# IBS Irritable Bowel Syndrome: A Concise Guide for Medical Professionals



## Jeffrey Roberts (Apr 15, 1987)

Originally from: http://www.gastro.org/adhf/ibs-guide.html







IBS Irritable Bowel Syndrome A Concise Guide for Medical Professionals What is it? Irritable bowel syndrome (IBS), a specific cluster of chronic abdominal symptoms, is the most common functional gastrointestinal disorder. About 15-20% of the general population suffer from IBS, including all racial/ethnic subsets and adult/adolescent age groups. Females predominate, especially among the most severely affected patients. IBS accounts for enormous direct medical costs as well as work absenteeism and other indirect costs. It is one of the most common diagnoses in primary care practice. Pathogenesis IBS is not explainable on structural or biochemical grounds. Various pathogenic mechanisms support a biopsychosocial concept: Abnormal motor function Visceral hyperalgesia, the enhanced perception of visceral stimuli Abnormal cerebral processing of bowel stimuli Luminal factors, such as malabsorbed sugars or previous infection Psychological factors The multifactorial nature of IBS emphasizes the need for an individualized approach to diagnosis and treatment! Diagnosis IBS usually can be diagnosed confidently by a typical history and limited laboratory and structural evaluation. Careful attention to the description of pain and bowel habit is critical. The characteristic features form the basis for diagnostic criteria developed by multinational consensus. The characteristic symptoms alone do not always differentiate IBS from organic disease, and inquiry should be made about medication use and potential dietary factors, such as caffeine, fructose in fruit juice and sorbitol in artificially sweetened candy. Psychosocial factors, including recent stress, may influence the clinical presentation. Importantly, warning ("alarm") signs that are not attributable to IBS should be sought: weight loss, hematochezia, fever, frequent nocturnal symptoms. Physical examination reveals no explanation for the symptoms. Diagnostic testing should be individualized according to the patientï¿½s age, predominant symptom, severity and duration of symptoms, and presence of psychosocial factors. In primary care, the emphasis should be on minimizing tests in patients with typical symptoms and no warning signs. The evaluation can be limited to that required for the physician to confidently provide explanation, reassure, and initiate therapy. Prolonged, fruitless diagnostic evaluation tends to increase patient anxiety and needlessly raises costs. In young patients, no testing or only basic blood tests, such as a complete blood count and erythrocyte sedimentation rate, may be considered. Other tests, especially large bowel endoscopy or barium enema, may be needed in some young patients and should be used more routinely in older patients. Management Establishing an effective clinical relationship is probably the most cost-effective and beneficial treatment for patients with IBS. The following steps are often helpful in establishing such a relationship: Acknowledge the pain Adopt an empathetic and non-judgmental point of view to maximize the therapeutic relationship Educate and reassure Set reasonable goals Help the patient take responsibility, as by using a symptom diary Know your limitations ï¿½ refer to specialists Most patients (70%) with IBS have mild symptoms and little or no psychological difficulties. A positive diagnosis coupled with education, reassurance, and dietary and lifestyle changes are often sufficient. Patients should be advised to eat well-balanced, regular meals, avoid food fads and excess fat, and reduce irritants such as caffeine, sorbitol, and alcohol. Regular exercise and efficient management of life stress should be encouraged. Patients with moderately severe symptoms (25%) often require pharmacotherapy directed at the gut. Some may be interested in psychological treatment to help manage associated emotional distress, when present. Patients with severe symptoms (5%) commonly have psychological co-morbidities and are more often seen in tertiary referral centers. For these patients, strong reassurance of the correct diagnosis is necessary to reduce concerns and health-care resource use. Antidepressants may be helpful to reduce pain and treat psychiatric disorders. Referral to a mental health professional to help manage symptoms and reduce stress can be useful. Medications for IBS are typically directed toward the predominant symptom, such as pain, diarrhea, or constipation. Pain-predominant symptoms The most frequently prescribed drugs for pain and bloating are the anti-spasmodic agents. These agents affect motor activity and reduce colonic responsiveness to eating and to stress. In the US, anticholinergics (e.g., hyoscyamine, dicyclomine) are the most commonly prescribed anti-spasmodics. These drugs are best taken 30 minutes before eating. Sublingual and suppository preparations of hyoscyamine are available. Antidepressants are also commonly used to treat pain-predominant IBS symptoms. Of the tricyclic antidepressants, desipramine and nortriptyline tend to have fewer side effects and may be preferred over amitriptyline and imipramine. Dosing of the tricyclic antidepressants is typically in the range of 50-100 mg/day, with starting doses of 10-25 mg/day to avoid side effects. Newer antidepressants, including the SSRIs, may also be helpful in IBS although fewer studies currently are available. In general, dosing for the SSRIs is similar as for psychiatric illnesses (e.g., 10-50 mg/day for paroxetine, 50-200 mg/day for sertraline, 10-40 mg/day for fluoxetine). Recent data indicate that alosetron (1 mg po bid), a 5-HT3 antagonist, can reduce IBS symptoms including abdominal pain in women with bowel habit patterns other than constipation. Diarrhea-predominant symptoms Loperamide (2-4 mg up to qid) will enhance intestinal water absorption, strengthen anal sphincter tone, and decrease intestinal transit ï¿½ thereby increasing stool consistency and reducing frequency. Prophylactic use of loperamide prior to events which typically trigger symptoms may reduce anxiety and increase confidence. In general, loperamide is preferable to diphenoxylate, codeine or other narcotics as it does not cross the blood-brain barrier. Alosetron also can improve stool consistency and reduce urgency in women with diarrhea-predominant symptoms. Constipation-predominant symptoms Increased dietary fiber can enhance colonic transit in patients with reduced fiber intake (<20-25 grams/day). In these patients, supplemental dietary fiber (e.g., wheat bran) or commercially available fiber products (e.g., psyllium, methylcellulose, calcium polycarbophil) should be recommended. Patients who develop bloating and gas with the addition of fiber should be instructed to gradually increase intake from a low starting dose or switch to another form of fiber. Newer agents with prokinetic effects on the colon also are being developed for IBS symptoms. Psychological therapies for IBS Psychological therapies should be considered for patients with motivation to use these non-pharmacological approaches, with refractory IBS symptoms, or with co-morbid psychiatric disorders. The most common psychological therapies used in IBS are stress management/relaxation, cognitive-behavioral psychotherapy, and hypnosis. In general, a psychologist is employed to design and administer these treatments. Rome II Diagnostic Criteria Abdominal discomfort or pain that has 2 of these features: Relief with defecation Onset associated with change in stool frequency Onset associated with change in form (appearance of stool) Symptoms for at least 12 weeks in the preceding 12 months (need not be consecutive weeks) The following symptoms, while not essential, increase the diagnostic confidence with their presence: Abnormal stool frequency (>3/day or <3/week) Abnormal stool form (lumpy/hard or loose/watery) Abnormal stool passage (straining, urgency, feelings of incomplete evacuation) Passage of mucus Bloating or feeling of abdominal distention From: Gut 1999; volume 45 (Supplement II)


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## JeanG (Oct 20, 1999)

This is an excellant article, Jeff!







JeanG


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