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Gender, Age, Society, Culture, and the Patient's Perspective in IBS new
      #263245 - 05/13/06 03:16 PM
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Gastroenterology. 2006 May;130(5):1435-1446.

Gender, Age, Society, Culture, and the Patient's Perspective in the Functional Gastrointestinal Disorders.

Chang L, Toner BB, Fukudo S, Guthrie E, Locke GR, Norton NJ, Sperber AD.

CNS/WH: Center for Neurovisceral Sciences and Women's Health; Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California.

Patients with functional gastrointestinal disorders (FGID) often experience emotional distress, a perceived lack of validation, and an unsatisfactory experience with health care providers. A health care provider can provide the patient with a framework in which to understand and legitimize their symptoms, remove self-doubt or blame, and identify factors that contribute to symptoms that the patient can influence or control. This framework can be strengthened with the consideration of various important factors that impact FGID but are often overlooked. These include gender, age, society, culture, and the patient's perspective. There is evidence for sex- and gender-related differences in FGID, particularly irritable bowel syndrome (IBS). Whereas the majority of FGID, including IBS, bloating, constipation, chronic functional abdominal pain, and pelvic floor dysfunction, are more prevalent in women than men, functional esophageal and gastroduodenal disorders do not appear to vary by gender. Limited studies suggest that sex differences in visceral perception, cardioautonomic responses, gastrointestinal motility, and brain activation patterns to visceral stimuli exist in IBS. Gender differences in social factors, psychological symptoms, and response to psychological treatments have not been adequately studied. However, there appears to be a greater clinical response to serotonergic agents developed for IBS in women compared to men. The impact of social and cultural factors on the meaning, expression, and course of FGID are important. The prevalence of IBS appears to be lower in non-Western than Western countries. Although further studies are needed, the existing literature suggests that they are important to consider from both research and clinical perspectives.

PMID: 16678557 [PubMed - as supplied by publisher]

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16678557&query_hl=7&itool=pubmed_docsum

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Introduction to IBS Constipation - the Problem new
      #263363 - 05/14/06 04:57 PM
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From Medscape Gastroenterology

IBS and Chronic Constipation Expert Column

Advances in the Pathophysiology of IBS and Chronic Constipation

Posted 04/27/2006

Michael D. Gershon, MD

Introduction -- The Problem

The irritable bowel syndrome (IBS) and chronic constipation are aggravating. The aggravated include patients, physicians, drug companies, and regulatory authorities. Patients suffer and their quality of life is impaired.[1-4] Nontraditionally, the effect on quality of life is worse in younger than older individuals.[5]

This suffering and unhappiness is transferred to physicians who must choose between traditional therapies with little evidence of benefit and modern drugs that they suspect are only slightly more effective than placebos and which may exert frightening side effects, such as ischemic colitis.[6-8] Physicians must also diagnose IBS, not satisfyingly with a blood test or biopsy, but as a symptom complex, based on the well-accepted Rome II criteria,[9-11] about which nongastroenterologists unfortunately know little.[12]

Drug companies see chronic constipation and IBS as a potentially lucrative market because of their wide prevalence (affecting respectively up to 15% and 20% of the population),[5,13-16] but they have been frustrated by attitudes of regulatory agencies. Regulatory agencies see neither IBS nor chronic constipation as life-threatening and tend to trivialize their symptoms as "lifestyle" complaints. Moreover, while it is easy to document the high costs associated with IBS and chronic constipation,[6,14,16] these costs are not borne by governments, but by patients and society. Potential efficacy of a drug is thus downplayed in favor of safety.

Medscape Gastroenterology. 2006;8(1) ©2006 Medscape

http://www.medscape.com/viewarticle/530404?src=mp




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Cytokines May Provide Marker for Irritable Bowel Syndrome new
      #263364 - 05/14/06 05:04 PM
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Cytokines May Provide Marker for Irritable Bowel Syndrome

NEW YORK (Reuters Health) Mar 03 - Patients with irritable bowel syndrome (IBS) have an overactivation of the hypothalamic-pituitary-adrenal axis and an increase of proinflammatory cytokines, according to researchers.

"Irritable bowel syndrome is a functional disorder with an etiology that has been linked to both psychological stress and infection," Dr. Timothy G. Dinan, of University College Cork, Ireland, and colleagues write in the February issue of Gastroenterology.

The researchers hypothesized that IBS is "an inflammatory disorder sustained by the hypothalamic-pituitary-adrenal axis." Of 151 subjects included in their study, 76 had IBS and 75 served as controls.

Cytokine levels were measured in 49 patients and 48 controls. A subset of 21 patients and 21 controls also underwent a corticotropin-releasing hormone stimulation test and measurement of adrenocorticotropic hormone and cortisol levels. A dexamethasone challenge was performed in the remaining 27 patients and 27 controls.

All IBS subgroups (diarrhea predominant, constipated, and alternators) had elevated levels of cortisol (p < 0.05) and the proinflammatory cytokines interleukin (IL)-6 and IL-8 (p < 0.001). The most marked elevation was observed in the constipated subgroup. No significant alterations in IL-10 were found.

IBS patients experienced an exaggerated release of both adrenocorticotropic hormone and cortisol after corticotropin-releasing hormone infusion. The adrenocorticotropic hormone response (delta-ACTH) significantly (p < 0.05) correlated with the IL-6 levels. Patients and controls exhibited a similar suppression of cortisol after a dexamethasone challenge.

"The elevation in proinflammatory cytokines may be centrally driven, as in the case of other biopsychosocial disorders," Dr. Dinan and colleagues note. They conclude that "the cytokine alterations described are worthy of exploration as a potential biomarker, and future studies should focus on the factors that drive the elevation."

Gastroenterology 2006;130:304-311.

http://www.medscape.com/viewarticle/524796



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Genetic cause for irritable bowel syndrome new
      #266192 - 05/29/06 01:48 PM
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Genetic cause for irritable bowel syndrome

LOS ANGELES, May 25 (UPI) -- Researchers suggest there is a possible genetic basis for irritable bowel syndrome, which affects nearly one in five U.S. adults.

IBS -- characterized by abdominal pain or cramping and changes in bowel function, including bloating, gas, diarrhea and constipation -- accounts for more than one of every 10 doctor visits in the United States.

"Because we don't understand the causes for the symptoms of IBS, it is difficult to identify a definitive therapy," says Dr. Yuri Saito, a Mayo Clinic gastroenterologist and the study's lead investigator. "This study was one of the first steps in getting at the root of the problem and determining whether there could be a genetic basis for the disorder."

Saito said individuals with IBS estimated that 20 percent of their first-degree relatives had IBS, while those relatives who participated in the study self-reported that 46 percent were actually affected by the disorder.

The control group estimated that 4 percent of their first-degree relatives had IBS, but when the relatives themselves were surveyed, 25 percent were affected, according to the finding reported at Digestive Disease Week 2006 in Los Angeles.

© Copyright 2006 United Press International, Inc. All Rights Reserved

http://www.upi.com/ConsumerHealthDaily/view.php?StoryID=20060525-122128-5575r

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Determinants of Healthcare-Seeking Behaviour in IBS new
      #267539 - 06/04/06 11:48 AM
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Determinants of Healthcare-Seeking Behaviour in IBS

From Alimentary Pharmacology & Therapeutics

R. E. Williams,* C. L. Black,† H.-Y. Kim,‡ E. B. Andrews,§ A. W. Mangel,§ J. J. Buda,§ & S. F. Cook,*

Aliment Pharmacol Ther. 2006;23(11):1667-1675. ©2006 Blackwell Publishing

Discussion
Our finding that 49% of IBS subjects in our sample had sought medical care for abdominal symptoms in the past year is higher than previous US population-based studies, which report consultation rates for IBS symptoms in the past 12 months of 14-25%.[1, 11, 19] However, our study likely represents a subset of IBS patients with more severe disease because the study design necessitated that all subjects fulfil a modified version of the Rome II criteria for a period of at least 2 years. We found that females were more likely than males to receive a diagnosis of IBS by a doctor despite the fact that males sought medical care for their abdominal symptoms more frequently than females. This finding has not been previously reported in the literature and is in contrast to a report by Borum,[20] who conducted a survey of internal medicine doctors and found that doctors perceive IBS as easier to diagnose in men than in women. Several researchers have reported that the Manning and Rome criteria are less sensitive in diagnosing IBS in men than in women,[21, 22] but our results show that doctors are less likely to diagnose IBS in men than in women even when the men have abdominal symptoms which fulfil criteria for IBS.

More than half (55%) of subjects that had sought health care in the past year reported that the purpose of their most recent doctor visit was to get treatment for symptoms because previous treatment was unsatisfactory. Patient dissatisfaction with IBS therapy is consistent with several recent literature reviews of IBS treatment, which found limited or no evidence for the efficacy of current IBS medications, with the possible exception of the newer serotenergic agents, which are currently only approved for use in a small subset of patients with IBS.[23-25]

While abdominal pain or discomfort was the most common reason for seeking care among the healthcare seekers in our study, the severity of abdominal pain was not significantly different between the healthcare seekers and those that did not seek health care for their IBS. Other studies have reported an association between the frequency and/or severity of abdominal pain and healthcare-seeking behaviour,[1, 5-11] but we likely did not find an association in our study because all subjects must have experienced some degree of abdominal pain in order to meet our criteria for IBS and must have experienced this symptom for at least 2 years in order to be included in the study.

While a few studies have reported symptoms other than abdominal pain such as bloating,[9, 10] mucus per rectum, urgency, incomplete evacuation[9] and diarrhoea[5, 9] to be associated with seeking health care for IBS, we evaluated numerous abdominal symptoms and found associations only with decreased bowel movements in females and abdominal cramping in males.

Although we found differences in males and females regarding specific factors motivating healthcare-seeking behaviour, our results in both sexes are consistent with the finding that the presence of medical conditions in addition to IBS is associated with seeking health care for IBS symptoms. Females suffering from dyspepsia and pelvic pain were more likely to seek health care for IBS than subjects without these comorbid conditions. In contrast to several other studies that did not report an association between age and healthcare-seeking behaviour,[1, 6, 9] we found that older females were more likely to seek medical care for IBS than younger females. This is probably because older subjects are more likely to suffer from comorbid conditions that we did not measure, such as hypertension or cancer, which put them in frequent contact with the medical system. Because we limited our original cohort to individuals between the ages of 18 and 65 years, we could not evaluate healthcare-seeking behaviour above our age limits. In men, having a working status of disabled is along a similar vain, as the disabling condition also likely causes the subject to have frequent medical visits.

Earlier studies of healthcare-seeking behaviour and IBS concluded that symptoms of psychological distress are unrelated to IBS, but influence which patients will seek medical care for the condition.[4, 5] Our results are contrary to this finding. In a previous analysis, we found that subjects that continued to have IBS over a 2-year period had more psychological impairment that subjects that did not continue to have IBS during the follow-up period.[26] However, among those subjects that continued to meet the IBS criteria there was no difference in mental health status between healthcare seekers and healthcare non-seekers. Other recent studies have also found no association between psychological morbidity and seeking health care for IBS.[6, 27]

While we did not find an association with mental illness, we did find that the extent to which the subjects' IBS affected their physical and social functioning, as reflected in the IBSQOL scores, was important in distinguishing between those subjects that sought medical care for their IBS symptoms and those that did not. Greater interference of gastrointestinal symptoms with work and activities[6] and reduced IBS-specific quality of life[12] have previously been identified as predictors of health care use among IBS subjects. In our study, quality of life issues had a greater impact on the healthcare-seeking behaviour of males than that of females.

Among females in our study, healthcare seeking was related to worry that their abdominal symptoms were related to cancer or other serious illness. Gick and Thompson[28] found that healthcare seeking among IBS subjects was associated with concern about the meaning of IBS symptoms but not anxiety trait in general. This is consistent with our finding that healthcare seekers were more likely than non-seekers to have anxiety regarding their IBS symptoms but not psychological dysfunction otherwise. Other studies have reported concern about the serious nature of their symptoms[10] and anxiety about abdominal pain[29] to be more prevalent in healthcare seekers than non-seekers, but these studies also report greater levels of psychological distress among healthcare seekers. The latter study included patients with all functional gastrointestinal disorders, not solely IBS.

In conclusion, we found that healthcare-seeking behaviour among IBS subjects were determined by the presence of comorbid medical conditions and the extent to which their IBS symptoms affected their physical and mental well-being rather than by the nature of their physical symptoms or any underlying psychological morbidity.




http://www.medscape.com/viewarticle/532484_1

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Rome III Diagnostic Criteria new
      #268981 - 06/12/06 04:16 PM
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Gastroenterology April 2006 Issue:
Rome III
Functional Gastrointestinal Disorders

© 2006 by the American Gastroenterological Association Institute

Table of Contents

The Functional Gastrointestinal Disorders and the Rome III Process
D. A. Drossman

Fundamentals of Neurogastroenterology: Basic Science
D. Grundy, E. D. Al–Chaer, Q. Aziz, S. M. Collins, M. Ke, Y. Taché,
and J. D. Wood

Applied Principles of Neurogastroenterology: Physiology/Motility Sensation
J. E. Kellow, F. Azpiroz, M. Delvaux, G. F. Gebhart, H. R. Mertz,
E. M. M. Quigley, and A. J. P. M. Smout

Pharmacological and Pharmacokinetic Aspects of Functional Gastrointestinal Disorders
M. Camilleri, L. Bueno, F. de Ponti, J. Fioramonti, R. B. Lydiard, and J. Tack

Gender, Age, Society, Culture, and the Patient's Perspective in the Functional Gastrointestinal Disorders
L. Chang, B. B. Toner, S. Fukudo, E. Guthrie, G. R. Locke, N. J. Norton,
and A. D. Sperber

Psychosocial Aspects of the Functional Gastrointestinal Disorders
R. L. Levy, K. W. Olden, B. D. Naliboff, L. A. Bradley, C. Francisconi,
D. A. Drossman, and F. Creed

Functional Esophageal Disorders
J. P. Galmiche, R. E. Clouse, A. Bálint, I. J. Cook, P. J. Kahrilas,
W. G. Paterson, and A. J. P. M. Smout

Functional Gastroduodenal Disorders
J. Tack, N. J. Talley, M. Camilleri, G. Holtmann, P. Hu, J.-R. Malagelada,
and V. Stanghellini

Functional Bowel Disorders
G. F. Longstreth, W. G. Thompson, W. D. Chey, L. A. Houghton, F. Mearin,
and R. C. Spiller

Functional Abdominal Pain Syndrome
R. E. Clouse, E. A. Mayer, Q. Aziz, D. A. Drossman, D. L. Dumitrascu,
H. Mo¨nnikes, and B. D. Naliboff

Functional Gallbladder and Sphincter of Oddi Disorders
J. Behar, E. Corazziari, M. Guelrud, W. Hogan, S. Sherman, and J. Toouli

Functional Anorectal Disorders
A. E. Bharucha, A. Wald, P. Enck, and S. Rao

Childhood Functional Gastrointestinal Disorders: Neonate/Toddler
P. E. Hyman, P. J. Milla, M. A. Benninga, G. P. Davidson, D. F. Fleisher,
and J. Taminiau

Childhood Functional Gastrointestinal Disorders: Child/Adolescent
A. Rasquin, C. Di Lorenzo, D. Forbes, E. Guiraldes, J. S. Hyams, A. Staiano,
and L. S. Walker

Design of Treatment Trials for Functional Gastrointestinal Disorders
E. J. Irvine, W. E. Whitehead, W. D. Chey, K. Matsueda, M. Shaw, N. J. Talley,
and S. J. O. Veldhuyzen van Zanten

The Road to Rome
W. G. Thompson


http://www.romecriteria.org/GastroIssue.htm

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Prevalence and Incidence of Chronic Constipation new
      #272687 - 07/05/06 05:35 PM
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Prevalence and Incidence

Chronic constipation is a highly prevalent disorder affecting approximately 15% of the US population. Two studies presented during this year's DDW meeting addressed the prevalence and incidence of chronic constipation. The first was a multinational study conducted by Wald and colleagues involving 13,958 persons from 7 different countries. The study authors demonstrated that constipation is highly prevalent worldwide, with rates ranging from 14% to 18% in France, Brazil, South Korea, and the United States. It is interesting to note that rates in 3 European countries were lower (5% in Germany and 8% in both Italy and the United Kingdom), although the investigators did not comment on why this may be. In all 7 countries, constipation was more prevalent in individuals aged 60 years and older. This study also reported that 30% to 40% of all persons who were constipated had used a laxative within the past year, and that laxative use was consistently higher in those older than 60 years. These findings extend previously published data from the United States and Canada showing that the prevalence of constipation is high and that a large number of patients require medication for their chronic condition.

http://www.medscape.com/viewarticle/536306?src=mp

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Treatment of Functional Diarrhea new
      #274375 - 07/17/06 01:54 PM
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Curr Treat Options Gastroenterol. 2006 Jul;9(4):331-342.

Treatment of Functional Diarrhea.

Dellon ES, Ringel Y.

Department of Medicine, Division of Gastroenterology and Hepatology and Center for Functional GI and Motility Disorders, University of North Carolina School of Medicine, 4107 Bioinformatics Building, CB #7080, 130 Mason Farm Road, Chapel Hill, NC 27599-7080, USA. ringel@med.unc.edu.

Functional diarrhea (FD), one of the functional gastrointestinal disorders, is characterized by chronic or recurrent diarrhea not explained by structural or biochemical abnormalities. The treatment of FD is intimately associated with establishing the correct diagnosis. First, FD needs to be distinguished from diarrhea-predominant irritable bowel syndrome (IBS), in which, unlike in FD, abdominal pain is a primary diagnostic criterion. Next, FD must be differentiated from the myriad organic causes of chronic diarrhea. Unlike IBS, in which a positive diagnosis can be made with an acceptable level of confidence using symptom-based criteria and minimal testing, the diagnosis of FD is still primarily a diagnosis of exclusion. Thus, the onus is on the physician to eliminate potential underlying causes, both common and uncommon, in the proper clinical setting. Once the diagnosis has been established, the clinician and patient should first focus on identifying, eliminating, and/or treating aggravating factors. These may include physiologic factors (eg, small bowel bacterial overgrowth), psychological factors (eg, stress and anxiety), and dietary factors (eg, carbohydrate malabsorption). Thereafter, appropriate treatment for functional diarrhea may be instituted. Treatment options include dietary and lifestyle modification, pharmacologic therapies, and alternative modalities. Although many of these strategies have been studied in IBS, almost none of them has been examined specifically in FD. Furthermore, given the poorly understood pathophysiologic basis of FD, these treatments primarily target a patient's symptoms and presumed altered physiology rather than underlying etiologic mechanisms. Therefore, we stress that treatment must be approached in an individualized manner and that dietary and pharmacologic therapies should be part of a comprehensive therapeutic approach in which education and reassurance form the foundation. In general, we attempt to remove dietary triggers and recommend increased fiber intake. We then add anticholinergic, antispasmodic, antimotility, and antidiarrheal agents as the first line of pharmacotherapy. Should a patient not respond to these, and for patients who have a significant degree of psychological dysfunction, central acting agents, including antidepressants and/or anxiolytics, may be beneficial. During the treatment period, we also recommend that physicians keep an open mind. If signs or symptoms that suggest an ongoing or previously unrecognized organic process develop, then a re-evaluation of the clinical picture is indicated.

PMID: 16836952 [PubMed - as supplied by publisher]

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=Abstract&list_uids=16836952&query_hl=22&itool=pubmed_docsum

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IBS -- Review and What's New - Abstract and Introduction
      #277290 - 08/05/06 03:58 PM
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From Medscape General Medicine™

MedGenMed Gastroenterology
IBS -- Review and What's New
Posted 07/26/2006


Amy Foxx-Orenstein, DO, FACG, FACP

Abstract
Irritable bowel syndrome (IBS) is a highly prevalent gastrointestinal motility disorder broadly characterized by abdominal pain/discomfort associated with altered bowel habits. The chronic and bothersome nature of IBS symptoms often negatively affects patient quality of life and activity level and places a substantial economic burden on patients and the healthcare system. Advances in research have led to a greater understanding of the underlying pathophysiology of IBS, particularly regarding the role serotonin plays in the gastrointestinal tract; the development of stepwise, symptom-based diagnostic strategies that allow for a diagnosis of IBS to be made without the need for extensive laboratory testing; and the development of treatment options targeting underlying pathophysiologic mechanisms that provide relief of the multiple symptoms associated with IBS. This review highlights recent advances in research and discusses how these findings can be applied to daily clinical practice.

Introduction

IBS -- a complex, multifaceted condition broadly characterized by abdominal pain/discomfort associated with altered bowel habits -- is among the most prevalent gastrointestinal (GI) motility disorders. Prevalence estimates for IBS range from 3% to 20%, with most estimates in North America ranging from 10% to 15%.[1-3] Women are affected by IBS more often than men (2:1 in the community setting and 3:1 to 4:1 in the tertiary care setting).[2] IBS-related symptoms are often chronic and bothersome, negatively affecting patient activities of daily living (eg, sleep, leisure time), social relationships, and productivity at work or school.[4-6] Patients with IBS typically score lower than population norms or those with other chronic GI and non-GI disorders on measures of quality of life.[7-10] IBS also puts a heavy economic burden on patients, employers, and the healthcare system, resulting in more than $10 billion in direct costs (eg, from office visits, medications) and $20 billion in indirect costs (eg, through work absenteeism and reduced productivity) each year.[11-14]

Advances in research during the past several decades have provided insight into the underlying pathophysiology of IBS, particularly the role of serotonin in the GI tract; the development of stepwise, symptom-based diagnostic strategies; and the development of targeted treatment options. This review discusses recent advances in research and explores how these findings can be applied in the clinical practice setting.

Amy Foxx-Orenstein, DO, FACG, FACP, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.

Medscape General Medicine. 2006;8(3) ©2006 Medscape

http://www.medscape.com/viewarticle/532089_1

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Making a Positive Diagnosis of IBS
      #279018 - 08/19/06 11:56 AM
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Making a Positive Diagnosis of IBS
From Medscape General Medicine™

MedGenMed Gastroenterology
IBS -- Review and What's New
Posted 07/26/2006

Amy Foxx-Orenstein, DO, FACG, FACP

IBS is not associated with any definitive biochemical, structural, or serologic abnormalities that define its presence. The hallmark feature of IBS is abdominal pain or discomfort associated with altered bowel habits, and, often, the abdominal pain prompts patients to seek medical care. Because the symptoms of IBS are common to a number of other GI conditions, IBS was long considered a "diagnosis of exclusion," leading to excessive testing of patients with characteristic symptoms. Fortunately, advances in research have led to the development of symptom-based approaches, aimed at standardizing IBS patient subgroups, and the development of consensus guidelines advocating a positive diagnosis of IBS based primarily on the pattern and nature of symptoms, without the need for excessive laboratory testing.[2,15]

In 1978, Manning and colleagues[16-18] proposed diagnostic criteria for IBS that were found to be reasonably sensitive and specific. More recently, an international group of experts in functional GI motility disorders convened to develop symptom-based criteria, known as the Rome criteria (Rome I,[19] Rome II,[15] and Rome III[20,21]), to better define and provide tools by which a positive diagnosis of these disorders could be made. The Rome I criteria for IBS were shown to be sensitive and specific.[22,23] The Rome II criteria, published in 1999,[15] were intended to simplify the more complex Rome I criteria by better defining the nonconsecutive, multisymptom nature of this disorder. Clinical studies validating the Rome II criteria are beginning to emerge.[24] Consensus has not yet been reached regarding which of the Rome criteria are more sensitive for identifying IBS patients in clinical practice[22,24,25] and which of the 2 more accurately estimates the prevalence of IBS.[17,26,27] A recent US population-based follow-up study found that the Rome II criteria were limited in capturing the fluctuating nature of IBS. Over a 2-year period, patients experienced symptoms episodically, including abdominal pain; the absence of pain at time of follow-up excluded many patients from meeting IBS criteria.[28] Overall, the Rome I and II criteria are considered useful for standardizing enrollment of patients into clinical trials. However, many clinicians believe that these criteria are too restrictive for use in clinical practice. The American College of Gastroenterology (ACG) Functional GI Disorders Task Force suggests using a broader definition of IBS: abdominal discomfort associated with altered bowel habits.[2] The Rome III working team met in the fall of 2004; updated criteria were published in April 2006. The principle difference between Rome III guidelines as compared with the Rome II criteria lies in the less restrictive timeframe for symptoms. Whereas the Rome II criteria require symptoms to be present for at least 12 weeks (not necessarily consecutive) in the past 12 months, the Rome III criteria require symptoms to originate for 6 months prior to diagnosis, and be currently active (ie, patient meets criteria) for 3 months. The categorization of IBS patients into the constipation, diarrhea, or mixed subtypes has also been revised (based on stool consistency).[20] It is hoped that the less restrictive symptom timeframe requirements of the Rome III guidelines will make them more clinically practical than the previous iterations.

The Rome III criteria, in conjunction with careful history-taking (medical, family, and medication) and thorough physical examination, can be applied as part of the stepwise, symptom-based approach to diagnosing IBS (Figure). The presence of alarm features (eg, rectal bleeding, history of colon cancer or inflammatory bowel disease) potentially indicative of organic disease necessitates further evaluation.[2]


Until recently, the role of diagnostic testing in diagnosing IBS was a topic of continuing debate. Recent evidence indicates that when a patient meets the Rome criteria, and has no features suggestive of organic disease, the pretest probability of making an accurate diagnosis of IBS based primarily on symptoms is high. In a systematic review conducted by Cash and colleagues,[32] the pretest probability of inflammatory bowel disease, colorectal cancer, or infectious diarrhea was found to be less than 1% in patients meeting symptom-based criteria for IBS. Extensive diagnostic testing rarely identifies organic GI disease in these patients. However, one exception is celiac disease: the pretest probability of celiac disease in patients meeting symptom-based criteria for IBS was 10 times higher than that in the general population.[32] Recently, testing for celiac disease in patients with suspected IBS with diarrhea (IBS-D) has been shown to be most financially feasible in areas in which the prevalence of celiac disease is at least 8%.[33] These findings were supported by the evidence-based recommendation made by the ACG Functional GI Disorders Task Force, whereby they concluded that there is insufficient evidence to recommend the routine performance of diagnostic testing in patients who meet symptom-based criteria for IBS (eg, Manning, Rome I, Rome II) -- therefore, supporting a symptom-based approach to making a positive diagnosis of IBS.[2]

The extent to which this guidance is implemented into clinical practice is based on clinical judgment and experience of the physicians. Most physicians agree that standard laboratory testing, such as complete cell blood count, chemistry panel, and erythrocyte sedimentation rate, should be performed in patients with symptoms of IBS. However, if these studies have been performed recently, after symptoms emerged, there is no need to repeat them. For a patient with IBS symptoms and no comorbid conditions, test results should all be within normal limits. Colonoscopy is generally not required in the absence of features indicative of organic disease (eg, family history of colon cancer), although it should be performed in individuals older than 50 years of age.[1] However, as mentioned previously, if the patient (regardless of age) underwent colonoscopy after the development of symptoms, a repeat test is not warranted. In addition to routine laboratory testing, thyroid function studies, ova and parasite examination, urinalysis, and breath tests for lactose intolerance may be considered. Globally, however, the value of diagnostic testing in IBS has not been established in patients who meet symptom-based criteria for IBS and who do not have symptoms indicative of organic disease; additional diagnostic testing does not increase the probability of detecting organic disease and does not alter the diagnosis of IBS once it is made.[32, 34-36]

A symptom-based diagnosis of IBS is durable. In a longitudinal study in which 75 patients were reevaluated 10 to 13 years after an initial IBS diagnosis, all patients still met the diagnostic criteria for IBS (Manning, Rome I, Rome II) and few had received an alternative diagnosis during that period.[37] In other studies with follow-up periods ranging from 3 to 5 years, development of organic disease occurred in less than 7% of patients initially given a diagnosis of IBS using the symptom-based approach.[38]

Historically IBS was considered a diagnosis by exclusion and was viewed as a purely psychosomatic condition. Within the past 2 decades, however, symptom-based diagnostic criteria have been established that allow physicians to positively and confidently diagnose IBS.

Amy Foxx-Orenstein, DO, FACG, FACP, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.

Medscape General Medicine. 2006;8(3) ©2006 Medscape


http://www.medscape.com/viewarticle/532089_2

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