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Irritable BowelSyndromeDiagnosis page ITC7-2

Treatment page ITC7-8

Practice Improvement page ITC7-14

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Section EditorsChristine Laine, MD, MPHDavid Goldmann, MD

Science WriterJennifer F. Wilson

The content of In the Clinic is drawn from the clinical information and education resources of the American College of Physicians (ACP), includingPIER (Physicians’ Information and Education Resource) and MKSAP (MedicalKnowledge and Self-Assessment Program). Annals of Internal Medicineeditors develop In the Clinic from these primary sources in collaboration withthe ACP’s Medical Education and Publishing Division and with the assistance of science writers and physician writers. Editorial consultants from PIER andMKSAP provide expert review of the content. Readers who are interested in these primary resources for more detail can consult http://pier.acponline.org and otherresources referenced in each issue of In the Clinic.

The information contained herein should never be used as a substitute for clinicaljudgment.

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What symptoms should prompt aclinician to consider IBS?Symptoms of IBS vary from personto person, but clinicians shouldconsider IBS if abdominal discom-fort or pain associated with boweldysfunction is present. Othersymptoms that suggest IBS includeprominent gastrocolic reflex, alter-nating constipation and diarrhea,and excess gas andflatulence. Gas-trointestinal symp-toms that wax andwane for morethan 2 years andthose that are exac-erbated by psy-chosocial stressshould raise suspi-cion for IBS over other diagnoses.

Three general pat-terns of bowelsymptoms arecommon in IBS:diarrhea-predomi-nant, constipation-predominant, andmixed (alternatingdiarrhea and con-stipation). Determining a patient’spredominant symptom pattern canbe useful in guiding managementbecause the different subgroups respond differently to the varioustherapeutic options. Because an

individual patient’s symptom pattern can change over time, itis debatable whether symptompattern clearly demarcates patients with different IBS subtypes.

Certain clinical features, oftencalled alarm features or red flagsymptoms, suggest that the diagno-sis is something other than IBS (2)

(see Box). Alarmfeatures includeweight loss, noctur-nal awakening be-cause of gastroin-testinal symptoms,blood in the stool,family history ofcolon cancer or in-flammatory boweldisease, recent useof antibiotics, andfever.

What are theaccepted diagnosticcriteria for IBS?History is the maindiagnostic tool forIBS. There are 2sets of symptom-based diagnostic cri-

teria to help discriminate IBS fromother disorders: the Manning crite-ria and the Rome criteria (Table 1).These criteria were developed foruse in clinical studies, but can behelpful in clinical settings.

1. Drossman DA. Thefunctional gastroin-testinal disorders andthe Rome III process.Gastroenterology.2006;130:1377-90.[PMID: 16678553]

2. Longstreth GF. Irrita-ble bowel syndrome.Diagnosis in themanaged care era.Dig Dis Sci.1997;42:1105-11.[PMID: 9201069]

3. Manning AP, Thomp-son WG, Heaton KW,Morris AF. Towardspositive diagnosis ofthe irritable bowel. BrMed J. 1978;2:653-4.[PMID: 698649]

© 2007 American College of Physicians ITC7-2 In the Clinic Annals of Internal Medicine 3 July 2007

Irritable bowel syndrome (IBS) is a common but poorly understood dis-order that interferes with normal colon function, resulting in abdominalpain, bloating, constipation, and diarrhea. No specific biological bio-

marker, physiologic abnormality, or anatomical defect has been discovered.Psychosocial stress may exacerbate symptoms.

IBS is 1 of 28 adult and 17 pediatric functional gastrointestinal disorders.These disorders are symptom-based and not explained by other pathologicallydefined diseases. IBS appears to be linked to motor and sensory physiologyand brain–gut interaction (1). Emerging theories suggest that alteration ofintestinal bacteria may also play a role in the condition. IBS affects as manyas 1 in 5 U.S. adults, occurs more often in women than in men, and beginsbefore the age of 35 in about half of all people who develop the disorder. IBSis recognized worldwide, but prevalence varies geographically.

Diagnosis

Alarm Features That SuggestPossible Organic Disease

Symptoms • Weight loss• Frequent nocturnal awakenings

due to gastrointestinal symptoms

• Fever• Blood mixed in stool

History• New onset, progressive

symptoms• Onset of symptoms after age 50• Recent antibiotic use• Family history of colon cancer or

inflammatory bowel disease

Physical Findings• Abdominal mass• Stool positive for occult blood• Enlarged lymph nodes


4. Thompson WG, Dote-wall G, Drossman DA,et al. Irritable bowelsyndrome: guidelinesfor the diagnosis.Gastroenterol Int.1989;2:92-95.

5. Thompson WG,Longstreth GF, Dross-man DA, et al. Func-tional bowel disor-ders and functionalabdominal pain. Gut.1999;45 Suppl 2:II43-7. [PMID: 10457044]

6. Longstreth GF,Thompson WG, CheyWD, et al. Functionalbowel disorders. Gas-troenterology.2006;130:1480-91.[PMID: 16678561]

7. Talley NJ, Phillips SF,Melton LJ, et al. Diag-nostic value of theManning criteria in ir-ritable bowel syn-drome. Gut.1990;31:77-81.[PMID: 2318433]

© 2007 American College of PhysiciansITC7-3In the ClinicAnnals of Internal Medicine3 July 2007

Manning and colleagues (3) pro-posed the first widely used IBS cri-teria in 1978 based on the symp-toms listed in Table 1.

In 1989, a group of experts met inRome and developed another set ofconsensus-based criteria known asthe Rome criteria to assist in thediagnosis of IBS and other func-tional gastrointestinal disorders (4).The Rome criteria, which are alsodisplayed in Table 1, were based ona broader array of symptoms thanthe Manning criteria and explicitlyconsidered both duration and fre-quency of symptoms. In 1999, thesame group of experts developedthe Rome II criteria, a modifiedversion of the earlier criteria in-tended to be more adaptable toclinical practice (5).

The group released the most recentversion of the Rome criteria, RomeIII, in 2006. Rome III did notchange the basic diagnostic criteriafor IBS but modified the time framefor symptoms and description ofIBS subtyping (6). Rome III speci-fies that symptoms must have begunat least 6 months before the diag-nosis can be established and thatpatients have fulfilled the Romecriteria for at least 3 months beforeIBS can be diagnosed. Rome III

recommends that clinicians baseclassification of IBS symptoms asdiarrhea-prominent; constipation-prominent; or mixed, based onstool consistency. Rome criteria aredynamic, and future studies areneeded to confirm the validity ofrecent changes intended to increasethe usefulness of the criteria in re-search and clinical settings (1).

When diagnostic criteria are satis-fied; warning symptoms are absent;the history and physical examina-tion suggest IBS; and the occultblood test, complete blood count(CBC), and erythrocyte sedimenta-tion rate (ESR) are normal, the riskfor overlooking organic disease maybe as low as 1% to 3%. Thus, ex-pert consensus is that physiciansshould limit evaluation to fulfill-ment of the Rome or Manning criteria if no alarm symptoms arepresent.

Even without exclusion of alarm features,the presence of at least 3 of the 6 Manningcriteria has an average sensitivity of ap-proximately 60% and specificity of approx-imately 80%. The criteria’s sensitivity andspecificity vary by study; however, the diag-nostic accuracy is known to be better inwomen, younger patients, and when morecriteria are fulfilled (7).

When Rome criteria have beensatisfied, warning symptomsare absent; the history andphysical examination suggestIBS; and the occult blood test,complete blood count, anderythrocyte sedimentationrate are normal, the risk foroverlooking organic diseasemay be as low as 1% to 3%.

Table 1. Symptom Criteria for Irritable Bowel SyndromeRome III*

Recurrent abdominal pain or discomfort at least 3 days per month in the past 3 months associated with 2 or more of the following:

1. Improvement with defecation

2. Onset with change in frequency of stool

3. Onset associated with a change in the form and appearance of stool

*Criteria must be fulfilled for at least the past 3 months with symptom onset at least 6 months beforediagnosis.

Manning†

Pain relief with defecation, often

Looser stools at pain onset, often

More frequent stools at pain onset, often

Visible abdominal distention

Mucus per rectum

Feeling of incomplete evacuation

†To establish IBS diagnosis, patient must meet 3 or more criteria.


Tolliver and coworkers showed that theRome criteria had a positive predictive val-ue of 98.5%—out of 196 patients, they ex-cluded 1 case of colon cancer, 1 of colitis,and 1 of peptic ulcer (8).

Vanner and colleagues prospectively stud-ied 95 patients who met the Rome criteriaand lacked red flags and found the positivepredictive value was 98% (9).

Investigators conducted interviews with alarge, community-based sample of U.S.women diagnosed with IBS, and theyfound that Rome I was significantly moresensitive than Rome II (84% vs. 49%; P <0.001). Only 58% of patients who had IBSaccording to Rome I criteria had IBS ac-cording to Rome II criteria; 17.7% did notmeet the criteria for either Rome I or II (10).

What is the utility of the physicalexamination in diagnosing IBS?The physical examination is usuallynormal in IBS, except for mild ab-dominal tenderness or a palpable,tender loop of colon. However,neither is sensitive or specific forIBS. Physical findings that are notassociated with IBS but that arenotable because they indicate theneed to seek other diagnoses in-clude fever, weight loss, lymphnode enlargement, abdominal mass,and hepatosplenomegaly. Thephysical examination should in-clude testing the stool for occultblood.

Which diagnostic tests are usefulin diagnosing IBS?There are no specific diagnostictests for IBS. Tests that may behelpful for ruling out diagnosesother than IBS include endoscopy,blood tests, evaluation of stoolsamples, and imaging studies. Clin-icians should use these tests withdiscretion depending on the pa-tient’s age, history, and symptompattern, and on the presence ofalarm features for organic disease.

EndoscopyFlexible sigmoidoscopy may behelpful in excluding colitis or obstructive lesions of the colon.However, if patients are young,

fulfill the Rome criteria, and haveno alarm features, a presumptivediagnosis of IBS can be made with-out endoscopy but should bereevaluated depending on thecourse of symptoms over time. Be-cause patients with IBS have ab-normally sensitive gastrointestinaltracts, they may find endoscopymore uncomfortable than do pa-tients without this condition. Rec-tal and colonic balloon studies haveshown hypersensitivity of the intes-tines in 55% to 93% of patientswith IBS (11). Thus, normal endoscopy can be particularly in-dicative of IBS when it causes morepain than expected or when it re-produces the patient’s symptoms.

Blood TestsA CBC and an ESR are reasonableto evaluate for anemia, elevatedsedimentation rate, or leukocytosisbecause these findings are not com-patible with IBS. Serum amylaseand liver enzyme levels may be use-ful if pancreatic or biliary disease issuspected.

Evaluation of Stool SamplesEvaluation of stool for Clostridium

diff icile may be helpful if the patienthas recently taken antibiotics. Ex-amination of stool for ova and par-asites may be helpful in patientswith diarrhea-predominant symp-toms, especially if travel historysuggests potential exposure to para-sites. In general, bacterial culturesare unlikely to be helpful in the di-agnosis of chronic diarrhea. How-ever, there is a form of IBS inwhich patients develop typical IBSsymptoms after resolution of anacute episode of dysentery. Thiscondition may take 6 months to re-solve and can lead to chronic IBS.Factors associated with post infec-tious IBS include age, female sex,severity of infection, and possiblypsychological predisposition.Awareness of the condition canlimit the search for persistent infection.

8. Tolliver BA, HerreraJL, DiPalma JA. Eval-uation of patientswho meet clinicalcriteria for irritablebowel syndrome.Am J Gastroenterol.1994;89:176-8.[PMID: 8304298]

9. Vanner SJ, DepewWT, Paterson WG, etal. Predictive value ofthe Rome criteria fordiagnosing the irrita-ble bowel syndrome.Am J Gastroenterol.1999;94:2912-7.[PMID: 10520844]

10. Chey WD, Olden K,Carter E, et al. Utilityof the Rome I andRome II criteria for ir-ritable bowel syn-drome in U.S.women. Am J Gas-troenterol.2002;97:2803-11.[PMID: 12425552]



Stool collection over a 24-hour pe-riod for quantification of volumemay be helpful in patients who re-port large-volume or watery diar-rhea. Normal stool volume is 200mL or less per day. Volumes over350 to 400 mL suggest etiologiesother than IBS.

Measurement of fecal calprotectinin stool samples can help to identi-fy patients with intestinal inflam-mation as an organic cause ofsymptoms mimicking IBS. In onestudy, the positive predictive valueof fecal calprotectin for organic dis-ease was 76% and the negative pre-dictive value was 89% (12).

A spot or 24-hour fecal fat test canshow malabsorption. Screening forceliac sprue with antigliadin andantiendomysial antibodies is bothsensitive and specific (13). If no fatmalabsorption is detected, clini-cians may still consider these anti-body tests in patients with unex-plained anemia or weight loss.

Imaging StudiesImaging studies should be used ju-diciously, but the following testsmay help to exclude conditions thatcould mimic IBS. A flat and up-right abdominal radiograph duringan episode of pain may show un-recognized bowel obstruction,aerophagia, or retained stool. Asmall bowel barium radiograph candiagnose ileal and jejunal Crohndisease, and dilatation or diverticulafavoring small bowel overgrowth.Computed tomography (CT) scan-ning will have low yield if there areno alarm symptoms.

What is the differential diagnosisthat clinicians should considerwhen evaluating a patient forpossible IBS?The differential diagnosis of a pa-tient presenting with symptoms ofIBS is extensive (Table 2). Thus,some clinicians feel obligated toperform a wide variety of diagnos-tic tests before attributing a pa-tient’s symptoms to IBS. However,

no definitive data support routineperformance of any diagnostictests in patients with potentialIBS. Clinicians should considersymptom patterns when trying toexclude serious diagnoses that canmasquerade as IBS.

Patients with Constipation-ProminentSymptomsIn patients with constipation, clini-cians should consider partialcolonic obstruction or non-IBScauses of colonic dysmotility.Nonobstructive causes of colonicsymptoms may be because of dys-motility secondary to medications,neurologic disease, hypothyroidism,pelvic floor dysfunction, or colonicinertia (colon transit > 5 days). Thediagnosis is not IBS if colonic dys-motility is present without pain orif there is another explanation forsymptoms, such as neurologic dis-order, pelvic floor disorder, orcolonic inertia (transit throughcolon > 72 hours, with predomi-nantly right colon delay). In pa-tients younger than 45 years of agewith mild, chronic constipation-predominant symptoms, normalCBC, and no alarm features, treat-ment with fiber or an osmoticlaxative should be offered beforeadditional diagnostic testing.

Patients with Diarrhea-PredominantSymptomsThe differential in patients withdiarrhea-predominant symptomsincludes inflammatory bowel dis-ease, infection, malabsorption, andeffects of medication and diet. Foryounger patients with mild, chronicdiarrhea-predominant symptoms,clinicians should consider flexiblesigmoidoscopy, CBC, and exami-nation of stools for ova and para-sites. For patient older than 45years or those with refractory, severe, or new-onset symptoms,evaluating the entire colon may bewarranted to exclude neoplasm.However, clinicians must keep inmind that non-IBS disease is unlikely if the patient satisfies

11. Mertz H, Naliboff B,Munakata J, Niazi N,Mayer EA. Alteredrectal perception is abiological marker ofpatients with irrita-ble bowel syndrome.Gastroenterology.1995;109:40-52.[PMID: 7797041]

12. Tibble JA, Sigthors-son G, Foster R, For-gacs I, Bjarnason I.Use of surrogatemarkers of inflam-mation and Rome criteria to distinguish organicfrom nonorganic intestinal disease.Gastroenterology.2002;123:450-60.[PMID: 12145798]

13. Bürgin-Wolff A, GazeH, Hadziselimovic F,et al. Antigliadin andantiendomysium an-tibody determina-tion for coeliac dis-ease. Arch Dis Child.1991;66:941-7.[PMID: 1819255]




Table 2. Differential Diagnosis of Irritable Bowel Syndrome*Disease Clinical Characteristics Diagnostic Strategy

Constipation-predominant symptoms

Strictures due to inflammatory Obstipation Colonoscopy vs. barium enema and bowel disease, diverticulitis, flexible sigmoidoscopyischemia, or cancer

Colonic inertia Very infrequent bowel movements Sitzmark transit study

Pelvic floor dysfunction† Straining, self-digitation Rectal examination, balloon expulsion study, anoretal manometry, defecography

Neurologic disease† Concurrent Parkinson disease, History and neurologic examinationautonomic dysfunction (Shy-Drager), multiple sclerosis

Medication† Opiates, cholestyramine, calcium- Medication historychannel blockers, anticholinergic medications

Hypothyroidism† Other hypothyroid symptoms and signs Serum thyroid-stimulating hormone

Diarrhea-predominant symptoms

Crohn disease Diarrhea may be from Colonoscopy, small bowel barium radiographinflammatory exudate, motility changes, small bowel overgrowth, or bile salt malabsorption

Ulcerative colitis Likely to have rectal bleeding Colonoscopy

Microscopic colitis† Generally middle-aged and older Colonoscopy/flexible sigmoidoscopy and biopsywomen with autoimmune disease (especially thyroiditis)

Parasites Giardia lamblia (stream and well O + P x 3, stool Giardia antigen, water); Ascaris lumbricoides, metronidazole trialEntamoeba histolytica (travel to developing world); Strongyloides stercoralis (travel to developing world, Kentucky, or Tennessee)

Clostridium difficile Recent antibiotics taken Stool ELISA, flexible sigmoidoscopy for pseudomembranes

Other bacteria IBS after dysentery may persist for Compatible history, possible initialmonths after infection with bacteria positive stool culture

Small bowel overgrowth Due to severe small bowel Abdominal radiograph, small bowel barium dysmotility, partial obstruction, radiograph, lactulose breath hydrogen test,blind loop, or jejunal diverticulosis antibiotic trial

Sprue† (gluten-sensitive enteropathy) May present with diarrhea, usually Usually steatorrhea, positive gliadin, steatorrhea endomysial serum antibodies; endoscopy with

small bowel biopsy is gold standard

Lactose intolerance† Symptoms worse with lactose Avoidance trial, lactose breath testconsumption

Postgastrectomy syndrome Postprandial symptoms History of problems worse after gastric surgery

HIV enteropathy May have chronic GI infections, Clinical suspicion, HIV test, low CD4such as with cryptosporidium, CMV, Blastocystis hominis, amoeba

Gastrointestinal endocrine tumor Carcinoid, gastrinoma, VIPoma Urine 5HIAA, fasting gastrin (followed by secretin stimulation test), serum VIP

Pain-predominant symptoms

Aerophagia, bloating Patient may be anxious (nervous air Abdominal radiograph with painswallowing), can be exacerbated by antireflux surgery

Intermittent small bowel More likely with history of previous Abdominal radiograph with pain, smallabdominal surgeries bowel barium radiograph


Rome criteria and lacks alarmsymptoms.

Patients with Pain-Predominant SymptomsIn patients with refractory, pain-

predominant symptoms, a flat and

upright abdominal radiograph dur-

ing a pain episode can be helpful in

revealing unrecognized bowel ob-

struction, aerophagia, or retained

stool. Serum amylase and liver en-

zyme levels may diagnose pancreat-

ic and biliary disease if symptoms

suggest these diagnoses. CT scan-

ning for neoplasms will have low

yield if there are no alarm symp-

toms. Other rare conditions that

may cause pain-predominant

abdominal symptoms with some

bowel dysfunction include intestinal

angina (generally associated with

weight loss and occult blood) and

endometriosis (in general cyclicwith menses).

Clinicians should use clinical judg-ment to modify these generalguidelines to allow less or moreevaluation.

Under what circumstances shouldclinicians consider consultationwith a gastroenterologist?Gastroenterologists often workwith primary care physicians andpatients to diagnose IBS and to ex-clude relevant disorders. Consulta-tion is warranted in the followingcases of diagnostic uncertainty:when patients do not fit Rome orManning criteria, when patientshave alarm symptoms, and whenpatients do not respond to initialmanagement. Consultation is alsonecessary if specialized diagnosticprocedures, such as endoscopy, are needed.


Table 2. Differential Diagnosis of Irritable Bowel Syndrome* (continued)Disease Clinical Characteristics Diagnostic Strategy

Crohn disease Small intestine or colon involvement Small bowel barium radiograph colonoscopy

Acute intermittent porphyria Rare; may have elevated liver Serum and urine porphyrins, especiallyenzymes and neurologic symptoms porphobilinogen, and delta aminolevulinic acid

Ischemia Intestinal angina especially in Mesenteric angiogramvasculopaths, food aversion, weight loss, pain 15–40 min after meals

Chronic pancreatitis Alcohol abuse, pain usually more Abdominal radiograph for calcifications, CTpersistent than with usual IBS scan, ERCP, endoscopic ultrasonography

Lymphoma of Gl tract Generally, weight loss CT scan, small bowel radiograph

Endometriosis Menstrual-associated symptoms, Laparoscopypelvic symptoms

*CMV = cytomegalovirus; CT = computed tomography; ELISA = enzyme-linked immunosorbent assay; ERCP = endoscopic retrograde cholangiopancre-atography; GI = gastrointestinal; IBS = irritable bowel syndrome; O + P = ova and parasites; VIPoma = vasoactive intestinal peptide-producing tumor.†Unlikely alone to cause abdominal pain.

Diagnosis... Clinicians should base the diagnosis of IBS on history and physical examination, paying careful attention to fulfillment of the Rome or Manning criteria and exclusion of alarm features. Patients who fulfill the criteria and haveno alarm features may need no additional testing other than a complete bloodcount and test for fecal occult blood to establish a presumptive diagnosis of IBS.Diagnostic testing should be judicious and focus on exclusion of specific non-IBSconditions that are consistent with the individual patient’s clinical presentation.

CLINICAL BOTTOM LINE



14. Prior A, Whorwell PJ.Double blind studyof ispaghula in irrita-ble bowel syndrome.Gut. 1987;28:1510-3.[PMID: 3322956]

15. Müller-Lissner SA. Ef-fect of wheat branon weight of stooland gastrointestinaltransit time: a metaanalysis. Br Med J(Clin Res Ed).1988;296:615-7.[PMID: 2832033]

16. Brandt LJ, BjorkmanD, Fennerty MB, et al.Systematic reviewon the managementof irritable bowelsyndrome in NorthAmerica. Am J Gas-troenterol.2002;97:S7-26.[PMID: 12425586]

17. Colwell LJ, PratherCM, Phillips SF, Zins-meister AR. Effects ofan irritable bowelsyndrome educa-tional class onhealth-promotingbehaviors and symp-toms. Am J Gas-troenterol.1998;93:901-5.[PMID: 9647015]

18. Owens DM, NelsonDK, Talley NJ. The irri-table bowel syn-drome: long-termprognosis and thephysician-patient in-teraction. Ann InternMed. 1995;122:107-12. [PMID: 7992984]

19. Creed F, Craig T,Farmer R. Functionalabdominal pain, psy-chiatric illness, andlife events. Gut.1988;29:235-42.[PMID: 3345935]

20. Bennett EJ, TennantCC, Piesse C, Bad-cock CA, Kellow JE.Level of chronic lifestress predicts clini-cal outcome in irrita-ble bowel syndrome.Gut. 1998;43:256-61.[PMID: 10189854]

21. Drossman DA, San-dler RS, McKee DC,Lovitz AJ. Bowel pat-terns among sub-jects not seekinghealth care. Use of aquestionnaire toidentify a populationwith bowel dysfunc-tion. Gastroenterolo-gy. 1982;83:529-34.[PMID: 7095360]

22. Drossman DA, Leser-man J, Nachman G,et al. Sexual andphysical abuse inwomen with func-tional or organicgastrointestinal dis-orders. Ann InternMed. 1990;113:828-33. [PMID: 2240898]

Is dietary modification effective inthe management of IBS?Dietary modification is not provento reduce IBS symptoms, and ma-jor exclusion diets are not recom-mended. However, it may be reasonable to consider dietary modification for individual cases inwhich specific foods seem to triggersymptoms. In addition, common-sense dietary recommendations di-rected at the predominant symptomcan help to minimize symptoms.Clinicians should talk with patientsabout their dietary habits to:

• Evaluate for lactose intolerance• Evaluate consumption of caf-

feine, fructose, or artificialsweeteners, all of which canhave laxative effects

• Inquire about laxative-contain-ing herbal products

• Determine whether patientswith gas and bloating are drink-ing excess carbonated beverages,drinking with a straw, or chew-ing gum, all of which can lead aperson to swallow too much air

• Advise against excess intake offats, which can lead to gas retention

• Advise avoidance of certain car-bohydrates, such as beans, cab-bage, broccoli, and cauliflower,if they trigger symptoms. Theymay be difficult to digest andlead to fermentation and gas inthe colon.

Inadequate dietary fiber may causeconstipation, and clinicians oftenencourage patients with constipation-predominant IBS to increase fiberintake. Studies suggest that fiber ishelpful for relief of constipation,but not for relief of pain (14, 15).Fiber is not effective for patientswith diarrhea-predominant IBSand may even exacerbate symp-toms. Achieving constipation reliefwith fiber may require high-dosetherapy, which patients are oftenunable to tolerate.

A systematic review studied the role ofbulking agents in IBS (wheat bran, cornfiber, calcium polycarbophil, ispaghulahusk, and psyllium) and concluded thatthey were no more effective than placeboin providing global symptom relief of IBS .However, the authors deemed all of the tri-als inadequate because of methodologicalflaws or small sample size (16).

Are there nonpharmacologicinterventions aside from diet that are useful in themanagement of IBS?In addition to advice about diet,important nonpharmacologic as-pects of IBS care include reassur-ance, education with advice abouttrigger avoidance, stress manage-ment, and exercise. Clinicians mustreassure patients that their symp-toms are not because of a life-threatening disorder and assistthem in developing effective self-management strategies. Patients dobetter and use health care more ef-ficiently when it is acknowledgedthat their symptoms are not imag-ined, that the symptoms have physi-ologic causes that are poorly under-stood but real, and that they canthemselves control some symptomtriggers.

In an uncontrolled study, advice about dietand exercise, stress management, and ap-propriate use of medications was associat-ed with alleviation of IBS symptoms in 80%of patients (17).

Retrospective analysis of outpatient chartsat a referral center showed a correlationbetween patient education, including dis-cussion of psychosocial stressors, and re-duced future visits(18) .

It may be helpful to ask patients tocomplete daily diaries of symptoms,including entries for stressors,mood, events, thoughts, and diet.Clinicians should use the diary information to help patients under-stand the role of psychosocial stres-sors and to help them develop self-management strategies.

Treatment



23. Hazlett-Stevens H,Craske MG, MayerEA, Chang L, NaliboffBD. Prevalence of ir-ritable bowel syn-drome among uni-versity students: theroles of worry, neu-roticism, anxietysensitivity and vis-ceral anxiety. J Psy-chosom Res.2003;55:501-5.[PMID: 14642979]

24. Gwee KA, Leong YL,Graham C, et al. Therole of psychologicaland biological fac-tors in postinfectivegut dysfunction.Gut. 1999;44:400-6.[PMID: 10026328]

25. Guthrie E, Creed F,Dawson D, Tomen-son B. A controlledtrial of psychologicaltreatment for the ir-ritable bowel syn-drome. Gastroen-terology.1991;100:450-7.[PMID: 1985041]

26. North of England IBSResearch Group. Thecost-effectiveness ofpsychotherapy andparoxetine for severeirritable bowel syn-drome. Gastroen-terology.2003;124:303-17.[PMID: 12557136]

27. Talley NJ, Owen BK,Boyce P, Paterson K.Psychological treat-ments for irritablebowel syndrome: acritique of con-trolled treatment tri-als. Am J Gastroen-terol.1996;91:277-83.[PMID: 8607493]

28. Jailwala J, ImperialeTF, Kroenke K. Phar-macologic treat-ment of the irritablebowel syndrome: asystematic review ofrandomized, con-trolled trials. AnnIntern Med.2000;133:136-47.[PMID: 10896640]

29. International Foun-dation for FunctionalGastrointestinal Dis-orders. IBS in the realworld survey. Mil-waukee, WI: Interna-tional Foundationfor Functional Gas-trointestinal Disor-ders; 2002:1-19.

What is the role of psychotherapyin the care of patients with IBS?Psychosocial stressors are associatedwith symptoms (19–21). Patientswith IBS are more likely to havehad early life or current trauma, including losses or abuse (22), andare more likely to have generalizedanxiety disorder and worry (23).Psychological distress is associatedwith IBS after dysentery (24). Psy-chological therapy to minimizeanxiety can reduce symptoms.

One randomized, controlled trial (RCT) involving patients whose symptoms hadnot improved withstandard medical treat-ment for at least 6months showed thattwo thirds of the pa-tients receiving psy-chotherapy had less di-arrhea but not lessconstipation; they alsohad less intermittentpain, but those withconstant abdominalpain did not improve(25).

Other research hasfound that pscho-therapy also results in decreased useof health care resources. So whilepsychotherapy has costs on thefront end, it may reduce long-termmedical costs (26). However, trialsof psychological treatment in IBShave methodological inadequacies,mostly because of difficulties increating a true control group or inadequately blinding trials (27).Consequently, it has not been de-finitively determined whether psy-chotherapy is any more beneficialfor IBS than other interventions.

Which pharmacologic therapiesare effective in IBS?The choice of drug therapy de-pends on an individual’s symptoms,and effectiveness varies from pa-tient to patient (28). Drugs used inmanagement of patients with IBS

include antispasmodics, laxatives,antidiarrheals, antidepressants, andantibiotics. IBS drugs are describedin Table 3. Limited effectiveness ofconventional treatment options isfrustrating for patients but alsocommon.

In a study of 350 IBS patients, more thanhalf of patients (55%) taking prescriptiondrugs for IBS felt that they were ineffectiveor only somewhat effective, more than60% reported adverse effects from thesemedications, and 40% of patients takingover-the-counter medications reportedthat they were ineffective (29).

The U.S. Food andDrug Administra-tion (FDA) has ap-proved only 2 drugsto treat IBS:tegaserod maleate, a5-HT

4–receptor ag-

onist that increasesintestinal motility,and alosetron hy-drochloride, a 5-HT

3–receptor an-

tagonist medicationthat decreases ab-

dominal sensitivity. However,tegaserod was taken off the marketin March 2007 because of safetyconcerns, and use of alosetron hasbeen restricted.

AntispasmodicsAntispasmodics are indicated onan as-needed basis as a first-linetreatment for IBS pain. The 2antispasmodics available in theUnited States, dicyclomine andhyoscyamine, block the action ofacetylcholine at parasympatheticsites in secretory glands, smoothmuscle, and the central nervoussystem. The effect is reduced con-tractions in the colon. The drugsare particularly helpful when takenbefore meals if postprandial ur-gency, diarrhea, and cramping are aproblem. Adverse reactions increaseas dose increases.

Stress management optionsinclude the following:• Stress reduction training and

relaxation therapies, such asmeditation

• Counseling and support• Regular exercise, such as

walking or yoga• Changes to the stressful

situations in your life• Adequate sleep• Hypnotherapy.


30. Poynard T, Naveau S,Mory B, Chaput JC.Meta-analysis ofsmooth muscle re-laxants in the treat-ment of irritablebowel syndrome. Al-iment PharmacolTher. 1994;8:499-510.[PMID: 7865642]

31. Drossman DA, Whitehead WE,Camilleri M. Irritablebowel syndrome: atechnical review forpractice guidelinedevelopment. Gas-troenterology.1997;112:2120-37.[PMID: 9178709]


For patients who are anxious or forwhom antispasmodics alone are notsuccessful, clinicians should consid-er a sedative–antispasmodics com-bination. The risk for abuse ofsedative–antispasmodics is low be-cause of the small dose of sedativesin most formulations and becauseof the unpleasant anticholinergicside effects that occur with dose elevation.

A meta-analysis of 26 RCTs with antispas-modics supports their utility in the man-agement of IBS symptoms. The study,

which incorporated only trials of anti-spasmodics that are not approved by theFDA (cimetropium bromide, pinaveriumbromide, trimebutine, octilium bromide,and mebeverine), found that the drugswere significantly better than placebo for improving overall symptoms andpain. Patients receiving active drugs hadmore adverse effects (6% mean difference; P < 0.01) than those receiving placebo, butthe adverse reactions were not serious (30).

LaxativesExpert consensus suggests osmotic-type laxatives if fiber is unsuccessful

Table 3. Drugs Commonly Used in the Treatment of Irritable Bowel Syndrome*Class/Agent Mechanism of Action Dosing Benefits Side Effects Notes

Antispasmodics Reduce contractions Generally given as Reduce pain Dry mouth, somnolence, Effective to blunt (Dicycolime, in colon and small needed, especially constipation, urine gastrocolonic response ifhyocsyamine) bowel that may before meals retention, diplopia; side diarrhea/urgency or

produce diarrhea effects usually minor postprandial pain; first-line and cramps agents for pain

Combination Additive effect of Generally given as Useful for pain, Drowsiness, additive Potential for abuse antispasmodics/ sedative to reduce needed, especially especially if effect with alcohol; minimized by anticholinergicsedatives GI motility before meals patient anxious other side effects similar componentClidinium, and anti- to those of antispasmodics;bromide/ spasmodics do not take beforechlordia- alone have driving or taskszepoxide, failed requiring alertnessphenobarbital, hyocsyamine, atropine/ scopolamine

Laxatives Draw water into colon Titrate to effect Reduce Hypermagnesemia, Less cramping and probably PEG solution, distention of hyperphosphatemia safer long-term than magnesium colon due to if renal insufficiency; stimulant cathartics (whichcitrate, sodium retained stool; can cause gas and may cause tachyphylaxis phosphate, PEG-based bloating and “cathartic colon”);sorbitol lavage solutions first-line agents after fiber

useful for severe in constipation-predominantconstipation when IBS; avoid in IBS with gasa few glasses are and bloatingtaken at bedtime

Antidiarrheals µ-Opiate agonists have Titrate to effect Reduce diarrhea Can cause constipation; No known long-term Loperamide, primarily gut effect but not pain atropine can give dry sequelae from repeated diphenoxylate/ to increase segmenting mouth, urine retention, use; loperamide has no atropine contractions and decrease tachycardia CNS penetration; abuse

propulsive ones of diphenoylate prevented by combination with atropine

Antidepressants Mechanism is uncertain Lower doses than Reduce pain Anticholinergic effects Tricyclics are first-line Tricyclics, needed to treat with tricyclics, diarrhea agents in patients with painSSRIs depression with SSRIs and diarrhea, no definitive

data on SSRIs

Antibiotics Aims to restore Rifaximin 400 mg Symptom Antibiotic resistance; Resistance is less of a Neomycin, normal intestinal 3 times/d for improvement ototoxicity and CNS concern with rifaximinrifaximin bacteria 10 days in correlates with symptoms with because it is not absorbed

recent trial normalization of neomycinintestinal bacteria

*CNS = central nervous system; GI = gastrointestinal; IBS = irritable bowel syndrome; PEG = polyethylene glycol; SSRIs = selective serotonin reuptake inhibitors.


for initial therapy of constipation(31). Osmotic laxatives, like mag-nesium citrate or sodium phos-phate, are used to rapidly emptythe lower intestine and bowel. Although not usually used forlong-term or repeated correction ofconstipation, they are consideredsafe and effective for severe consti-pation when used daily or as need-ed. Low-dose daily administrationof another type of hyperosmoticlaxative, polyethylene glycol, in-creases bowel frequency and decreases symptoms in chronic constipation in which fiber supple-mentation is not successful (32).Polyglycol is a large molecule thatcauses water to be retained in thestool, which softens the stool andincreases the number of bowelmovements.

Patients with IBS should avoidregular use of stimulant cathartics,such as senna, cascara, and phe-nolphthalein. Stimulant catharticsincrease the risk for cramps andtachyphylaxis and may lead to amarkedly slow “cathartic colon.”

AntidiarrhealsNonabsorbable synthetic opioidscan be useful to treat patients withdiarrhea-predominant IBS. Theseantidiarrheal agents work by pe-ripheral μ-opioid receptors to re-duce visceral nociception via affer-ent pathway inhibition. The effectis to reduce propagating contrac-tions and to increase segmentingcontractions in the bowel, whichslows transit and allows more timefor water absorption.

Loperamide is the first-line agentfor diarrhea. It can be taken asneeded or on a scheduled basis depending on the severity and fre-quency of symptoms. Two RCTs(33, 34) showed that loperamideis effective for diarrhea; however,it did not significantly relieve painin either study. There are no identified safety concerns associatedwith repeated use of loperamide.

Other opioid antidiarrheal agentsare also likely to be effective.Diphenoxylate hydrochloride com-bined with atropine sulfate is usedin IBS to slow gastrointestinaltransit. Diphenoxylate is a consti-pating meperidine congener thatreduces excessive gastrointestinalpropulsion and motility, and at-ropine discourages abuse by speed-ing up the heart rate. Diphenoxy-late may exacerbate constipation.

5-HT AntagonistsTegaserod, a 5-HT

4–receptor ago-

nist, was the only drug approved bythe FDA for relief of abdominaldiscomfort, bloating, and constipa-tion in patients with IBS (35).However, on March 30, 2007, theFDA requested that the manufac-turer withdraw tegaserod from themarket because of an associationbetween use of the drug and myo-cardial infarction and stroke. In ananalysis of over 18 000 patients,adverse cardiovascular events occurred in 13 of 11 614 patients(0.11%) receiving tegaserod com-pared with 1 of 7031 patients(0.01%) receiving placebo(www.fda.gov/cder/drug/advisory/tegaserod.htm).

Alosetron, a 5-HT3–receptor an-

tagonist that can provide relief indiarrhea-predominant IBS, increas-es colonic compliance, reduces in-testinal transit, and reduces painand diarrhea (36). It was withdrawnfrom the market in 2000 because ofthe occurrence of serious life-threatening gastrointestinal effectsand was reintroduced in 2002 withrestricted availability and use. Alosetron carries a 1 in 700 risk ofischemic colitis and thus should bereserved for women with severe, refractory IBS symptoms causingsignificant impairment in quality of life. Prescribing physicians mustregister with the manufacturer(phone: 888-825-5249), and patientsmust sign a consent form to begintherapy. Three separate double-blind, randomized, placebo-controlled

32. Andorsky RI, Gold-ner F. Colonic lavagesolution (polyethyl-ene glycol elec-trolyte lavage solu-tion) as a treatmentfor chronic constipa-tion: a double-blind,placebo-controlledstudy. Am J Gas-troenterol.1990;85:261-5.[PMID: 2178398]

33. Cann PA, Read NW,Holdsworth CD,Barends D. Role ofloperamide andplacebo in manage-ment of irritablebowel syndrome(IBS). Dig Dis Sci.1984;29:239-47.[PMID: 6365490]

34. Efskind PS, BernklevT, Vatn MH. A dou-ble-blind placebo-controlled trial withloperamide in irrita-ble bowel syndrome.Scand J Gastroen-terol. 1996;31:463-8.[PMID: 8734343]

35. Talley NJ. Serotonin-ergic neuroentericmodulators. Lancet.2001;358:2061-8.[PMID: 11755632]

36. Watson ME, Lacey L,Kong S, et al. Alos-etron improves qual-ity of life in womenwith diarrhea-pre-dominant irritablebowel syndrome.Am J Gastroenterol.2001;96:455-9.[PMID: 11232690]

37. Camilleri M, North-cutt AR, Kong S, etal. Efficacy and safe-ty of alosetron inwomen with irritablebowel syndrome: arandomised, place-bo-controlled trial.Lancet.2000;355:1035-40.[PMID: 10744088]

38. Camilleri M, CheyWY, Mayer EA, et al.A randomized con-trolled clinical trial ofthe serotonin type 3receptor antagonistalosetron in womenwith diarrhea-pre-dominant irritablebowel syndrome.Arch Intern Med.2001;161:1733-40.[PMID: 11485506]



trials have shown that alosetron fordiarrhea-predominant IBS had anoverall “adequate response” rate ofnearly 60%. Improvement overplacebo was approximately 15%(37–39).

AntidepressantsAntidepressants can be helpful inalleviating IBS symptoms. Accord-ing to a recent meta-analysis of 12studies, the number needed to treatfor benefit in 1 person was 3.2 (40).

Clinicians should consider tricyclicantidepressants to reduce pain anddiarrhea. The mechanism of actionof these drugs in IBS is unclear,but it is known that they act prima-rily by blocking the uptake of neu-rotransmitters at specific presynap-tic nerve endings in the centralnervous system. As a result, theyprevent synaptic receptor overstim-ulation. The benefit of tricyclics inIBS seems to be independent of theanticholinergic effects or antide-pressant effects. The requireddosage is less than that required forthe treatment of depression. Severalstudies have shown benefits fortricyclic use (41–43). Tricyclicscan be used in combination withantispasmodics.

Use of selective serotonin reuptakeinhibitors (SSRIs) is not well-studied in patients with IBS, butearly findings suggest that SSRIscan improve the quality of life inpatients who have severe IBS withassociated psychological stress. Thismay be primarily a psychologicaleffect. Patients may also benefitfrom pain alleviation; however, a co-hort study that associated paroxetinewith improved quality of life in IBSdid not find any association with alleviated abdominal pain (26).

SSRIs might be a consideration forolder patients or in persons withconstipation because they lack

anticholinergic side effects. SSRIsmay trigger episodes in patientswith diarrhea-predominant IBSwhile being helpful for patientswith constipation.

AntibioticsAlterations in gut flora have beenidentified in patients with IBS, andsome hypothesize that intestinalbacterial overgrowth may play arole in symptoms. The antibioticneomycin has been shown to im-prove IBS symptoms. This effectseems to correlate with normaliza-tion of intestinal bacterial flora (44,45). However, neomycin effectivelyeliminates bacterial overgrowth inonly about 25% of patients (45),and side effects limit its use. Lowefficacy, side effects, and concernsabout antimicrobial resistance alsoapply to other antibiotics that havebeen previously investigated fortreating bacterial overgrowth (46).For this reason, researchers havebeen seeking an antibiotic for IBSthat is not systemically absorbed,has minimal adverse effects, and effectively eliminates bacterial over-growth. One drug that meets thesecriteria is rifaximin.

An RCT assigned 87 patients who met theRome I criteria for IBS to receive either 400mg of rifaximin 3 times daily for 10 days orplacebo. A questionnaire was adminis-tered before treatment and 7 days aftertreatment. The primary outcome wasglobal improvement in IBS. Patients werethen asked to keep a weekly symptom di-ary for 10 weeks. Over the 10 weeks of follow-up, rifaximin resulted in greater im-provement in IBS symptoms than placebo.In addition, rifaximin recipients had a low-er bloating score after treatment. This pre-liminary, short-duration trial suggeststhat rifaximin improves IBS symptoms forup to 10 weeks after discontinuation oftherapy (47).

What are some possible futuretreatments for IBS?Several new drugs are being studiedfor the treatment of IBS. IBS thera-py is moving from “symptom-based”

39. Camilleri M, Mayer EA,Drossman DA, et al.Improvement in painand bowel function infemale irritable bowelpatients with alos-etron, a 5-HT3 recep-tor antagonist. Ali-ment Pharmacol Ther.1999;13:1149-59.[PMID: 10468696]

40. Jackson JL, O’MalleyPG, Tomkins G, et al.Treatment of func-tional gastrointestinaldisorders with antide-pressant medications:a meta-analysis. Am JMed. 2000;108:65-72.[PMID: 11059442]

41. Myren J, Løvland B,Larssen SE, Larsen S. Adouble-blind study ofthe effect of trim-ipramine in patientswith the irritable bow-el syndrome. Scand JGastroenterol.1984;19:835-43.[PMID: 6151243]

42. Greenbaum DS, MayleJE, Vanegeren LE, et al.Effects of desipramineon irritable bowel syn-drome comparedwith atropine andplacebo. Dig Dis Sci.1987;32:257-66.[PMID: 3545719]

43. Drossman DA, TonerBB, Whitehead WE, etal. Cognitive-behav-ioral therapy versuseducation and de-sipramine versusplacebo for moderateto severe functionalbowel disorders. Gas-troenterology.2003;125:19-31.[PMID: 12851867]

44. Pimentel M, Chow EJ,Lin HC. Eradication ofsmall intestinal bacte-rial overgrowth re-duces symptoms of ir-ritable bowelsyndrome. Am J Gas-troenterol.2000;95:3503-6.[PMID: 11151884]

45. Pimentel M, Chow EJ,Lin HC. Normalizationof lactulose breathtesting correlates withsymptom improve-ment in irritable bow-el syndrome. A dou-ble-blind,randomized, placebo-controlled study. Am JGastro-enterol.2003;98:412-9.[PMID: 12591062]

46. Attar A, Flourié B,Rambaud JC, et al. An-tibiotic efficacy insmall intestinal bacte-rial overgrowth-relat-ed chronic diarrhea: acrossover, randomizedtrial. Gastroenterology.1999;117:794-7.[PMID: 10500060]




therapy to “hypthesis-based” therapy.

Rather than treating symptoms,

new IBS approaches aim to treat

the underlying pathophysiology.

Trials are currently underway fortreating IBS with renzapride, a5-HT

3–receptor antagonist and

a 5-HT4–receptor agonist (48, 49).

Tachykinin antagonists, like sub-stance P and neurokinin A, mightalso be useful for treating IBS.Tachykinins are present in the gas-trointestinal tract and are involvedin such functions as gastrointestinalmotility, visceral sensitization, andautonomic reaction to stress. Stud-ies in animals and healthy humanshave yielded promising results (50, 51). Neutrophins, a family of neuropeptides that includes neutrophin-3, are also undergoingpreclinical study as potential thera-peutic agents for functional gas-trointestinal disorders. Studies haveshown that recombinant humanneutrophin-3 increased stool fre-quency; facilitated stool passage inpatients with constipation; and ac-celerated gastric, small bowel, andcolonic transit in healthy persons(52, 53). Antibiotics and probioticsaim to normalize intestinal bacteria.

Is there evidence to support theeffectiveness of complementaryand alternative medicinetreatments for IBS?Patients with IBS frequently trynontraditional therapies, particu-larly if traditional approaches totreatment do not relieve theirsymptoms. While some patientshave some relief with such thera-pies, data to support their use aresparse (54) (Table 4).

What components of care shouldclinicians integrate into follow-upof patients with IBS?There are no specific data on whichto base a recommendation on thefrequency or the components offollow-up for patients with IBS.However, a common-sense ap-proach includes monitoring foralarm features, progression ofsymptoms, and management ofpsychosocial stressors. The typicalsymptom course in IBS is chronicand fluctuating. Clinicians shouldconsider additional diagnostic testsor referral if alarm features developor if symptoms are refractory andpersistent. Clinicians should em-phasize to patients that the long-term prognosis is good. Carefullyexplaining the prognosis can sig-nificantly reduce patient distress.

47. Pimentel M, Park S,Mirocha J, Kane SV,Kong Y. The effect of anonabsorbed oral an-tibiotic (rifaximin) onthe symptoms of theirritable bowel syn-drome: a randomizedtrial. Ann Intern Med.2006;145:557-63.[PMID: 17043337]

48. Meyers NL, Tack J,Middleton S, et al. Effi-cacy and safety orrenzapride in patientswith constipation-pre-dominant irritablebowel syndrome [Ab-stract]. Gut.2002;51(suppl III): A10.

49. George A, Meyers NL,Palmer RMJ. Efficacyand safety of renza-pride in patients withconstipation-predomi-nant IBS: a phase IIBstudy in the UK pri-mary healthcare set-ting [Abstract]. Gut.2003;52:A91.

50. Julia V, Morteau O,Buéno L. Involvementof neurokinin 1 and 2receptors in vis-cerosensitive responseto rectal distension inrats. Gastroenterology.1994;107:94-102.[PMID: 7517374]

51. Lördal M, Navalesi G,Theodorsson E, MaggiCA, Hellström PM. Anovel tachykinin NK2receptor antagonistprevents motility-stimulating effects ofneurokinin A in smallintestine. Br J Pharma-col. 2001;134:215-23.[PMID: 11522614]

52. Coulie B, Szarka LA,Camilleri M, et al. Re-combinant humanneurotrophic factorsaccelerate colonictransit and relieveconstipation in hu-mans. Gastroenterolo-gy. 2000;119:41-50.[PMID: 10889153]

53. Coulie B, Lee JS, Ly-ford G, et al. Recombi-nant human neu-rotrophin-3 increasesnoncholinergicsmooth muscle con-tractility and decreas-es nonadrenergic(NANC) inhibition ofmyenteric neurons inguinea-pig colon [Ab-stract]. Gastroenterol-ogy. 2000;118:A710.

54. Spanier JA, HowdenCW, Jones MP. A sys-tematic review of al-ternative therapies inthe irritable bowelsyndrome. ArchIntern Med. 2003;163:265-74.[PMID: 12578506]

Table 4. Alternative and Complementary Therapies Used by Patients with IrritableBowel SyndromeTherapy Proposed Action Notes

Acupuncture Relief of chronic pain No definitive studies available; results ofexisting studies are mixed

Hypnosis Relief of chronic pain No definitive studies available

Peppermint oil Natural antispasmodic believed to Ineffective in 2 crossover trials; somerelax intestinal smooth muscle effect noted in one parallel trial

Ginger Natural antispasmodic believed to No evidence from high-quality trialsrelax intestinal smooth muscle

Aloe Natural antispasmodic believed to No evidence from high-quality trialsrelax intestinal smooth muscle

Chinese herbal Natural antispasmodic believed to Global improvement noted in 1 studytherapy relax intestinal smooth muscle

Probiotics Aim to replenish the beneficial Bifidobacteria infantis showed symptomintestinal bacteria that may be improvement in early clinical studieslacking in patients with IBS


When should clinicians considerconsulting a specialist fortreatment?When management strategies are

not effective, clinicians should con-

sider consulting a gastroenterologist.

Gastroenterologists may have greater

knowledge of treatment options

because of increased familiarity with

the disorder. Clinicians should con-

sider referral to a mental health pro-

fessional for patients with refractory

symptoms leading to impaired quali-

ty of life or major depression, anxiety

disorder, bipolar disorder, or other

serious psychological disease.


Practice Improvement Do professional organizations

offer recommendations for thecare of patients with IBS?In 2003, the American Gastroen-

terological Association developed

clinical practice guidelines for

IBS based on a comprehensive

review (31).

Are there performance measuresrelated to the care of patientswith IBS?Current proposed performance

measures in the United States donot include any measures specificallyrelated to the care of patients with IBS.However, the quality of the doctor–patient interaction is paramount in the care of patients with IBS.

A survey developed by the Ameri-can Gastrointestinal Associationmay be useful for evaluating a pa-tient’s satisfaction with his or hercare (www.gastro.org/wmspage.cfm?parm1=3266). However, the sur-vey has not yet been validated.

inthe

c linicTool Kit

in the clinic

Irritable BowelSyndrome

www.pier.acponline.orgIBS module of PIER, an electronic decision support resource

designed for rapid access to information at the point of care.

www.annals/intheclinic/toolsDownload copies of the Patient Information sheet that

appears on the following page for duplication and

distribution to your patients.

www.gastro.org/wmspage.cfm?parm1=3266Patient satisfaction surveys to enable the physician to

quantitatively measure the patient care experience as well

as physician–patient communication.

Treatment… Dietary advice, patient education, and stress management are essen-tial to effective IBS management. Drug therapy should target the individual patient’s symptom pattern, and options include antispasmodics, laxatives, anti-diarrheals, 5-HT antagonists, antidepressants, and antibiotics. Of the many non-traditional therapies that patients use to treat IBS, clinical trial data best supporta clinical benefit of probiotics.

CLINICAL BOTTOM LINE


HEALTH TiPS*

What You Can Do:

Find out what makes your IBS symptomsworse

• Stress at home or work• Some foods

Write down when your IBS symptoms happen

• Get help to deal with stress• Stay away from too much caffeine, soda,

fatty foods, and laxatives

See your doctor often to keep your IBS ontrack. Next doctor's visit ___________

Things to Ask your Doctor:

What causes IBS?

Do I need any tests?

Why do I have problems if all my tests are normal?

How can I deal with stress?

Do I need medicine for my IBS?

Why doesn't medicine always work for my IBS?

What are the side effects of my medicines forIBS?

THINGS PEOPLE SHOULD KNOW ABOUT IRRITABLE BOWEL SYNDROME

In the ClinicAnnals of Internal Medicine

*HEALTH TiPS are developed by the American College of Physicians Foundation and PIER and are designed to be understood by most patients.

Web Sites with Good Information about Irritable Bowel Syndrome

MedlinePLUSwww.nlm.nih.gov/medlineplus/irritablebowelsyndrome.html

National Institute of Diabetes and Digestive and Kidney Diseaseshttp://digestive.niddk.nih.gov/ddiseases/pubs/ibs_ez/

International Foundation for Functional Gastrointestinal Disorderswww.aboutibs.org/

Mayo Clinicwww.mayoclinic.com/health/irritable-bowel-syndrome/MM00461 (a short video clipthat provides information about irritable bowel syndrome)

• IBS causes pain, cramping, bloating, gas, diarrhea, and constipation. Another name for the condition is spastic colitis.

• The cause of IBS is believed to be intestines that are overly sensitive to normal intestinal movement, gas, some foods, and stress.

• There is no test for IBS, so doctors make the diagnosis by carefully evaluating symptoms and excluding other conditions.

• There is no cure, but people with IBS can control symptoms by healthy diet and exercise, managing stress, avoiding things that trigger symptoms, and taking medications to treat symptoms.

Irritable bowel syndrome (IBS) is a common problem that can cause constipation,diarrhea, or both. Sometimes there is stomach pain or gas. IBS comes and goes but never goes away for good. IBS does not cause cancer.

Pati

ent

Info

rmat

ion



CME Questions

A 24-year-old woman has a 7-monthhistory of occasional abdominal bloat-ing and constipation alternating withintermittent loose stools. She was welluntil 8 months ago, when she devel-oped diarrhea during a trip to Mexicothat was treated with ciprofloxacin.She has not had weight loss, fever, ornocturnal symptoms. Her stools aresmall in volume, soft, and brown anddo not contain blood or mucus.

Which of the following is most likelyto be the diagnosis in this patient?

A. Clostridium difficile infectionB. Helicobacter pylori infectionC. Diverticular diseaseD. Postinfectious irritable bowel

syndrome

A 25-year-old woman has a 7-monthhistory of progressively severe consti-pation, generalized abdominal pain,and bloating that have affected herability to work and handle other re-sponsibilities. She has approximatelyone firm bowel movement each week.Use of over-the-counter fiber productshas been ineffective. Her weight isstable, and she is otherwise healthy.Thyroid function tests and measure-ment of serum calcium and serumelectrolyte levels are normal.

Which of the following medications ismost appropriate at this time?

A. AlosetronB. A selective serotonin reuptake

inhibitorC. A tricyclic antidepressantD. MetronidazoleE. Polyethylene glycol

A 24-year-old woman is evaluated for3-year history of oral ulcers that occurfrequently, usually at times of stress,and last about 1 week. The ulcers areunrelated to rash, joint symptoms, orfever. She notes that over the past 4months they have become larger, recurmore frequently, and last longer (2 to3 weeks). She attributes a recent 4.4-kg (10-lb) unintentional weight loss topain while eating during outbreaks ofthe ulcers. Her medical history is sig-nificant for occasional abdominal painand diarrhea that was previously diag-nosed as irritable bowel syndrome. Shehas no history of an eating disorder, illicit drug use, blood transfusion, orany previous sexual activity. Her familyhistory is unrevealing. On examination,she has 2 mildly tender oral ulcera-tions that she notes have been presentfor about 6 days. Results of fecal occult blood testing are positive.

What is the best next step in themanagement of this patient?

A. ColonoscopyB. HIV serologyC. HyoscyamineD. AcyclovirE. Biopsy of oral lesions

A 28-year-old man is evaluated for 6weeks of intermittent abdominal painrelieved with bowel movements andincreased frequency of bowel move-ments with stool that is softer andless well-formed than previously. Hedenies fever, upper gastrointestinalsymptoms, or recent camping or travel.Physical examination is entirely nor-mal except for some mild abdominaltenderness to deep palpation in all 4 quadrants. Stool is negative for

occult blood. He has no family historyof cancer or inflammatory bowel dis-ease. He notes that the symptoms began when his wife filed for a divorce. He denies being depressed.

What is the most appropriate nextstep in the evaluation and manage-ment of this patient?

A. Flexible sigmoidoscopyB. Symptom diary and follow-up

visitC. Abdominal CT scanD. Radiographs of the abdomenE. Reassurance

A 34-year-old woman with a medicalhistory of childhood asthma and 2normal pregnancies is evaluated forabdominal pain and bloating almostdaily for the past 3 years since thebirth of her youngest child. She alsoreports diarrhea, which she describesas 2 to 6 loose bowel movements perday, never feels like her colon is com-pletely evacuated, and reports thatstool is sometimes watery. She deniesfever, weight loss, previous lactose intolerance, family history of cancer or inflammatory bowel disease, visibleblood or mucus in stools, and anti-biotic use. She has been prescribeddicyclomine, which provides some relief of pain but not diarrhea. Physi-cal examination is normal. You believethat the patient most likely has irrita-ble bowel syndrome.

Which of the following would be themost appropriate next step?

A. ColonoscopyB. Stool culturesC. Dietary historyD. AlosetronE. Fluoxetine

Questions are largely from the ACP’s Medical Knowledge Self-Assessment Program (MKSAP). Go to www.annals.org/intheclinic/ to obtain up to 1.5 CME credits, to view explanations for correct answers, or to purchase the complete MKSAP program.

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