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Irritable Bowel Syndrome
Introduction
Irritable bowel syndrome (IBS) is a common gastrointestinal disorder characterized by abdominal pain and altered bowel habits without an identifiable underlying cause. Some studies suggest that microscopic inflammation may be present.[1] Although the exact cause of the condition remains unclear, research suggests that factors such as gut motility changes, visceral hypersensitivity, and psychological influences contribute to its development.[2] More recent studies also highlight the role of gut microbiota in influencing brain function and behavior, further expanding the understanding of the gut-brain axis.[3]
The diagnosis of IBS has evolved over time, with the Rome IV criteria now serving as the standard for clinical assessment. Unlike in the past, IBS is no longer considered a diagnosis of exclusion despite sharing symptoms with various other conditions.[4] The guidelines help minimize unnecessary testing and support a more efficient diagnostic process.
The management of IBS varies based on its subtypes, which include IBS with constipation (IBS-C), IBS with diarrhea (IBS-D), mixed IBS (IBS-M), and unclassified IBS (IBS-U).[5] Treatment approaches range from medications to dietary and lifestyle modifications, with individualized care being essential. A strong patient-clinician relationship is crucial for effective symptom management and improving the quality of life for those affected by the condition.[6][7]
Etiology
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Etiology
The etiology of IBS is broad and not clearly understood. However, gastrointestinal motility, visceral sensation, brain-gut interaction, and psychosocial distress can all play a role in developing IBS.[8] Please refer to the Pathophysiology section for more information.
Several theories have been proposed to explain the etiology of IBS. Abnormal transit profiles and a heightened perception of normal motility may be present. Approximately one-third of patients with IBS may have altered colonic transit. Patients with constipation-predominant IBS experience delayed colonic motility, while those with diarrhea-predominant IBS have accelerated colonic transit. Another theory suggests that local histamine sensitization of afferent neurons leads to earlier depolarization. Intestinal hyperreactivity, along with neural and immunological changes in the colon and small bowel, may persist following gastroenteritis. Infection with Giardia lamblia has also been observed as a potential cause of IBS and chronic fatigue syndrome.[9]
Increased intestinal permeability has been observed, particularly in diarrhea-predominant IBS.[10] Pimentel et al observed that small bowel bacterial overgrowth could be a mechanism, explaining common symptoms such as bloating and distention in patients with IBS.[11] An association between gut microorganisms and the immune system has been identified, although this relationship is not yet fully understood.[12]
Epidemiology
Nearly 12% of patients seek medical help in primary care settings for complaints related to IBS.[6][13] Studies have demonstrated that the prevalence of IBS in the United States ranges between 4.4% and 4.8%; however, this is likely an underestimate, as most patients do not seek medical care.[5][6][14]
IBS has the highest prevalence of IBS in South America, at approximately 21%, and the lowest in Southeast Asia, at 7%.[15][16] In the United States, Israel, and Canada, IBS symptoms are about twice as common in women as in men.[17] Moreover, women are more likely to experience abdominal pain and constipation, whereas men are more likely to report diarrhea.[17] IBS is most commonly observed in adolescent and young adult women.[3]
The prevalence of IBS also decreases with age.[15] The frequency of IBS also varies based on specific subtypes, which include IBS-D, IBS-C, IBS-M, and IBS-U.[5] The prevalence of these subtypes differs between the United States and Europe. These subtypes are equally distributed in the United States, whereas IBS-C and IBS-M are more common in Europe.[18]
Pathophysiology
The pathophysiology of IBS is broad and includes abnormalities involving motility, visceral sensation, brain-gut interaction, and psychosocial distress.[15] These factors can usually be identified in the majority of IBS patients, although not all symptoms can be attributed to them.[15] Recent studies have also shown that altered gut immune activation and changes in the intestinal and colonic microbiome are associated with IBS.[15][19][20]
The following pathophysiological mechanisms have been associated with IBS:
-
Altered gastrointestinal motility includes aberrations in intestinal motility. The myoelectric activity of the gut consists of background slow waves and superimposed spike potentials. Intestinal dysmotility in IBS manifests as alterations in the slow-wave frequency and a late-peaking, blunted, postprandial response of spike potentials. These variations are more pronounced in patients prone to diarrhea. Current theories suggest that these motility abnormalities are linked to generalized smooth muscle hyperresponsiveness.
-
Visceral hyperalgesia is the second key phenomenon characterizing IBS.[21] This is characterized by visceral pain and a heightened perception of normal motility. A potential unifying mechanism is the sensitization of the afferent nociceptive pathways in the gut, which synapse in the dorsal column of the spinal cord.
- Psychopathology is the third aspect of the traditional 3-part complex of IBS. The exact relationship between psychiatric disturbances and IBS is not fully understood; however, patients with IBS have a higher incidence of major depression, panic disorder, anxiety disorders, and hypochondriasis. Some studies suggest that patients with IBS may experience suicidal ideation primarily due to bowel symptoms.[22] Whether psychopathology triggers the development of IBS or vice versa remains unclear.
Additionally, environmental contributors to IBS include early life stressors, food intolerance, antibiotics, and enteric infections.[15] Many patients often report that IBS symptoms are related to food intake; however, true food allergens have a limited role in IBS.[15][23]
Histopathology
Histopathology examination of the intestinal mucosa in patients with IBS may reveal chronic inflammatory cells, mast cells, enteroendocrine cells, and enteric nerves.[24] IBS-D is typically associated with a greater increase in mucosal T-lymphocytes than IBS-C.[24][25] Moreover, an increased number of nerve fibers that stain positive for neuron-specific enolase, substance P, and 5-hydroxytryptamine (5-HT) can be observed.[24][26] A significantly increased density of nerve fibers around mast cells has also been demonstrated.[26]
History and Physical
A detailed history is key to establishing a diagnosis of IBS, as it helps identify the various manifestations and aggravating factors.[3] Indeed, significant variability among patients with IBS is often observed, and a thorough history of symptoms can aid in identifying symptom subgroups and guide effective management.[27] The Rome criteria serve as the foundation for the questions used during the assessment.[28]
IBS typically presents with abdominal discomfort, altered bowel habits, constipation, diarrhea, or a combination of both. Other common complaints include bloating, distention, food-related symptoms, and changes in pain location and stool patterns over time.[15] Additional important aspects of history include travel and social factors.
Constipation presents with hard stools, infrequent or painful defecation, and resistance to laxatives. Diarrhea is characterized by small, frequent loose stools, often preceded by urgency and frequent defecation. Postprandial urgency is also a common symptom, along with alternating episodes of constipation and diarrhea.[29]
Rome IV Criteria
The Rome IV criteria are used to diagnose IBS, requiring at least 3 days per month over the past 3 months associated with 2 or more of the following:
- Improvement in abdominal pain or discomfort with defecation.
- Onset associated with a change in the frequency of stool.
- Onset accompanied by a change in form or appearance of stool [15]
Gastrointestinal Alarm Symptoms
Concerning features or symptoms inconsistent with IBS should raise suspicion for an underlying organic pathology and warrant further diagnostic evaluation. These include:
- Onset in patients age 55 or older
- Acute or progressive symptoms
- Nocturnal symptoms
- Chronic pancreatitis symptoms
- Fever
- Anorexia or unintentional weight loss
- Iron deficiency anemia
- Painless diarrhea
- Rectal bleeding or pain
- Jaundice
- Lymphadenopathy
- Steatorrhea
- Family history of organic gastrointestinal diseases (eg, colon cancer, celiac disease, or inflammatory bowel disease)
- Gluten intolerance [7]
Evaluation
A detailed history, physical examination, and appropriate investigations are essential for establishing the diagnosis of IBS. The specificity of the Rome criteria is enhanced by incorporating information on somatization, nocturnal stools, and affective disorders, as well as including C-reactive protein and hemoglobin levels along with other diagnostic studies.[30] Routine serology or genetic analysis is not recommended for patients with IBS, as celiac disease is relatively uncommon among IBS patients in the United States.[31]
Routine diagnostic testing is not recommended in the absence of alarm findings, such as weight loss, hematochezia, or iron deficiency.[6] The American College of Gastroenterologists (ACG) advises that laboratory testing or diagnostic imaging is unnecessary for patients aged 50 or younger with typical IBS symptoms but no alarm features (eg, iron deficiency anemia, weight loss, or a family history of organic gastrointestinal diseases).[32] However, patients aged 50 and older will require more extensive testing. If symptoms are inconsistent with IBS or alarm symptoms are present, a complete blood cell count, comprehensive metabolic panel, inflammatory markers (such as erythrocyte sedimentation rate or C-reactive protein), and thyroid-stimulating hormone levels should be checked.[6]
For patients with predominant diarrhea, fecal leukocytes and stool tests for Clostridium difficile, Giardia, and Cryptosporidium should be ordered when appropriate.[6] Testing for celiac disease may also be necessary, with tissue transglutaminase antibody as the preferred initial test. A colonoscopy is recommended if there is a family history of inflammatory bowel disease or colon cancer or if alarm symptoms are present.[6] Random biopsies should be performed during colonoscopy if the patient presents with diarrhea. Hydrogen breath testing may be considered in these patients to rule out bacterial overgrowth and to screen for lactose and/or fructose intolerance in patients with persistent diarrhea.[33]
Gallbladder ultrasonography should be conducted in patients with recurrent dyspepsia and characteristic postprandial pain. A computed tomography scan of the abdomen is recommended to screen for obstruction, tumors, or pancreatic disease if clinically indicated.
Treatment / Management
One of the key goals in managing IBS is to establish a strong patient-clinician relationship by actively listening, demonstrating empathy, and setting realistic treatment expectations.[15][34] As IBS is a symptom-based disorder, treatment aims to alleviate symptoms such as pain, bloating, cramping, and diarrhea or constipation.[15] Management primarily focuses on offering psychological support and recommending dietary modifications. Pharmacological treatment should target the modulation of persistent visceral hyperalgesia.[21]
Dietary Modifications
Fiber supplements and laxatives may be beneficial for constipation. Medications such as loperamide or probiotics can help manage symptoms in patients with diarrhea.[15] Moreover, physical activity has also been shown to enhance colonic transit time and improve overall symptoms.[35] Strong recommendations for treating the constipation-predominant subtype include linaclotide and lubiprostone.[36] Judicious water intake is recommended for patients who predominantly experience constipation. Avoiding caffeine may help reduce anxiety and prevent symptom exacerbation. Additionally, avoiding legumes may reduce abdominal bloating.
Patients often associate food intake with IBS symptoms, particularly foods such as wheat products, onions, fruits, vegetables, sorbitol, and some dairy. These foods contain short-chain, poorly absorbed, highly fermentable carbohydrates known as FODMAPs. FODMAPs have been associated with increased gastrointestinal symptoms in IBS patients.[15] A diet low in FODMAPs has been shown to help reduce these symptoms.[37](A1)
Cognitive and Pharmacological Therapies
Patients with persistent and chronic abdominal symptoms may respond to low-dose tricyclic antidepressants or selective serotonin reuptake inhibitors.[6] Many studies suggest that psychological therapies, such as cognitive behavioral therapy, may be equally effective; however, more long-term research is needed.[38] Alosetron is an option for treating IBS-D in females; however, it carries a risk of ischemic colitis. Additionally, gluten intolerance has been associated with IBS. Volta et al observed that patients with gluten or wheat sensitivity may represent a subset of those with IBS.[39](A1)
Rifaximin is a nonabsorbable broad-spectrum antibiotic that is sometimes used to treat patients with IBS. This drug has been shown to reduce abdominal pain and diarrhea in IBS patients. The effectiveness of rifaximin in treating IBS provides evidence supporting the notion that bacterial overgrowth may have a role in the etiology of the condition.
Differential Diagnosis
The list of differential diagnoses of IBS is extensive. Clinical symptoms, primarily whether the patient predominantly experiences diarrhea or constipation, can help guide the assessment of conditions with similar presentations. Patients exhibiting features of these differential diagnoses should undergo further evaluation to confirm the appropriate diagnosis.[40]
For patients with IBS presenting with diarrhea, the differential diagnoses include:
- Lactose intolerance
- Caffeine and alcohol intake
- Gastrointestinal infections (eg, giardiasis, amoebiasis, and HIV)
- Inflammatory bowel disease
- Medication-induced diarrhea (eg, antibiotic use, proton pump inhibitors, nonsteroidal anti-inflammatory drugs [NSAIDs], angiotensin-converting enzyme [ACE] inhibitors, and chemotherapy)
- Celiac disease [41]
- Malignancies
- Colorectal cancer
- Hyperthyroidism
- VIPoma [42]
- Ischemic colitis [40]
For patients with predominant constipation, the differential diagnoses include:
Prognosis
IBS is a chronic condition characterized by recurrent symptoms of varying severity. However, life expectancy in individuals with IBS is comparable to that of the general population. The diagnosis typically remains stable during follow-up.[46] The use of ambulatory health services by IBS patients can be reduced when a positive relationship and strong rapport are established between the patient and clinician.[46]
Patients with IBS may have a higher risk of ectopic pregnancy and miscarriage but not stillbirth. This remains unclear whether this increased risk is due to IBS itself or the medications used for its treatment.[47] Additionally, the coexistence of anxiety and depression in patients with IBS is frequently observed, and these conditions are often linked to lower socioeconomic status and average per capita income.[48]
Complications
IBS is generally a manageable condition, and complications are rare. However, the following complications may occur in patients with IBS:
- Chronic constipation can cause anal fissures or hemorrhoids.[49]
- Chronic diarrhea can lead to hemorrhoids and rectal bleeding.
- Poor quality of life.
- Mental health issues, such as anxiety and depression.
- Poor dietary intake potentially results in nutritional deficiencies.
Consultations
In patients with IBS, consultations with gastroenterologists and nutritionists are essential. Gastroenterologists often specialize in IBS care and are invaluable members of the healthcare team. They can tailor treatment plans to the individual patient and stay updated on advancements in IBS management. Given that patients often believe certain foods are linked to their symptoms and the established association between FODMAPs and IBS, nutritionists play a crucial role in providing dietary recommendations for patients.
Deterrence and Patient Education
If a patient with IBS experiences concerns about abdominal pain, bloating, cramping, or changes in bowel habits, a visit to a primary care clinician is recommended. A gastroenterology consultation is advised to guide management and treatment if IBS is diagnosed.
Enhancing Healthcare Team Outcomes
Effective management of IBS requires a coordinated, interprofessional approach to enhance patient-centered care, improve outcomes, and ensure patient safety. Physicians and advanced practitioners play a crucial role in diagnosing IBS using the Rome IV criteria, distinguishing it from other gastrointestinal disorders, and developing individualized treatment plans tailored to the patient's symptom subtypes. They also engage in shared decision-making with patients, incorporating dietary modifications, psychological support, and pharmacological treatments when appropriate. Specialty-trained nurses contribute by educating patients and their families on symptom management, lifestyle changes, medication adherence, and monitoring treatment responses while relaying essential information to the healthcare team.
Pharmacists are crucial in ensuring safe and effective medication use by reviewing prescriptions for potential interactions, discussing possible adverse effects, and providing guidance on proper usage. Open communication between all healthcare professionals involved in IBS management fosters better symptom control and minimizes unnecessary medical interventions. Care coordination among primary care clinicians, gastroenterologists, nurses, and pharmacists ensures that patients receive a comprehensive, interprofessional approach to care. By improving interprofessional communication, healthcare teams can enhance patient safety, reduce the need for excessive testing and medications, and ultimately improve the overall quality of life for individuals with IBS.
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