Irritable Bowel Syndrome Message Boards

Gastroenterology Expert Column
Diagnosing Irritable Bowel Syndrome: What's Too Much, What's Enough?
Posted 03/12/2004

Susan Lucak, MD

Introduction
Irritable bowel syndrome (IBS) is the most common gastrointestinal disorder diagnosed in clinical practice in the United States. Because there is no biological marker to confirm the diagnosis of IBS, it is a diagnosis that has challenged clinicians for decades. In the past, IBS was a "waste-basket" diagnosis given to patients with unexplained gastrointestinal symptoms. It was considered to be "the diagnosis of exclusion" when extensive work-up for organic disease yielded no diagnosis.
In recent decades, it was recognized that patients with IBS experienced a constellation of specific gastrointestinal symptoms. Manning criteria were described in 1978,[1] followed by Rome I in 1989[2] and Rome II criteria in 1999.[3] Rome I and Rome II criteria were initially developed by multinational working groups to provide a framework for the selection of patients in diagnostic and therapeutic trials. These criteria are being continuously modified as we gain new knowledge about functional bowel disorders.
Recently published diagnostic guidelines[4,5] recommend using symptom-based criteria in making the diagnosis of IBS in clinical practice. Using these criteria in conjunction with "alarm features" allows a physician to minimize the extent of diagnostic testing needed to make the diagnosis of IBS. Furthermore, recent systematic review of the literature indicates that performing a number of diagnostic tests did not result in a significant increase in the diagnosis of organic gastrointestinal disease.[6]

This column discusses novel approaches to the diagnosis of IBS."

""Alarm Features"
An important aspect of making the diagnosis of IBS is the absence of "red flag" or "alarm features" ( Table 2 ).[4,11,12] Unexplained weight loss may reflect disorders such as malignancy, inflammatory bowel disease (IBD), or celiac disease. Persistent diarrhea or severe constipation may be associated with an organic disease.

IBS is generally an intermittent and recurrent disorder. Symptoms of IBS tend to disappear at night when the patient is asleep. Thus, nocturnal gastrointestinal symptoms warrant search for a diagnosis other than IBS. The onset of new gastrointestinal symptoms after the age of 50 should prompt the physician to look for organic disease, particularly colorectal cancer. Blood in stool may reflect IBD or an infectious process or colon cancer. Family history of IBD, celiac disease, or gastrointestinal malignancy requires evaluation for these diseases. Fever suggests the possibility of an infectious or inflammatory disorder. Anemia should alert the physician to look for IBD or colorectal cancer. Signs of bowel obstruction, malabsorption, extraintestinal signs of IBD, or thyroid dysfunction should all prompt organic disease work-up. Any laboratory test abnormalities should be pursued appropriately. Absence of these "alarm features" serves to support, not establish, the diagnosis of IBS."

Summary and Conclusions
What's too much when we think about diagnosing IBS is to do exhaustive and duplicate testing. In a retrospective, community-based study in Olmsted County, Minnesota, two thirds of patients who consulted for gastrointestinal symptoms had to wait at least 2 years to have their IBS diagnosed, despite averaging nearly 5 healthcare visits per year.[20] Such an approach is not only costly and inefficient, but it delays treatment and fosters frustration on the part of the patient and the physician.

What's enough is to use symptom-based criteria, "alarm features," and guidelines proposed by the ACG IBS Task Force and the AGA Technical Review on IBS in making a more timely diagnosis of IBS. Although additional studies are necessary to validate Rome II criteria and to assess diagnostic testing in prospective studies, the expert guidelines allow the diagnosis of IBS to be made with greater efficiency, certainty, and confidence. Furthermore, once a diagnosis of IBS is made, it is retained in more than 93% of cases with a long-term follow-up. Considering legal aspects of IBS diagnosis, symptom-based criteria and guidelines set forth by the ACG and AGA are becoming key elements in establishing standard of care. It has become clear that the diagnosis of IBS can and should be made quickly so that treatment can be initiated as soon as possible. This promotes greater patient confidence in the physician."

Introduction
Epidemiology
Symptom-based Criteria
"Alarm Features"
Physical Examination
Diagnostic Testing
Differential Diagnosis and Durability of Diagnosis
Legal Risks in Diagnosing IBS
Summary and Conclusions

http://www.medscape.com/viewarticle/465760_1

Diagnosis, Pathophysiology, and Treatment of Irritable Bowel Syndrome

Diagnosis of IBS
Symptoms of IBS can be common to any number of gastrointestinal disorders. Abdominal pain, bloating, and diarrhea or constipation can easily generate an extensive list of potential diagnostic possibilities. To adopt an open-ended approach to diagnosis and to value all diagnostic possibilities equally has never been an effective approach in the diagnosis of IBS. However, with the development and validation of the Rome II criteria for the diagnosis of IBS, our approach to the diagnosis of this traditionally perplexing disorder is rapidly changing.

Diagnosing the patient with IBS should include 3 steps. First, determine whether the patient at first encounter meets the Rome diagnostic criteria for IBS. Second, conduct a history and physical examination looking for so-called "alarm factors." Third, perform diagnostic testing.

Diagnostic Criteria
The latest version of the Rome diagnostic criteria (Rome II) for IBS were first published in abbreviated form in 1999[7] and in full form in 2000.[8] See the Table below. The Rome criteria have been shown to be both sensitive and specific for the diagnosis of IBS[9] and can be used advantageously in clinical practice. If a patient presents with symptoms suggestive of IBS and epidemiologically fits the profile of a patient most likely to have IBS (ie, younger than 40 years of age and with typical symptoms), the Rome criteria can be used to validate the physician's initial impression. Starting with a "positive approach" to diagnosing IBS, as opposed to adopting a diagnosis of exclusion, sets the entire physician-patient encounter off in a positive and thoughtful direction. Providing the diagnostic framework presented by the Rome criteria gives the physician an intellectual basis for making an IBS diagnosis with confidence.[10]

History-Taking
The key to history-taking in a patient with suspected IBS is first and foremost to look for the presence of so-called "alarm factors." It is clear that the symptoms of IBS can be typical of many other structural disorders of the gastrointestinal tract. Diarrhea, abdominal bloating, and constipation can all represent an extraordinarily wide spectrum of gastrointestinal pathology. The challenge using the framework provided by the Rome II diagnostic criteria is to rapidly exclude the possibility of other disorders. The key is to look for symptoms in the history that are atypical of IBS and suggestive of other disorders. The list of so-called "alarm factors" can certainly be open to debate and discussion.

Physical Examination
After a patient history has been completed and the absence of "alarm factors" documented, a physical examination should always be performed. The physical examination should focus specifically on ruling out inflammatory bowel disease, colorectal or other gastrointestinal cancers, and malabsorption caused by luminal or pancreatic causes. Look for extraintestinal manifestations of inflammatory bowel disease, such as ophthalmic changes, Sicca syndrome, intraoral lesions (eg, aphthous ulcers), and skin or arthritic changes suggestive of inflammatory bowel disease. Likewise, signs of malabsorption, such as muscle wasting, nail or perioral changes, and weight loss should all be ruled out. Finally, the issue of colorectal cancer must be addressed. There is agreement in the functional bowel community that the best guide to help clarify this situation is to follow the colorectal cancer screening guidelines of the American Cancer Society. It is therefore recommended that patients 50 years of age or older who have never had a screening colonoscopy should have one performed as part of an IBS evaluation. Likewise, individuals 40 years of age or older who have a family history of colorectal cancer in a first-rank relative should also have a screening colonoscopy.[11] Finally, the use of sigmoidoscopy in individuals younger than 50 years old who have no family history is open to some discussion.[12]

Small bowel (to rule out Giardia or small bowel malabsorption) or colonic (to rule out microscopic colitis) biopsies may be indicated, particularly for patients with loose or watery stools.[13] These studies, although they include some diagnostic testing, may be considered part of the "physical examination" and initial evaluation of the patient with suspected IBS.

Diagnostic Testing
The use of diagnostic testing in IBS has become an increasingly controversial topic. Traditionally, the "diagnosis of exclusion" approach encouraged extensive diagnostic testing to evaluate patients with suspected IBS to rule out other possible causes of the disorder. Given the high prevalence of IBS , this approach has been subject to considerable scrutiny over the last 5 years.[10] Numerous studies have shown that the use of routine lactase hydrogen breath-testing for sugar malabsorption,[14] abdominal ultrasound,[15] routine computed tomography scanning, particularly in younger patients, and more esoteric tests, such as screening for acute intermittent porphyria[16] or thyroid testing for hyper- or hypothyroidism,[17] rarely yield data that change the diagnosis of IBS. Testing for bacterial overgrowth has been recently proposed by 1 group as a possible cause of IBS-like symptoms.[18] However, the article supporting the reasonableness of this approach studied a cohort of patients who were specifically referred by their treating physician to a tertiary center specializing in bacterial overgrowth. These patients were specifically referred to the tertiary center to rule out the possibility of bacterial overgrowth. However, given the selection bias in this study, the applicability of these data to the universe of IBS patients is open to some question. Based on the available literature, routine testing for bacterial overgrowth in patients with suspected IBS cannot be routinely recommended at this time.

One additional issue that is rapidly evolving in the area of IBS diagnosis is the issue of celiac disease. A number of studies have recently demonstrated a higher prevalence of celiac disease in the North American population than was previously thought, as well as a possible higher prevalence among patients with IBS-like symptoms.[19] This issue is yet to be completely resolved. It would therefore seem prudent for physicians who have patients with suspected IBS who have subtle signs or symptoms of celiac disease, such as osteoporosis in a premenopausal female or male, infertility, mild anemia, or weight loss, to evaluate the patient by obtaining celiac disease markers. Endoscopy with small bowel biopsy can confirm any equivocal serologic results.

Given these data, it would seem reasonable for the patient with IBS who presents absent alarm factors and who has a normal physical examination to have a complete blood count and chemistry panel and perhaps erythrocyte sedimentation rate measurement and thyroid function testing in the form of thyroid-stimulating hormone (TSH) levels. As noted above, in patients with diarrhea, additional initial investigation may be warranted, particularly investigation for the possibility of microscopic colitis and perhaps celiac disease.[17] For the majority of patients, this should end the initial evaluation. It is at this point that the physician should begin treatment and follow the patient prospectively. Failure to respond to reasonable treatment for IBS after a period of 2-4 weeks should certainly invite the physician to question the validity of IBS diagnosis and to consider additional evaluation as indicated. See the Figure below for a schematic that outlines this approach.

Of course recently they have published the rome lll criteria.

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My website on IBS is www.ibshealth.com

Print Remind Me Notify Moderator

Wronmg, first again you don't know what a diagnoses of IBS itself means.

You keep saying mainstream, your alternative practioners DON"T DO IBS research they get it from science itself. This condition has never been proven to exist in over twenty years of looking for it with powerful microscopes of the intensines looking at specific cells, no candida overgrowth.

Youer cured, yet you say candida never goes away? You problably had mild IBS and diet helped as well as you think its helping.

IRRITABLE BOWEL SYNDROME
Lin Chang, M.D.
CNS: Center of Neurovisceral Sciences & Women's Health, CURE: Digestive Diseases Research Center,
Division of Digestive Diseases, David Geffen School of Medicine at UCLA
Corresponding Author:
Lin Chang, M.D.
Center for Neurovisceral Sciences & Women's Health
CURE: Digestive Diseases Research Center
VA Greater Los Angeles Healthcare System
11301 Wilshire Blvd., Building. 115, Room. 223
Los Angeles, CA. 90073

PREVALENCE AND EPIDEMIOLOGY
Irritable bowel syndrome (IBS) is the most common
functional gastrointestinal (GI) disorder with worldwide
prevalence rates ranging from 9-23%. Functional
disorders are conditions where there is an absence of
anatomical or biochemical abnormalities on diagnostic
tests which could explain symptoms. IBS is a chronic
functional bowel disorder characterized by abdominal pain
or discomfort and alterations in bowel habits. It is the most
common disorder diagnosed by gastroenterologists and
accounts for up to 12% of total visits to primary care
providers Gender appears to play an important role in IBS.
Two-thirds of individuals with IBS are female with an
estimated prevalence in women ranging from 14-24%. Of
those who seek healthcare services including tertiary and
ambulatory care for IBS and other functional bowel
disorders, women lead men by a ratio of 2-2.5:1 while
others estimate the rate to be higher at 3-4:1. However, the
gender distribution appears to be less than 2:1 among IBS
non-patients (individuals with symptoms of IBS but who
have not sought health care) in the community. It is not
known if this increased female prevalence represents a
reporting bias, i.e. if female patients are more willing than
men to disclose that they have IBS-related symptoms, or if
it represents a biological difference.
Not all individuals with IBS symptoms seek medical care
for their symptoms. Based on different epidemiological
studies performed in different countries, 20-75% of
individuals meeting symptom criteria for IBS will seek
medical care for their symptoms at some point in their
lives. There are between 2.4 and 3.5 million annual
physician visits for IBS in the United States, during which
2.2 million prescriptions are written. The cost to society in
terms of direct medical expenses and indirect costs
associated with loss of productivity and work absenteeism
is considerable. It has been estimated that the total cost of
IBS is 30 billion dollars per year which includes 20 billion
dollars for indirect costs and 10 billion dollars for direct
costs.
SYMPTOMS OF IBS
Gastrointestinal (GI) symptoms. The hallmark symptoms
of IBS are chronic abdominal pain and/or discomfort and
alterations in bowel habits, such as diarrhea, constipation
or alternating diarrhea and constipation. Abdominal pain
has been reported as primarily crampy or as a generalized
ache with superimposed periods of abdominal cramps,
although sharp, dull, gas-like, or nondescript pains are also
common. The intensity and location of abdominal pain in
IBS are highly variable, even at different times within a
single patient. The abdominal pain and/or discomfort
experienced by IBS patients is often severe enough to
interfere with daily activities. Several factors exacerbate or
reduce the pain of IBS. Many IBS patients report
increased symptoms during periods of stress or emotional
upset such as job or marital difficulties. Defecation may
provide temporary relief from the abdominal pain of IBS,
whereas ingestion of food may exacerbate the discomfort
in a subset of patients.
Based on bowel habits, patients are commonly subclassified
into those having mainly diarrhea, mainly
constipation, and those alternating between the two
patterns. IBS patients with constipation may experience
infrequent bowel movements (<3/week), hard stools,
straining, and sensation of incomplete evacuation. IBS
patients with primarily diarrhea report frequent bowel
movements (>3/day), loose and/or watery stools frequent,
and urgency. The prevalence of the difference subgroups
based on bowel habits is similar. Other common IBS
symptoms include bloating, visible abdominal distension,
and mucus in the stool.
Upper gastrointestinal symptoms are commonly reported
by IBS patients with 25% to 50% of patients reporting
heartburn, early satiety, nausea, abdominal fullness, and
bloating. Up to 87% have reported intermittent upper
abdominal discomfort or pain (dyspepsia) by
approximately 40% of patients.
Extra-intestinal symptoms and overlap with other
common pain syndromes. Many IBS patients also report
extra-intestinal (non-gastrointestinal) symptoms such as
fatigue, muscle pain, sleep disturbances, and sexual
dysfunction. Up to two-thirds of IBS patients report extraintestinal
symptoms compared to less than 15% of healthy
individuals. These extra-intestinal symptoms may be due
to IBS co-morbidity with other stress-related syndromes
such as fibromyalgia, chronic fatigue syndrome, and
interstitial cystitis. Epidemiological studies have confirmed
the clinical impression that IBS frequently overlaps with
these other conditions in the same patient, suggesting
shared pathophysiologic mechanisms.
Psychological symptoms. Some IBS patients also have
psychological distress symptoms such as anxiety and
depression particularly in those with severe symptoms and
health care seeking behavior. Somatization, anxiety and
depressive disorders are also more commonly seen in IBS
patients than in healthy controls. Psychosocial trauma and
early adverse life events (e.g., parental separation or
physical/verbal/sexual abuse history) may profoundly
affect symptom severity, daily function, and health
outcome. Although these adverse events such as abuse
may be quite prevalent in IBS patients, a significant
number have not discussed this with anyone and a smaller
number will actually inform their physicians.

DIAGNOSIS OF IBS
The diagnosis of IBS is based on identifying characteristic
symptoms and excluding organic disease. An early
confident diagnosis permits tests to be minimized and
reassures the patient that there is no lethal disease. There
are no physical findings or diagnostic tests that confirm the
diagnosis of IBS. Therefore, diagnosis of IBS involves
identifying certain symptoms consistent with the disorder
and excluding other medical conditions which may have a
similar clinical presentation. The symptom-based Rome II
diagnostic criteria for IBS (Table 1) emphasize a "positive
diagnosis" rather than exhaustive tests to exclude other
diseases. A validation study of the Rome criteria after
excluding patients with symptoms suggestive of other
medical conditions other than IBS ("alarm signs" e.g.
bloody stools, weight loss, family history of colon cancer,
refractory and severe diarrhea) showed that 100% of
individuals who met the diagnosis of IBS based on the
Rome criteria truly had IBS rather than an alternative
diagnosis. At 2 years follow-up, none of the IBS patients
required a change in diagnosis.
Other medical conditions which may present with
symptoms similar to those seen in IBS include
inflammatory bowel disease, GI infections, lactose
intolerance, thyroid disease, microscopic or collagenous
colitis and malabsorption syndromes such as celiac sprue
(Table 2). A medical history and physical examination,
laboratory and GI tests can help to exclude these other
diagnoses. These tests include routine blood tests, stool
studies for infection, and endoscopic procedures such as
upper endoscopy, sigmoidoscopy and colonoscopy. In
patients < 50 years of age who meet diagnostic criteria for
IBS and have no "alarm signs" suggestive of diseases other
than IBS, initial screening tests such as a complete blood
count to check for anemia and a chemistry panel can be
obtained. Other screening tests to consider are a thyroid
test (TSH) and a blood test for celiac sprue. However,
further tests and procedures such as a colonoscopy are not
generally recommended. Patients ≥ 50 years of age with
IBS symptoms should undergo a screening colon
examination with either a colonoscopy or flexible
sigmoidoscopy and barium enema if these tests have not
been done previously, regardless if they have alarm signs
(see Figure 1).
In some centers, the presence of bacterial overgrowth is
often determined because this condition may cause
symptoms similar to those of IBS. It is most commonly
diagnosed by a lactulose hydrogen breath test. Two studies
from the same research group found that 78% to 84% of
patients with IBS had bacterial overgrowth. In patients
with evidence of bacterial overgrowth, those treated with
an antibiotic such as neomycin had a greater reduction in
their GI symptoms compared with placebo. Although these
data are intriguing, there are some methodologic
limitations in these studies and, therefore, the use of
widespread hydrogen breath testing for bacterial
overgrowth is still not generally advocated.
PATHOPHYSIOLOGIC MECHANISMS OF IBS
Although psychological and physiological abnormalities
have been described, the overall pathophysiology of IBS is
not well understood. Similar to other chronic medical
conditions, a multi-component conceptual model of IBS,
which involves genetic, physiologic, emotional, cognitive,
and behavioral factors, has been formulated (Figure 2).
Although all factors are closely interconnected, the
importance of individual factors in the generation of IBS
symptoms may vary greatly between individuals.
Previously, IBS was considered primarily a disorder of
altered gut motility. Currently, increased bowel sensitivity
(visceral hypersensitivity) and altered brain-gut
interactions are felt to play a principal role in the
pathophysiology of IBS. Recently, it has been found that
genetic and environmental factors are important in IBS but
further studies are needed to understand the importance of
these factors in the prevalence, symptoms, physiologic
responses and response to treatment in IBS.
Altered intestinal motor function. Altered intestinal
motility has been found in IBS, particularly exaggerated
contractions (motor response) in the lower (sigmoid) colon
to psychological stress and food intake. These alterations
may explain why many IBS patients experience typical
IBS symptoms following meals and develop exacerbations
during stressful life events. These changes in bowel
motility are likely due to alterations in the autonomic
nervous system outflow to the intestine.
Increased gut sensitivity. There has been compelling
evidence that IBS patients have enhanced perception of
bowel (visceral) stimuli such as food or distensions of the
gut wall. The initial clinical observations that led to the
hypothesis that patients with IBS have visceral
hypersensitivity included the presence of recurring
abdominal pain as a principal symptom, the presence of
tenderness during palpation of the sigmoid colon (left
lower abdominal area) during physical examination in
many patients, and excessive pain often reported by
patients during endoscopic examination of the sigmoid
colon. Published studies measuring visceral sensitivity
suggest that a variety of abnormal sensations or
perceptions in relation to bowel stimuli may be more
frequent in IBS patients. At least two perceptual
alterations can be distinguished, a hypervigilance
(increased attention or vigilance) towards expected
aversive events arising from the bowel, and hyperalgesia
(lowered threshold to pain) which is inducible by sustained
painful visceral stimulation. These findings are paralleled
by similar findings of target system hypersensitivity in
other disorders such as fibromyalgia and myofascial pain
disorder. In contrast to their enhanced perception of
visceral pain, most IBS patients have normal or even
decreased pain sensitivity and tolerance for painful cold
and mechanical stimulation of somatic (skin and muscle).
However, there is a recent study that has demonstrated
increased somatic sensitivity to thermal heat in IBS
patients. Patients with IBS who also have co-existing
fibromyalgia have increased somatic sensitivity
comparable to patients with fibromyalgia alone.
Increased stress mediators in IBS. There is increasing
evidence to support the prominent role of stress in the
pathophysiology and in the clinical presentation of IBS
symptoms. There are few published reports on alterations
in stress mediators, such as catecholamines and cortisol to
stress or visceral stimulation in IBS. Several studies have
reported increased in catecholamines (norepinephrine and
epinephrine) and cortisol levels in IBS patients. However,
it remains to be determined whether these neuroendocrine
alterations play a direct role in gut function and symptom
generation.
Altered brain-gut communication in IBS. A unifying
hypothesis to explain the functional bowel disorders is that
they result from a dysregulation of the brain-gut axis. An
evolving theory is that normal gastrointestinal function
results from an integration of intestinal motor, sensory,
autonomic and CNS activity and GI symptoms may relate
to dysregulation of these systems. Brain imaging studies
such as functional magnetic resonance imaging (fMRI) and
positron emission tomography (PET) have been performed
in IBS patients to measure brain activation patterns to
visceral stimuli. These studies suggest that brain
activation responses to visceral stimuli are distinctly
different in IBS patients compared to healthy individuals.
IBS patients may have different emotional and cognitive
processing of sensory information from the gut compared
to healthy individuals.
Post-infectious IBS. Symptoms suggestive of IBS occur
in approximately 7-30% of patients following acute GI
infections, often persisting for years following complete
resolution of the infection. A large cohort study identified
a self-reported history of acute gastroenteritis as a major
risk factor for the development of IBS. Reported risk
factors for the development of post-infectious IBS include
female sex, the duration of the acute diarrheal illness and
the presence of sustained psychosocial stressors around the
time of infection. Post-infectious IBS is not restricted to a
particular organism and has been documented with a
variety of bacterial infections (Salmonella, Campylobacter
and E. coli) as well as parasitic infection. However, the
role of acute viral gastroenteritis in this condition is
unknown.
In post-infectious IBS, low grade GI inflammation or
immune activation may be a basis for altered motility,
and/or nerve and mucosal (lining of bowel) function of the
gut in IBS. Recent studies have also shown that in a subset
of unselected IBS patients (no documented history of a
preceding gut infection), there is evidence of increased
inflammatory cells in the colon mucosa. It remains to be
determined if altered gut immune function is a general
characteristic of IBS patients. The implication of stressful
life events in the development of post-infectious IBS
suggests a convergence of central (brain) and peripheral
(gut) mechanisms in the clinical presentation of this
syndrome.
Gender differences. In addition to IBS, many functional
GI disorders and other chronic visceral pain disorders (e.g.
interstitial cystitis and chronic pelvic pain) and somatic
pain disorders (e.g. fibromyalgia, myofascial pain
disorder) are more common in women than in men.
Increasing evidence suggests that gender differences exist
in the symptoms, pathophysiologic responses and response
to certain treatments in IBS. Female IBS patients are more
likely to be constipated, complain of abdominal distension
and certain extra-intestinal symptoms. Studies have also
supported an influential role of ovarian hormones (e.g.
estrogen and progesterone) on bowel function and pain
sensitivity which can in part explain the gender differences
in IBS. Several investigators have reported a variation in
GI symptoms during different phases of the menstrual
cycle, particularly increased abdominal pain and loose
stools at the perimenstrual (just prior to and at time of
menses) phase.
TREATMENT
Treatment of IBS includes both non-pharmacologic and
pharmacologic therapies. An important component of nonpharmacologic
treatment for IBS is a successful physicianpatient
relationship. The physician should strive to
establish effective bi-directional communication with the
patient, gain the patient's confidence with a concise,
appropriate medical evaluation and offer reassurance and
education that IBS is a real medical condition with a
potential impact on health related quality of life but
without significant long/term health risk. Some IBS
patients, especially those presenting with new onset of
symptoms, express relief that their symptoms are not
caused by a serious condition such as malignancy. Other
components of non-pharmacologic treatment of IBS
include diet recommendations, lifestyle modifications, and
psychosocial intervention if needed.
Patients with mild IBS symptoms comprise the most
prevalent group, and are usually treated by primary care
practitioners, rather than specialists. These patients have
less significant functional impairment or psychological
disturbance. These patients do not see a clinician very
often, and usually maintain normal daily activities.
Treatment is directed toward education, reassurance, and
achievement of a healthier lifestyle and occasional
medication. Dietary advice may include avoiding
offending foods which can trigger symptoms (e.g. lactose
or fructose products, fatty foods, caffeine, gas-producing
foods). Fiber supplementation has been shown to be
effective for symptoms of constipation.
Pharmacologic therapy is best used in IBS patients with
moderate to severe symptoms refractory to physician
counseling and dietary manipulations. First line treatment
has traditionally been aimed at treating the most
bothersome symptom because of the lack of effective
treatment for the overall improvement of multiple
symptoms in IBS patients. However, new therapies for
IBS have been recently introduced and have been shown to
effectively treat multiple symptoms of IBS.
Anticholinergic/Antispasmodic agents. After fiber
preparations, antispasmodic agents are the next most
commonly prescribed group of medications for the
treatment of IBS. However, several studies do not provide
firm evidence that anticholinergic agents are efficacious in
the IBS population as a whole. Only a few of these
antispasmodics have been shown to be more effective than
placebo in relieving abdominal pain in high quality clinical
IBS trials but these are not currently available in the U.S.
Antidiarrheal agents. In IBS patients with diarrhea,
antidiarrheal agents such as loperamide and diphenoxylate
can be effective in decreasing bowel movement frequency,
improving stool form by enhancing intestinal water and ion
absorption, and increasing anal sphincter tone at rest.
These physiologic actions seem to explain the
improvement in diarrhea, urgency, and fecal soiling
observed in patients with IBS. These medications do not
typically relieve abdominal pain and may cause
constipation.
Psychotropic medications. The rationale of using this
class of drugs in IBS may relate to several factors, such as
the prominent co-morbidity of IBS with psychologic
distress symptoms and the effects of these agents on gut
motility and pain sensation. Among the classes of
antidepressant medications, the tricyclics have been most
extensively evaluated in IBS. At lower doses than those
usually used to treat depression (starting at 10 mg and up
to 75 mg nightly), amitriptyline and desipramine have been
found to be significantly more effective than placebo in
patients with IBS. Antidepressants have analgesic (pain
relief) properties, which may benefit patients
independently of the psychotropic effects of the drugs.
Treatment with tricyclics should begin with low doses
(e.g., 10 mg/day) and increased as needed up to full
therapeutic doses. Selective serotonin reuptake inhibitors
(SSRIs, e.g. paroxetine, citalopram) and selective serotonin
and noradrenergic reuptake inhibitors (SNRIs, e.g.
venlafaxine) have not been well studied for treatment of
IBS, and are more expensive, but have less side effects
than tricyclics and empirically may help reduce painful
symptoms and improve general well-being and quality of
life.
Novel serotonin agents. The prominent role of serotonin
in GI motility and sensation has led to the development of
novel serotonin agents such as alosetron and tegaserod in
the treatment of IBS. Most of serotonin (also known as 5-
HT) in the body resides in the bowel wall within
enterochromaffin cells lining the gut (mucosa) and nerve
cell bodies. Serotonin is released from the
enterochromaffin cells and acts on receptors on the nerves
within the bowel wall. These nerves may be part of the
nervous system which resides completely within the bowel
wall, known as the enteric nervous system, or may be
nerves that transmit painful and non-painful information
by projecting from the bowel to the spinal cord and brain.
Activation of these nerves by serotonin leads to the release
of other neurotransmitters and through their actions, it
plays a major role in gut motility, secretion and sensation.
Alosetron (Lotronex), which is a 5-HT3 antagonist, has
been shown to be effective in relieving pain, normalizing
bowel frequency, and reducing urgency in non-constipated
IBS female patients. This medication was approved by the
FDA last year but was later withdrawn because of the
adverse events of constipation and ischemic colitis, the
latter being observed in 0.1%-1% of patients receiving the
medication. Future studies are being planned to determine
if there is a causal association of alosetron and ischemic
colitis. However, alosetron has recently been re-approved
and now is available for the treatment of women with
severe diarrhea-predominant IBS under the Restricted Use
Program. Alosetron is indicated only for women with
severe diarrhea-predominant IBS who have: chronic IBS
symptoms (generally lasting ≥ 6 months), no evidence of
anatomic or biochemical abnormalities of the GI tract
which could explain their symptoms, and failed to respond
to conventional therapy. IBS is considered severe if it
includes diarrhea and ≥ 1 of the following: frequent and
severe abdominal pain/discomfort, frequent bowel urgency
or fecal incontinence, or disability or restriction of daily
activities due to IBS. Physicians must enroll in the
Restricted Use Program in order to prescribe alosetron.
Patients should discuss with their physicians about the
risks and benefits of the medication before being
prescribed it. Both should sign the Patient-Physician
Agreement form. The starting dose of alosetron is now 1
mg orally once daily. If the patient does not experience
complete relief of their symptoms after 1 month, the dose
can be increased to 1 mg orally twice daily which was the
originally approved dose. Any patient who experiences
increased abdominal pain, blood in their stool and/or
constipation should immediately stop their medication and
contact their physician.
Tegaserod (Zelnorm) is a partial 5-HT4 agonist, which
has been shown to be effective in relieving the global
symptoms of IBS with constipation. It has been recently
approved for the treatment of IBS with constipation in
women. Tegaserod has been shown to accelerate GI transit
time in IBS patients and therefore would increase stool
frequency, and increase electrolyte secretion in the bowel
and thus improve stool form. In addition to its motility
enhancing properties, tegaserod has been shown to have
pain inhibitory properties in animal studies and therefore
may reduce abdominal pain although human studies are
needed to confirm this effect. Unlike other currently
available medications for IBS with constipation, tegaserod
appears to be effective in treating the multiple symptoms
of IBS. The subject's global assessment of relief of IBS
symptoms, change in number of bowel movements,
abdominal pain and bloating are all reportedly improved in
female patients with IBS with constipation taking
tegaserod as compared to placebo. The only adverse events
which were seen at a small but significantly higher rate in
patients taking tegaserod compared to placebo were
headache and transient diarrhea.
Psychological treatments. Referral for psychological
treatment can be recommended as part of a multicomponent
treatment program to help the patient better
manage the symptoms, or to address psychosocial
difficulties (e.g., abuse, loss) that may be interfere with
daily function and ability to cope with the illness. In
general, these treatments are reserved for patients with
moderate to severe symptoms, particularly if they
experience psychological distress. However, the patient
must be motivated and see this type of treatment as
relevant to their personal needs. Psychological treatments
used to treat IBS include psychotherapy (dynamic and
cognitive-behavioral therapy), relaxation therapy,
hypnotherapy, and biofeedback therapy. Psychological
treatments can also be combined. Review of well-designed
treatment studies of IBS supports the superiority of
psychological treatment over conventional medical
therapy. Follow-up studies (duration 9-40 months), have
demonstrated that psychological treatment maintained
superiority over placebo, indicating that these methods
have lasting value. The choice of treatment will depend on
patient requirements, available resources and the
experience of the therapist.
CONCLUSIONS
IBS is a common, chronic disorder characterized by
exacerbations and remissions, which presents with
symptoms of abdominal pain and/or discomfort and altered
bowel habits. It has a chronic relapsing course and can
overlap with other functional GI (dyspepsia) and non-GI
(fibromyalgia) disorders.
The clinical diagnosis of IBS is based on identifying
symptom criteria with a "positive diagnosis" and excluding
organic disease with minimal diagnostic evaluation.
Clinicians should feel secure with the diagnosis of IBS, if
made properly, because it is rarely associated with other
explanations for symptoms. Although there are many
expensive and sophisticated tests available for the
evaluation of IBS symptoms, these are generally not
needed for patients with typical symptoms and no features
suggestive of organic diseases.
An integrated diagnostic and treatment approach first
requires an effective physician-patient relationship. A
careful history will also identify the need for diagnostic
studies and treatments as determined by the nature and
severity of the predominant symptoms, and the degree and
extent of influencing psychosocial and other factors.
The fact that definite structural or biochemical
abnormalities for these disorders cannot be detected with
conventional diagnostic techniques does not rule out the
possibility that neurobiological alterations will eventually
be identified to explain fully the symptoms of most
functional disorders. Examples of such a shift in
perspective from symptom-based disorders without
detectable abnormalities to medically treatable diseases
based on specific neurobiological alterations include
affective disorders (depression, anxiety) and migraine
headaches. Similar to other chronic illnesses, a
multicomponent model that involves physiologic,
affective, cognitive, and behavioral factors can be
formulated for IBS. Although all factors are closely
interconnected, the importance of individual factors in the
generation of IBS symptoms may greatly vary between
individuals. Physiologic factors implicated in the
generation of IBS symptoms include hypersensitivity of
the GI tract to normal events, autonomic dysfunction
including altered intestinal motility response to stress and
food intake, alterations in fluid and electrolyte handling by
the bowel, and alterations in sleep.
Many of the traditional therapies have been used to treat
specific IBS symptoms because they have not been shown
to significantly relieve global symptoms, which would
improve an overall sense of well-being. However, the
discovery of novel serotonergic agents such as tegaserod
and alosetron have been shown to be effective in treating
global symptoms in patients with IBS compared with
placebo. More recently published studies evaluating the
efficacy of antidepressants, such as tricyclics and SSRIs,
suggest that these medications may help improve general
well-being in addition to treating psychological comorbidity
in affected individuals but further studies are
needed. Psychological and behavioral therapies have also
been showed to be effective for IBS however it potentially
can be limited by the availability of experienced therapists.
Instituting a multidisciplinary approach using nonpharmacologic
and pharmacologic therapeutic modalities
may result in the most effective outcome. Future studies
will further enhance our understanding of this condition
and lead to newer, more effective treatments.

http://www.ibs.med.ucla.edu/PDFs/IBSReviewArticle.pdf

This has nothing to do with me at all these are not my beliefs, like you use your beliefs, these are evidence based peer reviiew studies on millions of IBS pateints around the world, verse your persceptipn and you called IBS a catch all diagnoses, which is wrong from the start.

And while you may have been helped from diet, many IBSers are not totally helped by diet.

You have no idea what altered motility, viceral hypersensivity, rectal hypersenisvity and altered brain gut axis even means in IBS. Even if candida over growth existed at all, it can't physically cause the SPECIFC CLUTER of IBS symptoms used to diagnose IBS, absent ANY organic diseases.

IBS is NOT an infection, which you don't understand either.

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My website on IBS is www.ibshealth.com

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