Irritable Bowel Syndrome (IBS)
Irritable bowel syndrome (IBS) is characterized by recurrent abdominal discomfort or pain that is accompanied by at least two of the following: relief by defecation, change in frequency of stool, or change in consistency of stool. The cause is unknown, and the pathophysiology is incompletely understood. Diagnosis is clinical. Treatment is symptomatic, consisting of dietary management and drugs, including anticholinergics and agents active at serotonin receptors.
The cause of IBS is unknown. No anatomic cause can be found on laboratory tests, x-rays, and biopsies. Emotional factors, diet, drugs, or hormones may precipitate or aggravate GI symptoms. Historically, the disorder was often considered as purely psychosomatic. Although psychosocial factors are involved, IBS is better understood as a combination of psychosocial and physiologic factors.
Psychologic distress is common among patients with IBS, especially in those who seek medical care. Some patients have anxiety disorders, depression, or a somatization disorder. Sleep disturbances also coexist. However, stress and emotional conflict do not always coincide with symptom onset and recurrence. Some patients with IBS seem to have a learned aberrant illness behavior (ie, they express emotional conflict as a GI complaint, usually abdominal pain). The physician evaluating patients with IBS, particularly those with refractory symptoms, should investigate for unresolved psychologic issues, including the possibility of sexual or physical abuse. Psychosocial factors also affect the outcome in IBS.
A variety of physiologic factors seem to be involved in IBS symptoms. These factors include altered motility, visceral hyperalgesia, and various genetic and environmental factors.
Visceral hyperalgesia refers to hypersensitivity to normal amounts of intraluminal distention and heightened perception of pain in the presence of normal quantities of intestinal gas; it may result from remodeling of neural pathways in the brain-gut axis. Some patients (perhaps 1 in 7) have reported their IBS symptoms began after an episode of acute gastroenteritis (termed postinfectious IBS). A subset of patients with IBS has autonomic dysfunctions. However, many patients have no demonstrable physiologic abnormalities, and, even in those that do, the abnormalities may not correlate with symptoms.
Constipation may be explained by slower colonic transit, and diarrhea may be explained by faster colonic transit. Some patients with constipation have fewer colonic high amplitude-propagated contractions, which propel colonic contents over several segments. Conversely, excess sigmoid motor activity may retard transit in functional constipation.
Postprandial abdominal discomfort may be attributed to an exaggerated gastro-colonic reflex (the colonic contractile response to a meal), the presence of colonic high amplitude-propagated contractions, increased intestinal sensitivity (visceral hyperalgesia), or a combination of these factors. Fat ingestion may increase intestinal permeability and exaggerate hypersensitivity. Ingestion of food high in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (collectively called FODMAPs) are poorly absorbed in the small intestine and may increase colonic motility and secretion.
Hormonal fluctuations affect bowel functions in women. Rectal sensitivity is increased during menses but not during other phases of the menstrual cycle. The effects of sex steroids on GI transit are subtle. The role of small-bowel bacterial overgrowth in IBS is controversial.
IBS tends to begin in adolescence and the 20s, causing bouts of symptoms that recur at irregular periods. Onset in late adult life is less common but not rare. Symptoms rarely rouse the sleeping patient. Symptoms are often triggered by food, particularly fats, or by stress.
Patients have abdominal discomfort, which varies considerably but is often located in the lower abdomen, steady or cramping in nature, and relieved by defecation. In addition, abdominal discomfort is temporally associated with alterations in stool frequency (increased in diarrhea-predominant IBS and decreased in constipation-predominant IBS) and consistency (ie, loose or lumpy and hard). Pain or discomfort related to defecation is likely to be of bowel origin; that associated with exercise, movement, urination, or menstruation usually has a different cause.
Although bowel patterns are relatively consistent in most patients, it is not unusual for patients to alternate between constipation and diarrhea. Patients may also have symptoms of abnormal stool passage (straining, urgency, or feeling of incomplete evacuation), pass mucus, or complain of bloating or abdominal distention. Many patients also have symptoms of dyspepsia. Extra-intestinal symptoms (eg, fatigue, fibromyalgia, sleep disturbances, chronic headaches) are common.
Diagnosis of IBS is based on characteristic bowel patterns, time and character of pain, and exclusion of other disease processes through physical examination and routine diagnostic tests.
Because patients with IBS can develop organic conditions, testing for other conditions should also be considered in patients who develop alarm symptoms or markedly different symptoms during the course of IBS. Common illnesses that may be confused with IBS include
However, uninflamed colonic diverticula do not cause symptoms, and their presence should not be considered explanatory.
The bimodal age distribution of patients with inflammatory bowel disease makes it imperative to evaluate both younger and older patients. In patients > 60 with acute symptoms, ischemic colitis should be considered. Patients with constipation and no anatomic lesion should be evaluated for hypothyroidism and hyperparathyroidism. If the patient’s symptoms suggest malabsorption, tropical sprue, celiac disease, and Whipple disease must be considered. Defecatory disorders should be considered as a cause of constipation in patients who report symptoms of difficult defecation.
Rare causes of diarrhea include hyperthyroidism, medullary cancer of the thyroid, or carcinoid syndrome, gastrinoma, and vipoma. However, secretory diarrhea caused by vasoactive intestinal peptide (VIP), calcitonin, or gastrin is typically accompanied by stool volumes > 1000 mL daily.
Particular attention should be given to the character of the pain, bowel habits, familial interrelationships, and drug and dietary histories. Equally important are the patient’s overall emotional state, interpretation of personal problems, and quality of life. The quality of the patient-physician interaction is key to diagnostic and therapeutic efficacy.
The Rome criteria are standardized symptom-based criteria for diagnosing IBS. The Rome criteria require the presence of abdominal pain for at least 1 day/wk in the last 3 mo along with ≥ 2 of the following (1):
Patients generally appear to be healthy. Palpation of the abdomen may reveal tenderness, particularly in the left lower quadrant, at times associated with a palpable, tender sigmoid. A digital rectal examination, including a test for occult blood, should be done on all patients. In women, a pelvic examination helps rule out ovarian tumors and cysts or endometriosis, which may mimic IBS.
The diagnosis of IBS can reasonably be made using the Rome criteria as long as patients have no red flag findings, such as rectal bleeding, weight loss, and fever, or other findings that might suggest another etiology. Many patients with IBS are overtested; however, CBC, biochemical profile (including liver tests), ESR, stool examination for ova and parasites (in patients with diarrhea predominance), thyroid-stimulating hormone and calcium for patients with constipation, and flexible sigmoidoscopy or colonoscopy should be done.
During flexible fiberoptic proctosigmoidoscopy, introduction of the instrument and air insufflation frequently trigger bowel spasm and pain. The mucosal and vascular patterns in IBS usually appear normal. Colonoscopy is preferred for patients > 50 with a change in bowel habits, particularly those with no previous IBS symptoms, to exclude colonic polyps and tumors. In patients with chronic diarrhea, particularly older women, mucosal biopsy can rule out possible microscopic colitis.
Additional studies (such as ultrasonography, CT, barium enema x-ray, upper GI esophagogastroduodenoscopy, and small-bowel x-rays) should be undertaken only when there are other objective abnormalities. Fecal fat excretion should be measured when there is a concern about steatorrhea. Testing for celiac disease and small-bowel x-rays are recommended when malabsorption is suspected. Testing for carbohydrate intolerance or small-bowel bacterial overgrowth should be considered in appropriate circumstances.
Patients with IBS may subsequently develop additional GI disorders, and the clinician must not summarily dismiss their complaints. Changes in symptoms (eg, in the location, type, or intensity of pain; in bowel habits; in constipation and diarrhea) and new symptoms or complaints (eg, nocturnal diarrhea) may signal another disease process. Other symptoms that require investigation include fresh blood in the stool, weight loss, very severe abdominal pain or unusual abdominal distention, steatorrhea or noticeably foul-smelling stools, fever or chills, persistent vomiting, hematemesis, symptoms that wake the patient from sleep (eg, pain, the urge to defecate), and a steady progressive worsening of symptoms. Patients > 40 are more likely than younger patients to develop an intercurrent physiologic illness.
Therapy is directed at specific symptoms. An effective therapeutic relationship is essential for effectively managing IBS. Patients should be invited to express not only their symptoms but also their understanding of their symptoms and the reasons prompting a visit to the health care practitioner (eg, fear of serious disease). Patients should be educated about the disorder (eg, normal bowel physiology and the bowel’s hypersensitivity to stress and food) and reassured, after appropriate tests, about the absence of a serious or life-threatening disease. Appropriate therapeutic goals (eg, expectations regarding the normal course or variability in symptoms, adverse effects of drugs, the appropriate and available working relationship between the physician and the patient) should be established.
Finally, patients can benefit by being actively involved in the management of their condition. When successful, this can enhance the patient’s motivation to adhere to treatment, foster a more positive physician-patient relationship, and mobilize the coping resources of even the most chronically passive patients. Psychologic stress, anxiety, or mood disorders should be identified, evaluated, and treated. Regular physical activity helps relieve stress and assists in bowel function, particularly in patients with constipation.
In general, a normal diet can be followed. Meals should not be overly large, and eating should be slow and paced. Patients with abdominal distention and increased flatulence may benefit from reducing or eliminating beans, cabbage, and other foods containing fermentable carbohydrates. Reduced intake of sweeteners (eg, sorbitol, mannitol, fructose), which are constituents of natural and processed foods (eg, apple and grape juice, bananas, nuts, and raisins), may alleviate flatulence, bloating, and diarrhea. Patients with evidence of lactose intolerance should reduce their intake of milk and dairy products. A low-fat diet may reduce postprandial abdominal symptoms.
Dietary fiber supplements may soften stool and improve the ease of evacuation. A bland bulk-producing agent may be used (eg, raw bran, starting with 15 mL [1 tbsp] with each meal, supplemented with increased fluid intake). Alternatively, psyllium hydrophilic mucilloid with two glasses of water may be used. However, excessive use of fiber can lead to bloating and diarrhea, so fiber doses must be individualized. Occasionally, flatulence may be reduced by switching to a synthetic fiber preparation (eg, methylcellulose).
Drug therapy is directed toward the dominant symptoms. Anticholinergic drugs (eg, hyoscyamine 0.125 mg po 30 to 60 min before meals) may be used for their antispasmodic effects.
In patients with constipation-predominant IBS (IBS-C), the chloride channel activator lubiprostone 8 mcg or 24 mcg po bid and the guanylate cyclase C agonist linaclotide 145 mcg or 290 mcg po once/day may be helpful. Polyethylene glycol laxatives have not been well-studied in IBS. However, they have been shown to be effective for use in chronic constipation and for bowel lavage before colonoscopy and are thus frequently used for IBS-C.
In patients with diarrhea-predominant IBS (IBS-D), oral diphenoxylate 2.5 to 5 mg or loperamide 2 to 4 mg may be given before meals. The dose of loperamide should be titrated upward to reduce diarrhea while avoiding constipation. Rifaximin is an antibiotic that has been shown to relieve symptoms of bloating and abdominal pain and to help decrease looseness of stools in patients with IBS-D. The recommended dose of rifaximin for IBS-D is 550 mg po tid for 14 days. Alosetron is a 5-hydroxytryptamine (serotonin) 3 (5HT3) receptor antagonist that may benefit women with severe IBS-D refractory to other drugs. Because alosetron has been associated with ischemic colitis, its use in the US is under a restricted prescribing program. Eluxadoline has mixed opioid receptor activity and is indicated for treatment of IBS-D.
For many patients, tricyclic antidepressants (TCAs) help relieve symptoms of diarrhea, abdominal pain, and bloating. These drugs are thought to reduce pain by down-regulating the activity of spinal cord and cortical afferent pathways arriving from the intestine. Secondary amine TCAs (eg, nortriptyline, desipramine) are often better tolerated than parent tertiary amines (eg, amitriptyline, imipramine, doxepin) because of fewer anticholinergic, sedating antihistaminic, and alpha-adrenergic adverse effects. Treatment should begin with a very low dose of a TCA (eg, desipramine 10 to 25 mg once/day at bedtime), increasing as necessary and tolerated up to about 100 to 150 mg once/day.
SSRIs are sometimes used in patients with anxiety or an affective disorder, but studies have not shown a significant benefit for patients with IBS and they may exacerbate diarrhea.
Preliminary data suggest that certain probiotics (eg, Bifidobacterium infantis) alleviate IBS symptoms, particularly bloating. The beneficial effects of probiotics are not generic to the entire species but specific to certain strains. Certain aromatic oils (carminatives) can relax smooth muscle and relieve pain caused by cramps in some patients. Peppermint oil is the most commonly used agent in this class.
IBS is recurrent abdominal discomfort or pain accompanied by ≥ 2 of the following: relief by defecation, change in frequency of stool (diarrhea or constipation), or change in consistency of stool.
Etiology is unclear but appears to involve both psychosocial and physiologic factors.
Exclude more dangerous diseases by testing, particularly in patients with red flag findings, such as older age, fever, weight loss, rectal bleeding, or vomiting.
Common illnesses that may be confused with IBS include lactose intolerance, drug-induced diarrhea, post-cholecystectomy diarrhea, laxative abuse, parasitic diseases, eosinophilic gastritis or enteritis, microscopic colitis, small-bowel bacterial overgrowth, celiac disease, and early inflammatory bowel disease.
Typical testing includes CBC, biochemical profile (including liver tests), ESR, stool examination for ova and parasites (in patients with diarrhea predominance), thyroid-stimulating hormone and calcium (for patients with constipation), and flexible sigmoidoscopy or colonoscopy.
A supportive, understanding, and therapeutic relationship is essential; direct drug therapy toward the dominant symptoms.