber or laxatives are usually effective.Low-dose tricyclic antidepressants. Thanks to a better understanding of what causes IBS pain, treatment options to relieve IBS symptoms now include low-dose tricyclic antidepressants.While no good controlled studies have yet validated the effectiveness of these drugs for relieving IBS pain, most IBS experts swear by them. "Low-dose tricyclics relieve abdominal pain," Dr. Lacy said, "and they're safe." (The ACG position paper did note, however, that these drugs may cause constipation and urged physicians to use caution when prescribing them for IBS patients who present with this as their main complaint.)In theory, selective serotonin reuptake inhibitors (SSRIs) should also help relieve pain and constipation caused by IBS, as well as any concomitant anxiety and depression. Only a handful of clinical trials, however, have examined the drugs' effectiveness in relieving IBS symptoms. As a result, many gastroenterologists say they reserve SSRIs for IBS patients who also have excessive anxiety or depression.Nondrug treatmentsWhile drug therapies are more successfully targeting IBS, novel treatments like cognitive behavioral therapy are receiving more attention. A small study by British researchers found that the symptoms of three-quarters of IBS patients who had not benefited from dietary or drug therapy significantly improved after just six sessions of cognitive behavioral therapy.Another British study found cognitive behavioral therapy to be significantly more effective than psychotherapy in relieving IBS symptoms. Even more impressive, most of the patients successfully treated in the study found their IBS symptoms hadn't returned more than a year later.While Dr. Lacy said these results are promising, he pointed out that very few people know how to do cognitive behavioral therapy properly. In addition, most insurers won't pay for it.Research into other nondrug therapies has also been encouraging. A study led by Dr. Drossman and published in the July 2003 issue of Gastroenterology found that 70% of IBS patients improved when they received cognitive behavioral therapy directed toward bowel symptoms from a psychotherapist. By comparison, only 37% of subjects in the control group who received only IBS education reported improvement. Although an accompanying editorial in the issue lauded the study's findings, it pointed to some of the same challenges that may stop cognitive behavioral therapy from being widely accepted. Patients tend to prefer pills over psychotherapy, and insurance companies may not pay for treatments. In addition, few psychotherapists have trained in strategies to manage IBS or pain.While many patients may not yet be ready for cutting-edge treatments, IBS experts stress the importance of taking time to educate patients about IBS. One goal should be reassuring them that they don't have a more deadly condition such as ulcerative colitis or colon cancer."A lot of the improvement IBS patients experience probably comes as a result of them being reassured and having their symptoms explained to them," said Dr. Longstreth. "The doctor is functioning as the placebo." With that in mind, Dr. Lacy said, don't expect any quick cures when working with IBS patients. "Doctors really want to cure things,s but this is not something you can cure," he explained. "You need to take a nice deep breath, realize it's going to be a chronic problem, and don't get discouraged or let your patients get discouraged." Margie Patlak is a freelance science writer in Elkins Park, Pa.The information included herein should never be used as a substitute for clinical judgment and does not represent an official position of ACP.--------------------------------------------------------------------------------TopThe Rome II diagnostic criteria for irritable bowel syndromeThe Rome II criteria define irritable bowel syndrome (IBS) as abdominal discomfort or pain for at least 12 weeks (not necessarily consecutive) in the preceding 12 months, with two of the three following features:The pain is relieved with defecation. Onset is associated with a change in frequency of stool. Onset is associated with a change in form (appearance) of stool. The Rome II criteria state that the following symptoms cumulatively support an IBS diagnosis:Abnormal stool frequency (for research purposes, "abnormal" may be defined as greater than three bowel movements per day and less than three bowel movements per week); Abnormal stool form (lumpy/hard or loose/watery stool); Abnormal stool passage (straining, urgency or feeling of incomplete evacuation); Passage of mucus; and Bloating or feeling of abdominal distention. Source: December 2002 Gastroenterology.--------------------------------------------------------------------------------TopIBS: An anatomy of what goes wrong in the bodyAlthough the precise trigger of irritable bowel syndrome (IBS) remains unknown, researchers in the last decade have made substantial progress in understanding what goes awry in patients who suffer from the condition. Studies have shown that many IBS sufferers are hypersensitive to stimuli in the gut. Their brains process those stimuli differently, and many also have heightened gut-immune responses.As a result, researchers are beginning to look at IBS as an explainable disease rather than as a mysterious disorder. "As more of these abnormalities are being found in IBS, the distinction between a functional disorder and an organic disorder is being blurred," noted George F. Longstreth, MD, chief of gastroenterology at Kaiser Permanente Medical Care Program in San Diego.Researchers at the University of California, Los Angeles, for example, found that when they used an inflatable balloon to distend the rectum and lower colon of IBS patients, PET scans of the brain showed greater activity in the brain's emotion and attention processing centers than in those of normal control subjects given the same stimulus. Those findings were confirmed by researchers at Vanderbilt University who used MRI studies instead of PET scans. "Patients with IBS are hypervigilant," explained Brian Lacy, MD, director of the Marvin M. Schuster Center for Digestive and Motility Disorders at Johns Hopkins Bayview Medical Center in Baltimore. "They listen to their guts too carefully and hear every little contraction, gurgle and peristaltic wave."Other studies have shown that IBS patients have lower visceral pain thresholds and greater gut reactions to psychological stress than control subjects. Those data have led some to hypothesize that a visceral hypersensitivity causes many IBS symptoms.Whether that hypersensitivity originates in the brain or in the nervous system of the gut is unclear. Regardless of its origin, treatments that target the region of the brain shown to be hyperactive in IBS patients can effectively relieve symptoms. That's why therapies like cognitive behavioral therapy, alosetron, low-dose tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs) and cognitive therapy all work.Although abnormalities in brain processing are thought to play a role in IBS, researchers have also found how some symptoms stem from the actions of nerves in the gut. The role of the "gut-brain" connection has recently gained more prominence as researchers continue to uncover its extensive influence on bowel motility, secretion, immune responses and signaling to the central nervous system. Much of that influence gets carried out via the neurotransmitter serotonin. Remarkably, about 95% of the body's serotonin is found in the gut. Two serotonin receptor subtypes, 5-HT3 and 5-HT4, are thought to be responsible for the majority of the neurotransmitter's intestinal effects. It's no surprise, then, that alosetron and tegaserod, the first two drugs shown to affect the broad spectrum of IBS symptoms, target 5-HT3 and 4. SSRIs may also act on the bowel's nervous system, although they are thought to have a greater effect on the brain. There's also preliminary evidence that many IBS patients have a heightened immune response in the gut that includes a boosted number of mast cells, natural killer cells, lymphocytes and serotonin-laden enterochromaffin cells. Interestingly, between 10% and 30% of patients who recover from food poisoning develop IBS, especially if they were under undue psychological stress at the time they developed acute gastroenteritis."There's one theory that the infection and stress alter the permeability of the gut mucosa so that bacteria or viruses invade the gut where they don't belong," Dr. Lacy said. "This leads to chronic inflammation that could result in disordered motility and sensation by injuring nerves in the gut." The excessive numbers of enterochromaffin cells in some IBS patients could cause many IBS symptoms just by releasing their granules of serotonin.The popular media have given a lot of play to a recent study by Mark Pimentel, MD, a gastroenterologist at Cedars-Sinai Medical Center in Los Angeles. He found that IBS patients were more likely to have an overgrowth of small intestinal bacteria as indicated by a breath test. After seven days of treatment with neomycin, their lactulose breath testing normalized.Experts, however, question the validity of the study, citing several methodological shortcomings like short-term follow-up. "If these patients improved after one week," Dr. Longstreth said, "that's hardly good enough, since IBS naturally waxes and wanes."All the basic research on IBS suggests that in the future, patients with the disorder may be subdivided based on the underlying mechanisms of their symptoms."We're starting to understand IBS not as a single entity but as a collection of pathophysiological subgroups," said gastroenterologist Douglas A. Drossman, FACP, co-director of the University of North Carolina Center for Functional Gastrointestinal and Motility Disorders at Chapel Hill. "Each subgroup might require different treatment." http://www.acponline.org/journals/news/sep03/ibs.htm#body


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## 21185

EricGood information. RE: cognitive therapy versus psychotherapy. In my experience same thing. Why would insurance be concerned on what type of mental health therapy you'd consider before they would approve payment for insurance. That confuses me.


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## Kathleen M.

CBT is one specific type of psychotherapy.Some insurances will cover all of your CBT sessions as it usually is designed to go for a few months then stop.Other forms of talk therapy may go for much longer periods. Mental health is typically one area insurance companies try to limit your number of sessions so they sometime do care quite a bit what kind of therapy you are getting.K.


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## eric

In Oregon here they just passed a new bill on this and have passed a similar bill in Wasington state now for about a year.Mental health parity takes effect in 2007"SALEM, Ore. (AP) - As of January 1st, all insurance companies in Oregon are required to offer the same level of coverage for mental health treatments as they do for physical conditions. Oregon lawmakers approved Senate Bill 1 in 2005 to mandate what's known as 'mental health parity.' Insurance companies and business groups fought against the requirement, saying it would increase insurance costs. But lawmakers were persuaded, after hearing dramatic stories from the family members of mentally ill people. State lawmakers in Oregon and Washington voted for mental health parity around the same time in 2005. But Washington state's law took effect a year ago, while Oregon lawmakers gave insurance companies until 2007 to prepare for the new policy. "


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## eric

FYIIs It Irritable Bowel Syndrome Or Something Else? http://www.aboutibs.org/Publications/IBS0206.htmlBringing One Of America's Most Common Health Issues To LightUnderstanding IBS Reduces Stigma Associated With Condition, Helps Sufferers Get Treatmenthttp://www.aboutibs.org/Publications/Understanding.htmlImportant Findings from New National Survey: Most People with Symptoms of IBS Go Undiagnosed Survey shows lack of awareness of IBS may impact medical carehttp://www.aboutibs.org/Publications/ibsSurvey.htmIrritable Bowel SyndromeThe Burden of Illnesshttp://www.aboutibs.org/Publications/IBSBurden.htmlIrritable Bowel SyndromeThe Burden of Illnesshttp://www.aboutibs.org/Publications/IBSBurden.htmlTalking to Your DoctorAbout Irritable Bowel Syndrome http://www.aboutibs.org/Publications/TalktoDocIBS.htmlIrritable Bowel Syndrome: It's About Lost Potential April Is IBS Awareness Month: IFFGD Offers Information and Support to Those Affected by Irritable Bowel Syndrome http://www.iffgd.org/About/PressNews/04_02_02.html


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## eric

worth readingChronic Abdominal Pain in Children http://pediatrics.aappublications.org/cgi/.../full/115/3/812


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## Mary:::)))

You should be a doctor Eric ::







)).....You do more research than many of them do!







I still get a copy of this thread......so interesting ::







))Mary::







))


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## eric

Thanks Mary, but never really wanted to be a doctor. I wouldn't be doing this if I didn't have IBS really as well as helping out where I can. However I do find some of it fascinating really.But I don't like blood and guts. LOL"ACG 2006 - Evaluation and Treatment of IBS and Chronic Constipation CME"DiagnosisPatients with IBS can be confidently and correctly diagnosed using the Rome criteria in conjunction with a complete history and thorough physical examination (reviewed by Lacy and De Lee[25]). The utility of routine laboratory testing is widely debated, however, especially in those presumed IBS patients with diarrhea predominance, because of concern regarding the possibility of missing the diagnosis of celiac disease or inflammatory bowel disease (IBD). During ACG 2006, studies were presented that evaluated the utility of tests commonly ordered in the evaluation of some IBS patients. Two separate studies[27,28] reported on the diagnostic accuracy of serologic markers for celiac disease and IBD in a prospective, multicenter, observational trial involving 323 patients with IBS symptoms (mean age = 39 years; 68% women) and 241 controls referred for routine colon cancer screening (mean age = 54 years; 43% women). Routine laboratory tests (complete blood count, thyroid-stimulating hormone, and electrolytes), testing for specialized IBD serologic markers (antineutrophil cytoplasmic antibodies, IgA, and IgG anti-Saccharomyces cerevisae antibodies, and anti-OmpC antibodies [outer membrane porin to Escherichia coli]), serologic tests for celiac disease (anti-gliadin, anti-endomysial, anti-tissue transglutaminase antibodies), and colonoscopy were performed in all patients. Patients with serologic evidence of celiac disease also underwent upper endoscopy with biopsies of the small intestine. In this large group of subjects, only 2 patients with IBS symptoms were diagnosed with IBD. In fact, IBD serologic markers had a false-positive rate of 30%, and this finding was similar in both control and IBS patients. Tests for celiac disease were more frequently positive in IBS patients (7.4%) than in controls (2.9%); however, biopsies confirmed the diagnosis of celiac disease in just 1.24% of IBS patients and 0.8% of controls. No single antibody test for celiac disease identified all patients with biopsy-proven celiac disease. This large, ongoing prospective study demonstrates that celiac disease is uncommon in patients with IBS, that no single antibody test can accurately diagnose all patients with celiac disease, and that serologic tests for IBD have a high false-positive rate. Testing for these disorders should thus be limited to those IBS patients with persistent symptoms who fail to respond to standard therapy and should not be routinely performed in all IBS patients.Two other studies presented during this meeting that discussed testing in IBS patients warrant mention. In the first of these studies, Whitlock and colleagues[29] measured lactoferrin, a marker of activated neutrophils, in stool specimens from 94 IBD patients, 22 IBS patients, and 27 healthy controls (mean age, race, and sex breakdown not provided). Although raw data were not included, the study authors reported that fecal lactoferrin differentiated active IBD from IBS patients and healthy controls with 100% sensitivity and specificity. In addition, the test appeared to be highly accurate in differentiating active IBD patients from inactive IBD patients. These preliminary results are very interesting and warrant confirmation in a multicenter, prospective trial. In the second study, Thiwan and colleagues[30] reported on whether the severity of pain during unsedated flexible sigmoidoscopy can be used to identify patients with IBS and visceral hypersensitivity. In this study, 141 patients with IBS (mean age = 34.9 years; 83% women) were found to be more hypersensitive to visceral pain (rectal barostat test) than 16 healthy controls (mean age = 35.7 years; all women). Using a pain-rating scale, IBS patients who were hypersensitive had more abdominal pain during sigmoidoscopy compared with those who were not hypersensitive. Unfortunately, the specificity of these findings was quite low (33%). Thus, the degree of abdominal pain or discomfort during flexible sigmoidoscopy cannot be accurately used to predict the presence of visceral hypersensitivity in IBS patients."http://www.medscape.com/viewarticle/547772Irritable Bowel SyndromeIssues in DiagnosisThe diagnosis of IBS remains problematic for many healthcare providers. Although guidelines now exist to enable a practitioner to confidently diagnose IBS without the need for extensive testing,[17] many physicians still diagnose this highly prevalent disorder only after all other possible diagnoses have been excluded. Spiegel and colleagues[18] highlighted the disparity in treatment approaches between primary care providers and IBS experts using an Internet survey of 2 validated IBS patient case vignettes. Not surprisingly, experts in the field of IBS were more likely to confidently diagnose IBS and not consider it a diagnosis of exclusion in comparison with primary care providers (ie, experts were less likely than nonexperts to endorse a diagnosis of exclusion: 8% vs 72%; P < .0001). In addition, experts were less likely to order diagnostic tests, which resulted in a significant reduction in costs. These findings underscore the need to confidently diagnose IBS as early as possible and to reduce the need for costly diagnostic tests that can be associated with some risk.Cash and colleagues[19] conducted a prospective study to assess the yield of diagnostic testing in patients with suspected IBS. Patients with suspected nonconstipation IBS and without alarm symptoms (weight loss, anemia, evidence of gastrointestinal bleeding) were compared with healthy volunteers after undergoing extensive testing (colonoscopy with random biopsies and extensive blood work including antibody testing for inflammatory bowel disease, celiac disease, and lactase genomics). In this study of 250 IBS patients (66% women; mean age = 44.8 years) and 201 healthy controls (42% women; mean age = 54), the only finding more common in IBS patients was a positive antibody test for celiac disease -- although biopsy-proven celiac disease was only slightly more common in IBS patients compared with controls (1.6% vs 1%; P = .07). These findings confirm results from prior systematic reviews showing that routine diagnostic testing in IBS patients without warning signs is unlikely to demonstrate any organic disease other than celiac disease more frequently than in healthy volunteers.http://www.medscape.com/viewarticle/536306


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## eric

FYI"Gut Bacteria and Irritable Bowel Syndrome By: Eamonn, M. M. Quigley M.D., Alimentary Pharmabiotic Centre, University College Cork, Cork, IrelandBacteria are present in the normal gut (intestines) and in large numbers the lower parts of the intestine. These "normal" bacteria have important functions in life. A variety of factors may disturb the mutually beneficial relationship between the flora and its host, and disease may result. The possibility that gut bacteria could have a role in irritable bowel syndrome (IBS) may surprise some; there is indeed, now quite substantial evidence to support the idea that disturbances in the bacteria that populate the intestine may have a role in at least some patients with IBS. This article presents a discussion of the possible role of bacteria in IBS and various treatment approaches."Do bacteria play a role in IBS?The possibility that gut bacteria could have a role Irritable Bowel Syndrome (IBS) may surprize some; there is indeed, now quite substantial evidence to support the idea that distrubances in the bacteria that populate the intestines may have a role in at least some patients with IBS. What is this evidence? It can be summarized as follows:1. surveys which found that antibiotic use, well known to distrub flora, may predispose individuals to IBS.2. The observation that some individuals may develop IBS suddenly, and for the first time, following an episode of stomach or intestinal infection (gatroenteritis) caused by a bacterial infection.3. recent evidence that a very low level of inflammation may be present in the bowel wall of some IBS patients, a degree of inflammation that could well have resulted from abnormal interactions with bacteria in the gut.4. The Suggestion that IBS maybe Associated with the abnormal presents, , in the small intestines, of types and numbers; a condition termed small bacterial overgrowth (SIBO)>5. Accumaliting evidence to indicate that altering the bacteria in the gut, by antibiotics or probiotics, may improve symptoms in IBS.For some time, various studies have suggested the presence of changes in the kind of colonic flora in IBS patients. The most consistent finding is a relative decrease in the population of one species of 'good' bacteria, bifidobacteria.However, the methods employed in these studies have been subject to question and other studies have not always reproduced these finding. Nevertheless, these changes in the flora, maybe primary or secondary, could lead to the increase of bacterial species that produce more gas and other products of their metabolism. These could CONTRIBUTE to symptoms such as gas, bloating and diarrhea.""We still don't know the exact role bacteria has in IBS. More research is needed."http://www.aboutibs.org/Publications/currentParticipate.html


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## Mary:::)))

Will I still be able to view Eric's thread in the new place?Mary::







))


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## eric

Rev Gastroenterol Disord. 2007 Spring;7(2):97-105.Functional Gastrointestinal Disorders in 2007 and Rome III: Something New, Something Borrowed, Something Objective.Talley NJ.Mayo Clinic College of Medicine, Jacksonville, FL.This review highlights the changes recommended by Rome III to the criteria for the functional gastrointestinal disorders and summarizes the practical implications for clinical practice. The committee retained functional dyspepsia as an umbrella term but emphasized its limited utility; they concluded that those with epigastric pain or burning probably constituted a set of patients very distinct from those who reported meal-related symptoms. Rome III added cyclic vomiting syndrome to the adult functional nausea and vomiting disorder category. The committee simplified clinical subtyping of irritable bowel syndrome. Problems remain with the Rome criteria for functional gallbladder and sphincter of Oddi disorders. Although these patients' pain is probably genuine, the exact characteristics that identify true biliary-type pain remain poorly defined from a scientific perspective. The Rome criteria have been criticized for potentially over-splitting what are truly interdependent conditions. Nevertheless, the Rome criteria remain the best standard we have for guiding diagnosis and helping choose therapy.PMID: 17597677


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## eric

EXPERT INSIGHTSThe New Rome III in Clinical Practice -Douglas A. Drossman, MD and Lin Chang, MD http://www.expertinsightscme.com/pdf/NewRomeIII.pdf


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## eric

Printer-Friendly Email This Discuss This From Nature Clinical Practice Gastroenterology & HepatologyDo Physicians Follow Evidence-Based Guidelines in the Diagnostic Work-up of IBS?Posted 06/21/2007Brennan MR SpiegelAuthor InformationIBS is a chronic disorder of gastrointestinal function that is characterized by recurrent abdominal pain and altered bowel habits in the absence of detectable organic disease. Although IBS is extremely prevalent, affecting up to 15% of the general adult population,[1] its diagnosis is not always straightforward for several reasons: IBS has no consistent biological marker, which leaves clinicians to rely on patient symptoms alone to make the diagnosis; the symptoms of IBS are often difficult to quantify objectively; and many organic conditions can masquerade as IBS. The last fact is the most troubling to both clinicians and patients, many of whom are unsettled by the prospect that alternative diagnoses have been overlooked (such as IBD, microscopic colitis, infectious colitis, small intestinal bacterial overgrowth, celiac sprue, and colon neoplasia, among many others). This uncertainty often prompts clinicians to approach IBS as a diagnosis of exclusion, by performing tests to exclude alternative etiologies.Conversely, the Rome III criteria encourage clinicians to make a positive diagnosis of IBS on the basis of validated symptom criteria, and emphasize that IBS is not a diagnosis of exclusion.[1] This recommendation is based on extensive evidence[2] that diagnostic tests generally have a very low yield in patients who fulfil the Rome criteria but who otherwise lack alarm signs or symptoms. Vanner et al. demonstrated that Rome-criteria symptoms have a positive predictive value of 98% for diagnosing IBS.[3] In other words, 98% of patients with Rome-criteria symptoms have IBS, rather than an underlying organic condition, after undergoing standard evaluations.The Rome II guidelines stated that IBS can be diagnosed so long as "there are no structural or biochemical abnormalities," whereas the Rome III guidelines state that IBS can be diagnosed in the absence of "alarm features," and is "often properly diagnosed without testing."[1] These statements are understandably difficult for many clinicians to reconcile, and some argue that they raise more questions than they answer: What diagnostic tests, if any, should be performed before clinicians can reliably diagnose IBS? Is it really possible to make a diagnosis of IBS without any information from diagnostic tests? Should basic blood count, serum biochemistry, and stool occult blood test, at the very least, be carried out in all potential IBS patients? What about tests for celiac sprue, or bacterial overgrowth?Diagnostic testing of patients with IBS symptoms remains prolific despite the dissemination of the Rome guidelines. For example, community-based surveys reveal that up to 50% of IBS patients undergo colonoscopy in the course of diagnostic evaluation.[4] Moreover, data indicate that 25% of all colonoscopies performed in the US are for IBS-type symptoms, and 10% of colonoscopies in patients under 50 years old are conducted for the evaluation of IBS symptoms. What is perhaps more surprising, however, is that IBS patients are more likely than matched controls without IBS to undergo abdominal surgeries, despite the knowledge that IBS symptoms almost invariably persist following surgery.[5] The excessive rate of abdominal operations in IBS patients suggests that some surgeries might serve as diagnostic tests to evaluate symptom response after removing potential culprit organs-the ultimate exclusionary diagnostic maneuver in IBS.To improve understanding of current diagnostic decision making in IBS, a national vignette survey was performed to assess whether clinicians believe that IBS is a diagnosis of exclusion, and find out which common diagnostic tests clinicians consider appropriate for suspected IBS. The beliefs of a group of 45 recognized experts in IBS were compared with those of a group of randomly selected community clinicians. The survey found that only 8% of IBS experts endorsed IBS as a diagnosis of exclusion compared with 72% of community clinicians[6]. Furthermore, clinicians who believed that IBS was a diagnosis of exclusion ordered 1.6 more tests and spent US$364 more on diagnostic tests per patient than those who did not (P < 0.0001). IBS experts only considered celiac sprue screening and a complete blood count as appropriate first-line routine tests for suspected IBS. By contrast, community clinicians considered complete blood count, serum biochemistry, stool leukocytes, and stool ova and parasite tests as consistently appropriate. Even the experts, however, were divided in their opinion about the appropriateness of many tests, including colonoscopy. In short, experts were more likely than nonexperts to comply with published guidelines, but both groups practice diverged from the guidelines and there were internal inconsistencies in beliefs about diagnostic testing.Why do clinicians continue to order tests for suspected IBS despite data that show that these tests generally have a low diagnostic yield? In light of the medical-legal interface in the US, one possibility is that some clinicians believe that diagnostic testing is a form of inoculation against litigation. Clearly this is an inappropriate reason to pursue diagnostic testing, especially as data indicate that the quality of the physician-patient relationship is a critical predictor of outcomes,[7] and probably a more important predictor of litigation than testing proclivity. A second possibility is the belief that even negative diagnostic tests are useful because they can allay patient concerns about serious illness and provide reassurance. We have shown, however, that a negative colonoscopy, in particular, is not associated with reassurance or improved quality of life in young IBS patients.[8] In fact, we found a nonsignificant trend towards less reassurance in patients who received a negative colonoscopy versus no colonoscopy at all. A third possibility is that IBS patients with multiple unexplained somatic complaints and physical illnesses potentially related to their underlying psychosocial distress are sometimes misclassified as having several underlying organic conditions, and subsequently undergo diagnostic tests to chase these symptoms. We found a linear and highly significant relationship between levels of such somatization and the amount of diagnostic testing in IBS, which suggests that clinicians should be aware of somatization in patients with IBS, and aggressively treat or refer such patients in lieu of performing potentially unnecessary tests.[9] The most common reason for diagnostic testing in IBS, however, might be that the Rome criteria have a 98%, rather than a 100%, positive predictive value, therefore, no matter how strong the evidence is that diagnostic testing has a low yield, a real possibility of underlying organic disease remains. This argument is simply not debatable, particularly in light of growing evidence that patients diagnosed with IBS are a heterogeneous population with a core of pure IBS patients surrounded by small subsets who have alternative diagnoses such as celiac sprue and bacterial overgrowth.Despite this reality, clinicians should keep in mind that time is on their side in IBS. In the absence of alarm features, conditions that masquerade as IBS are typically chronic and progress slowly. Moreover, cancer is no more common in IBS patients than controls, and patients over 50 years old should routinely undergo colorectal cancer screening regardless of IBS symptoms. In the absence of alarm features, clinicians should focus less on diagnostic testing and more on addressing patients' disease-specific fears and concerns by setting mutually reasonable goals and expectations, providing multimedia educational materials (such as those offered by the American Gastroenterological Association or the International Foundation for Functional Gastrointestinal Disorders), teaching self-empowerment techniques, and screening for and treating (or referring) somatization. Ultimately, however, clinicians must use their judgment, and should reserve the right to investigate further if their IBS patients have a poor response to therapy, experience worsening symptoms, or develop alarm features. Like most things in medicine, diagnostic testing in IBS remains a balance of art and science.http://www.medscape.com/viewarticle/558644


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