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In the Clinic
Irritable Bowel
Syndrome
Diagnosis
I
rritable bowel syndrome (IBS) is one of the
most common gastrointestinal disorders, with
a prevalence of 10%20%. It is a chronic con-
dition characterized by abdominal pain in con- Treatment
junction with altered bowel habits and abdomi-
nal distention and bloating. IBS can be clinically
subtyped into IBS with constipation, IBS with diar- Practice Improvement
rhea, or mixed IBS. Recent advances in IBS man-
agement include the new Rome IV criteria for di-
agnosis (released in 2016) and the addition of
new nonpharmacologic and pharmacologic ap-
proaches for treating patients who do not re-
spond to lifestyle and dietary modications.
Diagnosis
What symptoms should the subgroups respond differ-
prompt a clinician to ently to the various therapeutic
consider IBS? interventions. Individual symp-
Although symptoms may vary tom patterns can change over
from person to person, clinicians time; as a result, whether symp-
should consider IBS if a patient tom pattern clearly distin-
has abdominal discomfort or guishes among IBS subtypes
pain associated with bowel dys- is debatable.
function. Abnormal stool fre- Certain clinical features, often
quency (>3 bowel movements called alarm features or red-ag
per day or <3 bowel movements symptoms, suggest that the diag-
per week), excessive straining nosis is something other than IBS
during defecation, urgency, and (see the Box: Alarm Features
feeling of incomplete evacuation That Suggest Possible Organic
are common in patients with IBS Disease). Alarm features include
but are nonspecic. Other sug- weight loss, nocturnal awakening
gestive symptoms include post- due to gastrointestinal symp-
prandial exacerbation of symp- toms, blood in the stool, family
toms and excess gas and history of colon cancer or inam-
atulence. Gastrointestinal symp- matory bowel disease, recent use
toms that wax and wane for more of antibiotics, and fever.
than 2 years and are exacerbated
by psychosocial stress should What are the accepted
raise suspicion for IBS. The pres- diagnostic criteria?
1. Lovell RM, Ford AC. Global ence of other functional gastroin- History is the main diagnostic
prevalence of and risk
factors for irritable bowel testinal disorders (e.g., nonulcer tool for IBS. The Manning criteria
syndrome: a meta- dyspepsia) as well as functional and the Rome criteria are 2 sets
analysis. Clin Gastroen-
terol Hepatol. 2012;10: extraintestinal symptoms or syn- of symptom-based diagnostic
712-721.e4. [PMID:
22426087] dromes, such as chronic fatigue, criteria that help to discriminate
2. Camilleri M. Peripheral bromyalgia, sleep disturbance, between IBS and other disorders
mechanisms in irritable
bowel syndrome [Letter]. and psychiatric comorbidity, fa- (see the Box: Symptom Criteria
N Engl J Med. 2013;368: vor an IBS diagnosis (3).
578-9. [PMID: 23388017]
for Irritable Bowel Syndrome).
3. Ford AC, Marwaha A, Lim These criteria, which were devel-
A, Moayyedi P. Systematic Three defecation patterns oped for use in research studies,
review and meta-analysis
of the prevalence of irrita- are characteristic of IBS: can be helpful in clinical practice.
ble bowel syndrome in constipation-predominant (IBS-
individuals with dyspep-
sia. Clin Gastroenterol C), diarrhea-predominant (IBS-D), Manning and colleagues (4) pro-
Hepatol. 2010;8:401-9.
[PMID: 19631762]
and mixed (alternating diarrhea posed the rst widely used IBS
4. Manning AP, Thompson and constipation) (IBS-M). Deter- criteria in 1978 based on the
WG, Heaton KW, Morris
AF. Towards positive diag- mining a patient's predominant symptoms listed in the Box. In
nosis of the irritable symptom pattern is useful in 1989, a group of experts met in
bowel. Br Med J. 1978;2:
653-4. [PMID: 698649] guiding management because Rome and developed another set
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Diarrhea-predominant symptoms
Crohn disease Diarrhea, abdominal pain Colonoscopy, CT enterography, magnetic
resonance enterography, small bowel
barium radiograph
Ulcerative colitis Likely to have rectal bleeding in addition to Colonoscopy
diarrhea, abdominal pain, tenesmus
Microscopic colitis Watery diarrhea often with nocturnal Colonoscopy/exible sigmoidoscopy and
symptoms biopsy
Infectious Abdominal discomfort, diarrhea especially Ova and parasites x 3, stool culture, stool
in the setting of recent travel Giardia antigen, metronidazole trial
Clostridium difcile infection Recent antibiotic treatment Stool polymerase chain reaction
Small bowel bacterial overgrowth Diarrhea, bloating, abdominal distention Jejunal aspirate, lactulose breath hydrogen
test, antibiotic trial
Celiac disease Diarrhea, usually steatorrhea, anemia Tissue transglutaminase antibody,
endoscopy with small bowel biopsy
Lactose intolerance Symptoms worse with lactose consumption Avoidance trial, lactose breath test
Hyperthyroidism Loose stools and other features of Serum thyroid-stimulating hormone
hyperthyroidism
Neuroendocrine tumor Carcinoid, gastrinoma, VIP-producing Urine 5HIAA, fasting gastrin (followed by
tumor secretin stimulation test), serum VIP
Pain-predominant symptoms
Aerophagia, bloating Patient may be anxious (nervous air Abdominal radiograph
swallowing), can be exacerbated by
antireux surgery
Intermittent small bowel More likely with history of previous Abdominal radiograph, CT scan, small
obstruction abdominal surgeries bowel barium radiograph
Acute intermittent porphyria Rare; may have elevated liver enzymes and Serum and urine porphyrins, especially
neurologic symptoms porphobilinogen, and -aminolevulinic
acid
Ischemia Intestinal angina especially in patients with CT angiography, Doppler ultrasonography,
atherosclerosis, food aversion, weight mesenteric angiography
loss, pain 1540 min after meals
Chronic pancreatitis Epigastric pain usually more persistent than Abdominal radiograph to assess for
with usual irritable bowel syndrome calcications, CT scan, endoscopic
ultrasonography
Lymphoma of gastrointestinal Weight loss (typically) CT scan, small bowel radiograph
tract
Endometriosis Menstrual-associated symptoms, pelvic Laparoscopy
symptoms
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their condition. CBT has been medications are often recom- YA, Schiller LR, et al.
Effect of antidepressants
shown to improve quality of life mended for treatment of post- and psychological thera-
pies, including hypno-
prandial IBS symptoms, use for
and reduce symptom severity in therapy, in irritable
this indication has not been spe- bowel syndrome: sys-
patients with IBS, especially with tematic review and meta-
cically evaluated in clinical trials. analysis. Am J Gastroen-
regard to pain perception and terol. 2014;109:1350-
The most common adverse
comorbid depressive and anxiety 65; quiz 1366. [PMID:
events are dry mouth, dizziness, 24935275]
disorders. The number needed 26. National Institute for
and blurred vision. Health and Care Excel-
to treat for CBT is 3 patients, lence. Irritable bowel
which is superior to most drug A meta-analysis of 22 RCTs (n = 2893 pa- syndrome in adults.
Diagnosis and manage-
therapies (25). Limited small tients) with 12 antispasmodics found that ment of irritable bowel
these agents led to clinically meaningful im- syndrome in primary
studies suggest that integrating care. (Clinical guideline
both conventional pharmaco- provement in global symptoms and abdom- 61.) 2013.
27. Khalif IL, Quigley
therapy and behavioral therapies inal pain (RR, 0.74 [CI, 0.59 0.93]). The ef- EM, Makarchuk PA,
may provide the best symptom fect of individual agents was difcult to Golovenko OV,
Podmarenkova LF,
relief and highest quality of life to interpret given the small number of studies Dzhanayev YA. Interac-
evaluating each drug. Although the overall tions between symptoms
patients with IBS (22). The Na- and motor and visceral
quality of evidence was low, this meta- sensory responses of
tional Institute for Health and
analysis supports the utility of antispasmod- irritable bowel syndrome
Care Excellence guidelines rec- ics in IBS management (28).
patients to spasmolytics
(antispasmodics). J Gas-
ommend adjunctive psychother- trointestin Liver Dis.
2009;18:17-22. [PMID:
apy for patients whose symptoms Antidepressants. Low-dose anti- 19337628]
do not respond to pharmaco- depressants are recommended 28. Ruepert L, Quartero AO,
de Wit NJ, van der Hei-
therapy after 12 months or who in patients who are refractory to jden GJ, Rubin G, Muris
antispasmodics and dietary alter- JW. Bulking agents,
have continued symptoms (26). antispasmodics and
ations. Tricyclic antidepressants antidepressants for the
Which pharmacologic (TCAs) and selective serotonin treatment of irritable
bowel syndrome. Co-
therapies are effective? reuptake inhibitors are com- chrane Database Syst
Rev. 2011:CD003460.
Current pharmacologic treat- monly used to treat depression, [PMID: 21833945]
ments (Table 2) are generally anxiety, and neuropathic pain; 29. Gershon MD, Tack J. The
serotonin signaling sys-
aimed at improving 1 or more of however, the mechanism of ac- tem: from basic under-
standing to drug devel-
the predominant symptoms, such tion of these drugs in IBS is un- opment for functional GI
as abdominal pain or bloating, clear (29). They may take several disorders. Gastroenterol-
ogy. 2007;132:397-414.
constipation, or diarrhea. weeks to work, and the required [PMID: 17241888]
6 June 2017 Annals of Internal Medicine In the Clinic ITC89 2017 American College of Physicians
Treatments aimed at
IBS-C
Osmotic laxative: Causes water to be retained in the Used as rst-line treatment for Generally well-tolerated,
Polyethylene glycol colon leading to softer stools and IBS-C. Effective in improving may worsen bloating
increased stool frequency symptoms associated with
constipation, including
improved stool consistency,
increased frequency, and
decreased straining
Guanylate cyclase C Induces intestinal chloride and Effective as second-line treatment Most common treatment-
agonist: Linaclotide bicarbonate secretion via in IBS-C patients. Shown to related adverse event
activation of the cystic brosis reduce abdominal pain, leading to discontinua-
transmembrane conductance improve constipation, improve tion was diarrhea
regulator, resulting in acceleration global symptoms, and improve
of intestinal transit; may also have health-related quality of life
an analgesic effect
Treatments aimed at
IBS-D
Antidiarrheal: Inhibits peristalsis leading to Effective as rst-line treatment in Generally well-tolerated
Loperamide prolonged transit time and IBS-D or mixed IBS. Shown to
reduced stool frequency reduce stool frequency but
has no effect on global IBS
symptoms, abdominal pain,
or bloating
Selective 5-HT3 Decreases colonic motility and Approved for use in women who Ischemic colitis, severe
receptor antagonist: secretion have had severe IBS-D >6 mo constipation (leading
Alosetron and failure of conventional to an alosetron
treatment. Improves global prescribing program)
symptoms, abdominal pain,
and stool consistency
-opioid receptor Leads to slower gastrointestinal Newer agent effective in Nausea, constipation,
agonist and -opioid transit and decreased visceral improving abdominal pain abdominal pain, and
receptor antagonist: pain and diarrhea pancreatitis
Eluxadoline
HT3 = hydroxytryptamine3; IBS-C = constipation-predominant irritable bowel syndrome; IBS-D = diarrhea-predominant irritable
bowel syndrome; SSRI = selective serotonin reuptake inhibitor.
dosage is much lower than that started at low doses and in-
used to treat depression. TCAs creased gradually. Selective sero-
can be combined with antispas- tonin reuptake inhibitors may be
modics and, when taken at night, most helpful in persons with IBS
may improve sleep due to the and depression and may help
side effects of fatigue and drows- improve the patient's perception
iness. These drugs are generally of illness and overall well-being.
2017 American College of Physicians ITC90 In the Clinic Annals of Internal Medicine 6 June 2017
may diminish over time, necessi- tion when used daily or as needed. Manipulation of the
microbiota for treatment
tating repeated treatment. Probi- of IBS and IBD-
Linaclotide, a minimally ab- challenges and contro-
otics may work through direct sorbed guanylate cyclase C ago- versies. Gastroenterol-
ogy. 2014;146:1554-63.
alteration of microbiota or indi- nist, induces secretion of intesti- [PMID: 24486051]
rectly via gut immune modula- nal chloride and bicarbonate via
32. Ford AC, Quigley EM,
Lacy BE, Lembo AJ, Saito
tion, but their exact mechanism is activation of the cystic brosis YA, Schiller LR, et al.
not yet known (31). Efcacy of prebiotics,
transmembrane conductance probiotics, and synbiotics
in irritable bowel syn-
Low-quality data show a modest regulator, resulting in accelera- drome and chronic idio-
tion of intestinal transit; it also pathic constipation:
benet of probiotics on global systematic review and
IBS as well as abdominal pain, has an analgesic effect (35). Lina- meta-analysis. Am J
Gastroenterol. 2014;
bloating, and atulence, with a clotide is approved for treatment 109:1547-61; quiz
number needed to treat of 4; of IBS-C at a dosage of 290 1546, 1562. [PMID:
25070051]
however, these studies have mcg/d and can be used as 33. Mazurak N, Broelz E,
Storr M, Enck P. Probiotic
methodological limitations (32). second-line therapy after laxa- therapy of the irritable
Furthermore, determining who is tives have failed in patients with bowel syndrome: why is
the evidence still poor
most likely to benet, the optimal moderate to severe symptoms. and what can be done
about it? J Neurogastro-
formulation of organisms, and the It is effective in reducing ab- enterol Motil. 2015;21:
optimal dose and duration of treat- dominal pain as well as consti- 471-85. [PMID:
26351253]
ment is not well-understood (33). pation symptoms; however, the 34. McGraw T. Safety of
polyethylene glycol 3350
maximal effect on abdominal solution in chronic con-
Treatments for IBS-C
pain relief may take up to 12 stipation: randomized,
In patients with IBS-C, osmotic placebo-controlled trial.
weeks. Diarrhea is the most Clin Exp Gastroenterol.
laxatives, such as polyethylene 2016;9:173-80. [PMID:
glycol, can help increase the fre- common treatment-related ad- 27486340]
quency of spontaneous bowel verse event, although it is usu- 35. Castro J, Harrington AM,
Hughes PA, Martin CM,
movements and improve consti- ally mild to moderate. Ge P, Shea CM, et al.
Linaclotide inhibits co-
pation symptoms (34). Hyper- High-quality evidence supports use of linac- lonic nociceptors and
relieves abdominal pain
tonic osmotic laxatives, such as lotide for the treatment of patients with via guanylate cyclase-C
milk of magnesia, magnesium IBS-C, based on 3 RCTs involving 1773 pa- and extracellular cyclic
guanosine 3,5-
citrate, and sodium phosphate, tients. Patients treated with linaclotide had monophosphate. Gastro-
draw water into the bowel and enterology. 2013;145:
a clinically signicant reduction in abdomi- 1334-46.e1-11. [PMID:
should be used with caution in nal pain, less constipation, globally im- 23958540]
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Practice Improvement
What do professional Bowel Syndrome (50), and the
organizations recommend for 2008 National Institute for Health
the care of patients with IBS? and Care Excellence guidelines
Several clinical practice guide- from the United Kingdom (26).
lines have been developed to Are there performance
help providers manage patients measures related to the
with IBS. These include the 2014
care of patients with IBS?
American Gastroenterological
Current proposed performance
Association Institute Technical
measures in the United States do
Review and Guideline on the
not include any measures speci-
Pharmacological Management of
cally related to the care of pa-
Irritable Bowel Syndrome (30,
tients with IBS; however, the
49), the American College of
quality of the physicianpatient
Gastroenterology Monograph on
interaction is paramount.
the Management of Irritable
2017 American College of Physicians ITC94 Annals of Internal Medicine 6 June 2017
Tool Kit
_Online.pdf
Information from the American College of
IntheClinic
Gastroenterology.
www.mayoclinic.org/diseases-conditions/irritable-bowel
-syndrome/basics/denition/con-20024578
Detailed information on symptoms, risk factors,
preparing for the doctor's appointment, and general
Irritable Bowel clinical information from the Mayo Clinic.
Syndrome https://www.niddk.nih.gov/health-information
/digestive-diseases/irritable-bowel-syndrome
Information from the National Institutes of Health.
https://www.healthinfotranslations.org/pdfDocs
/IBS_SP.pdf
English and Spanish descriptions of irritable bowel
syndrome.
Clinical Guidelines
www.gastro.org/guidelines
Clinical practice guidelines from the American
Gastroenterological Association.
www.worldgastroenterology.org/guidelines/global
-guidelines/irritable-bowel-syndrome-ibs/irritable
-bowel-syndrome-ibs-english
Clinical practice guidelines from the World
Gastroenterology Organisation.
www.gastrojournal.org/article/S0016-5085(14)01089-0
/abstract
Guideline from the American College of Gastroenterol-
ogy.
6 June 2017 Annals of Internal Medicine ITC95 2017 American College of Physicians
How Is It Diagnosed? Foods that are low in ber (which can cause
Patient Information
There is no specic test for IBS. Your doctor will ask you constipation)
about your medical history and your symptoms and Other possible ways to treat IBS include the
may do a physical examination to make a diagnosis. following:
Endoscopy or imaging tests, such as CT scans, are Stress management, such as
usually not needed to diagnose IBS. Your doctor Counseling
may ask you to have certain tests to make sure there Meditation
is not another disease causing the symptoms, Regular exercise
especially if you have any of the following: Yoga
Weight loss, bloody stool, fever, or waking up Getting enough sleep
at night due to pain Behavioral therapies (if the IBS is related to a
Recent use of antibiotics psychological condition)
A family history of colon cancer or Medicines that target your symptoms
inammatory bowel disease.
Questions for My Doctor
How Is It Treated? What can trigger IBS?
Changing what you eat can sometimes help. What food or drinks should I stay away from?
Foods to avoid include the following: What other lifestyle changes do I need to make?
Fatty foods Is there a medicine I can take to treat my
Certain vegetables like beans, cabbage, symptoms?
broccoli, and cauliower What are the side effects of the medicine I will
Drinks with a lot of caffeine or carbonation be taking?
(such as soda) Could stress be causing my IBS?
Foods that are very high in ber (which can Should I have an imaging study to see if it
cause gas or bloating) really is IBS?