IRITABLE BOWEL

SYNDROME
GASTROENTEROLOGY-HEPATOLOGY DIVISION
INTERNAL MEDICINE DEPARTEMENT
FK-USU/ADAM MALIK HOSPITAL

Irritable Bowel - What is

it?

Irritable Bowel - What is it?

"The bowels are at one time

constipated, another lax, in the
same person. How the disease has
two such different symptoms I do
not profess to explain.
(Cumming, London Med Gaz, 1849.)
Other names:
Mucous colitis
Spastic colitis
Nervous colon
Irritable colon

Irritable Bowel - What is it?

Abdominal discomfort that is

Relieved with defecation
Associated with altered stool
frequency
Associated with altered stool
consistency

Possible Causes

Altered Bowel Motility

Visceral Hypersensitivity

May affect perceptions or central signal

processing

Neurotransmitter Imbalance

Abnormal excitability of neurons &

pathways

Psychosocial Factors

Abnormal timing & pattern of contractions

w/ food or stress

Increased serotonin levels?

Infection/Inflammation

Inflammatory cytokines may affect bowel

Possible Causes

To date, no single
conceptual model can
explain all cases of the
syndrome.
NEJM 2001; 344:1846-1850

What is a Syndrome?

Syndrome

A pattern of symptoms
indicative of some disease
Different causes for same
problem?
Different problems with similar
manifestations?

IBS Does it exist?

Factor analysis:

Irritable Bowel Syndrome

Defined by Factor
Analysis. Dig Dis Sci
1995; 40: 2647-55.
Six Manning criteria:
Frequent stools with
abdominal pain
Looser stools with
pain
Relief of pain with
defecation
Abdominal distension
Passage of mucus
A feeling of
incomplete evacuation
after defecation
Validation study
1344 students
Measured prevalence
of 22 GI Sx in past 6
months

3 three Manning
symptoms clustered
together among both
sexes and racial groups
More frequent bowel
movements with the
onset of pain
Looser stools with the
onset of pain
Relief of pain with
defecation
3 Manning symptoms did
not cluster with each
other or with the first
three symptoms.
Bloating
Mucus
Feeling of incomplete
evacuation

Epidemiology

Incidence/prevalence
Prevalence 3 - 22% world-wide
Reason for 20 - 50% of
gastroenterology visits
$8 billion in medical expenses per
year in the USA
26% prevalence among children
with recurrent abdominal pain
Predominant age
40% onset before age 35
50% onset age 35 - 50
Predominant gender
Female > Male (2:1) in the US

Irritable Bowel - Diagnosis

Differential Diagnosis

What is the differential diagnosis for IBS?

Differential Diagnosis
Endocrine tumors

(very uncommon)

Inflammatory bowel
disease

Laxatives
Constipating medications

Infections

Medications

Crohn's disease or
ulcerative colitis

Parasitic, bacterial, viral,

and opportunistic

Endocrine disorders

Hypothyroidism
Hyperthyroidism
Diabetes
Addison's disease

Adenocarcinoma
Villous adenoma

Intestinal pseudoobstruction

Malabsorption
syndromes

Celiac disease
Pancreatic insufficiency

Colorectal
carcinoma

Gastrinoma
Carcinoid

Diabetes
Scleroderma

Lactose
intolerance
Psychiatric
disorders

Depression
Anxiety
Somatization
disorder

Diagnostic Criteria
Manning

IBS diagnosed if 3 of the

following are present:
Abdominal pain
Pain relief with
defecation
Increased stool
frequency with pain
Looser stools with pain
Mucus in stools
Feeling of incomplete
evacuation

Rome III

Abdominal pain or
discomfort for at least
3 days per month for
the past 3 months, with
at least two of:
Improved with
defecation
Onset associated with
change in stool
frequency
Onset associated with
change in stool form

Diagnostic Red Flags

Further evaluation is mandated:
Weight loss
Evidence of bleeding or anemia
Signs of infection
Age over 50 at the onset of
symptoms

Diagnostic Sensitivity and

Specificity

Manning Criteria:
2 of 6 present
84-94% Sensitivity & 55-76%
Specificity
3 of 6 present
63-90% Sensitivity & 70-93%
Specificity
Rome 1:
65% Sensitivity & 100%
Specificity

Symptom Patterns

Constipation Predominant
Diarrhea Predominant
Abdominal Pain Predominant

Severity
Mild
Can be ignored if the patient does not think

about it

Moderate
Cannot be ignored but does not affect

patient's lifestyle

Severe/very severe
Affects patient's lifestyle

Investigations

What tests are needed for

IBS?

Investigations

Constipation predominant IBS

CBC, TSH, Electrolytes,
Sigmoidoscopy
Diarrhea predominant IBS
CBC, TSH, ESR, Electrolytes,
Sigmoidoscopy
Abdominal pain predominant IBS
CBC

result the tests?

Meta-analysis of 6 studies

Prevalence of disease if IBS criteria met:

Colitis/inflammatory bowel disease = 0.5% 1.0%
Colorectal cancer = 0% - 0.5%
Celiac disease = 4.7%
Gastrointestinal infection = 0% - 1.7%
Thyroid dysfunction = 6%
Lactose malabsorption = 22% - 26%
Endoscopy, ultrasound, and barium studies
only detected organic disease in 1% of
patients.
CBC and chemistries were unhelpful.

Red Flags

Warrant a more thorough

diagnostic evaluation.
Weight loss
Evidence of bleeding or
anemia
Signs of infection
Age over 50 at the onset of
symptoms

When can you stop the

tests?

Bottom line:
There is insufficient evidence to recommend
the routine performance of a standardized
battery of diagnostic tests in patients who
meet symptom-based criteria for IBS.

Am J Gastroenterol 2002; 97:2812-9.

Evaluation

Positive Manning or Rome 3?

Absence of alarm symptoms?
Symptom Pattern?
Also explore
Dietary fiber and food intolerances
Family history of intestinal disease
or malignancy
Family stress
Abuse history?
Depression or anxiety
Effect of symptoms on daily life

Irritable Bowel Management

What are important parts

of the management of
IBS?

Irritable Bowel Management

Strong physician-patient
relationship
Education,

Dietary
Reduce

reassurance

EtOH, caffeine, fat (?????)

Explore triggers
Life

stresses
Foods

Symptom-specific medications
Pain

predominant
Diarrhea predominant
Constipation predominant

Behavior Therapy for IBS

1.

2.

3.
4.

5.

6.

Provide information about IBS and normal GI

functioning, discuss the role of stress .
Analyze the patient's illness in terms of
symptoms, circumstances of first onset,
symptom triggers, contributing factors, and
consequences.
Teach relaxation techniques.
Teach patients to identify irrational thoughts
regarding their GI problems.
Discuss ways people cope with the problems
that chronic illness brings to daily life.
Discuss ways to manage difficulties the
individual may have in social situations
caused by GI problems.

Pharmacologic Treatment Reviews

Ann Int Med 133: 136.
Improved Pain
Amitryptiline
Improved
Constipation
Ispaghula
(Psyllium)
Ondansetron
Improved Diarrhea
Ispaghula
(Psyllium)
Amitryptiline
Ondansetron

JFP 52: 942

Good evidence for
Tegaserod for
constipation*
Alosetron for
women with
diarrhea IBS *
Fair evidence for
TCAs for Pain
Loperamide for
Diarrhea
Bulk for
Constipation
Antispasmodics for
Global Symptoms

Treatment
recommendations

Constipation- predominant IBS

Guar gum, fiber, exercise, episodic use of
antispasmodics, peppermint oil, and
adequate fluid intake.
Diarrhea-predominant IBS
Loperamide, episodic use of
antispasmodic agents, peppermint oil, and
dietary manipulation
Patients with pain-predominant or severe
IBS
TCAs and psychotherapy should be
considered.

IBS conclusion

Perform a symptom-directed history and

exam
Use lab testing judiciously if indicated
Defer further testing or imaging unless
clearly indicated
Begin education on the interaction of
emotional factors, coping styles,
environmental stressors and physiologic
factors in IBS
Begin working to establish a strong
physician-patient relationship
Consider a trial of dietary adjustments
Consider pharmacologic interventions based
on the patients symptom pattern

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