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Diagnostic Yield of Alarm Features in Irritable Bowel Syndrome
      06/20/05 03:44 PM
HeatherAdministrator

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Diagnostic Yield of Alarm Features in Irritable Bowel Syndrome and Functional Dyspepsia

Hammer J, Eslick GD, Howell SC, Altiparmak E, Talley NJ
Gut. 2004;53(5):666-672

Objective: The diagnostic value of the addition of alarm symptoms in distinguishing functional from organic gastrointestinal disease remains uncertain. We aimed to establish the value of alarm features in differentiating between organic disease and irritable bowel syndrome (IBS) and functional dyspepsia (FD).
Methods: A total of 568 consecutive patients (63% female; mean age 44.7 years) completed a detailed symptom questionnaire and then received a complete diagnostic workup, as required. Questionnaire data were collected prospectively and audited retrospectively; the treating physician was blinded to the results of the questionnaires. Patients were coded and allocated to the following diagnostic groups: IBS, FD, organic diseases of the upper gastrointestinal tract, or organic diseases of the lower gastrointestinal tract. Logistic regression was used to identify the best subset of symptoms that discriminated organic disease from functional illness. Separate models compared IBS (n = 214) with diseases of the lower gastrointestinal tract (n = 66), and FD (n = 70) with diseases of the upper gastrointestinal tract (n = 250).
Results: Age (50 years at symptom onset: odds ratio (OR) 2.65 (95% confidence interval 1.4–5.0); p = 0.002) and blood on the toilet paper (OR 2.7 (1.4–5.1);p = 0.002) emerged as alarm features that discriminated IBS from lower gastrointestinal illness. A diagnosis of IBS was typically associated with female sex (OR 2.5 (1.3–4.6); p = 0.004), pain on six or more occasions in the previous year (OR 5.0 (2.2–11.1); p<0.001), pain that radiated outside of the abdomen (OR 2.9 (1.4–6.3); p = 0.006), and pain associated with looser bowel motions (OR 2.1 (1.1–4.2); p = 0.03). A model incorporating three Manning criteria and alarm features yielded a correct diagnosis of IBS in 96% and a correct diagnosis of organic disease in 52% of cases. Alarm features did not discriminate FD from upper gastrointestinal disease. Patients with FD were significantly more likely to report upper abdominal pain (OR 3.7 (1.7–8.3); p = 0.002) and significantly less likely to report aspirin use (OR 0.26 (0.1–0.6); p = 0.001). The predictive value of symptoms in diagnosing FD was only 17%.
Conclusions: Symptoms plus alarm features have a high predictive value for diagnosing IBS but the predictive value for a diagnosis of FD remains poor. Current criteria for the diagnosis of IBS should incorporate relevant alarm features to improve the diagnostic yield.

Summary: With the burgeoning costs of healthcare, there is ever-increasing pressure placed on the healthcare provider to use the most cost-effective strategy to diagnose and treat a particular health problem. Irritable bowel syndrome (IBS) and functional dyspepsia (FD) are among the most common diagnostic problems presenting the gastroenterologist with the conundrum of whether to perform extensive diagnostic testing or to treat empirically. However, the accuracy of the latter option (a diagnosis based purely on the presenting gastrointestinal symptoms) potentially places a considerable liability on the practitioner, who is subject to the level of confidence that can be placed in the diagnosis that is suspected. Many clinicians have suggested that the presence of "alarm features," such as bleeding, dysphagia, weight loss, vomiting, or later age at onset, may be more suggestive of the need for early diagnostic testing for organic disease. Therefore, the working hypothesis for this present study conducted by Hammer and colleagues was that taking an accurate history to evaluate the presence of alarm features and symptoms would increase the diagnostic potential and avoid unnecessary diagnostic procedures in patients with functional disease. The aim thereby was to further evaluate the yield of these "alarm features" that might suggest that functional disease (eg, IBS and FD) is less likely.

A total of 806 patients consulting a gastroenterology practice in Australia were studied. These patients were prospectively asked to fill out a questionnaire and data were retrospectively analyzed. Although there were no sample-size calculations performed for this study initially, the study authors provided a creditable effort to justify the power of the study by post hoc calculations, which suggest that the sample size was more than appropriate. All functional disorders were diagnosed based on the history and physical examination, as well as on the appropriate exclusionary diagnostic tests, including upper and lower endoscopy. The treating physicians were blinded to the results of the questionnaire. All results were then reviewed by at least one other gastroenterologist. If there were disparate opinions, the diagnosis was established by consensus.

Alarm features that discriminated IBS from organic disease were as follows: onset of symptoms at age > 50 years (odds ratio [OR], 2.7; 95% confidence interval [CI] 1.4-5.0; P = .002) and blood on the toilet paper (OR, 2.7; 95% CI, 1.4-5.1; P = .004). Factors predictive of IBS were: female sex (OR, 2.5; 95% CI, 1.3-4.6; P = .004), pain occurring 6 or more times in a year (OR, 5.0, 95% CI, 2.2-11.1; P < .001), pain radiation out of the abdomen (OR, 2.9; 95% CI, 1.4-6.3; P = .006), and pain associated with loose bowel movements (OR, 2.1; 95% CI, 1.1-4.2; P = .03). A model formulated incorporating the Manning criteria (abdominal pain relieved with bowel movements, pain associated with more frequent stools, sensation of incomplete evacuation, passage of mucus, abdominal distension) and alarm features yielded a correct diagnosis of IBS in 96% and organic disease in 52% of cases.

Only 1 of 16 alarm features discriminated upper gastrointestinal disease from FD. Patients with organic upper gastrointestinal disease were less likely to report decreased appetite (OR, 0.49; 95% CI, 0.26-0.91; P = .02). Patients with FD were more likely to report upper abdominal pain (OR, 3.7; 95% CI, 1.7-8.3; P = .002), and reported less aspirin use (OR, 0.26, 95% CI, 0.1-0.6; P = .001). The predictive value of symptoms in diagnosing FD was only 17%. The study authors concluded that alarm features have a high predictive value for the diagnosis of IBS, but not for FD.

Commentary: So what does this all mean? For IBS, it means that alarm features are the most important factors for establishing the diagnosis. In this study, the absence of alarm features correctly identified IBS in 93% of patients, while the addition of the Manning criteria improved this statistic by only an additional 3%. It is puzzling to me why the investigators used the Manning criteria (developed back in 1978). Clearly, attempts have been made to improve the diagnostic accuracy of IBS through the development of, and revisions in, the Rome criteria (Rome I and II). The clinician reader should be aware that this study may have some limitations. First, there were very few cancers identified, a finding that may reflect a referral bias to the evaluation site. Additionally, the study authors did not fully evaluate all alarm features, rather only those listed on the validated questionnaire employed in this study.

For the dyspepsia portion of this report, data presented suggest that a symptom-based diagnosis had a very poor predictive value. Hence, evaluation of alarm features fails to satisfactorily improve the diagnostic yield of symptoms of FD.

The work group for Rome III revisions will begin late in 2004. It is likely, as based on this study, that the Rome criteria will need to be expanded to include key alarm features for both IBS and FD. Although this should help the diagnostic accuracy for IBS, in contrast, the diagnosis of FD will likely remain as a diagnosis of exclusion. This study provides very weighted support for the recommendation that testing is generally not required in patients with positive symptom criteria for IBS and an absence of alarm features. For the diagnosis of FD, however, it remains caveat emptor.



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Section 1 of 2


David A. Johnson, MD, FACG, FACP, Professor of Medicine, Chief of Gastroenterology, Eastern Virginia School of Medicine, Norfolk, Virginia


Disclosure: David A. Johnson, MD, FACG, FACP, has disclosed that he has received grants for clinical research from AstraZeneca, Wyeth, TAP, BSC, and Novartis.


Medscape Gastroenterology 6(1), 2004. © 2004 Medscape


http://www.medscape.com/viewarticle/479783#a2

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09/22/05 04:35 PM
* IBS and Functional Dyspepsia: Different Diseases or a Single Disorder With Different Manifestations?
HeatherAdministrator
09/13/05 01:03 PM
* Increased Prevalence of Obesity in Children With Functional Constipation
HeatherAdministrator
09/13/05 12:45 PM
* Irritable Bowel Syndrome: Toward an Understanding of Severity
HeatherAdministrator
09/01/05 11:19 AM
* How Do Symptoms in Chronic Constipation and IBS With Constipation Differ?
HeatherAdministrator
08/22/05 04:51 PM
* Role of Carbon Dioxide-Releasing Suppositories in the Treatment of Chronic Functional Constipation
HeatherAdministrator
08/22/05 04:32 PM
* Physiological Mechanisms Underlying Perceptions of Nausea and Stomach Fullness
HeatherAdministrator
08/07/05 04:33 PM
* Gastrointestinal infections can have lasting consequences as IBS
HeatherAdministrator
08/07/05 04:08 PM
* Dyspepsia and Irritable Bowel Syndrome After a Salmonella Gastroenteritis Outbreak
HeatherAdministrator
07/24/05 02:48 PM
* Abdominal Radiography Not Useful in Constipated Children
HeatherAdministrator
07/24/05 02:30 PM
* IBS—The Irritation of Inflammation
HeatherAdministrator
07/24/05 02:16 PM
* Irritable Bowel Syndrome in the United States: Prevalence, Symptom Patterns and Impact
HeatherAdministrator
07/05/05 03:40 PM
* IBS: Improving Diagnosis, Serotonin Signaling, and Implications for Treatment
HeatherAdministrator
07/05/05 03:30 PM
* Neural Cross-Talk May Explain Overlap of Irritable Bowel, Interstitial Cystitis
HeatherAdministrator
07/05/05 03:11 PM
* Health Economics of IBS
HeatherAdministrator
07/05/05 03:01 PM
* Overlapping Upper and Lower Gastrointestinal Symptoms in Irritable Bowel Syndrome
HeatherAdministrator
06/20/05 03:52 PM
* Diagnostic Yield of Alarm Features in Irritable Bowel Syndrome
HeatherAdministrator
06/20/05 03:44 PM
* Colon Cancer Test Misses Growths in Women
HeatherAdministrator
06/05/05 05:56 PM
* Nongastrointestinal symptoms of irritable bowel syndrome
HeatherAdministrator
05/22/05 07:14 PM
* Partnering With Gastroenterologists to Evaluate Patients With Chronic Constipation
HeatherAdministrator
05/08/05 06:16 PM
* Impairment in Work Productivity and Health-related Quality of Life in Patients With IBS
HeatherAdministrator
05/08/05 06:11 PM
* Nerves, Reflexes, and the Enteric Nervous System: Pathogenesis of the Irritable Bowel Syndrome
HeatherAdministrator
05/08/05 06:06 PM
* What Does the Future Hold for Irritable Bowel Syndrome
HeatherAdministrator
05/08/05 06:02 PM
* Towards a better understanding of abdominal bloating and distension in functional GI disorders
HeatherAdministrator
04/24/05 03:40 PM
* IBS is a risk factor for GERD
HeatherAdministrator
04/10/05 06:25 PM
* New Recommendations for Treating Children With Chronic Abdominal Pain
HeatherAdministrator
03/28/05 01:59 PM
* Irritable bowel syndrome in developing countries
HeatherAdministrator
03/28/05 01:29 PM
* Stress and the gastrointestinal tract
HeatherAdministrator
03/28/05 01:27 PM
* Alternating Bowel Habit Subtype in Patients with Irritable Bowel Syndrome
HeatherAdministrator
03/28/05 12:28 PM
* Fecal Microbiota of Irritable Bowel Syndrome Patients
HeatherAdministrator
03/04/05 12:11 PM
* Post-infectious IBS in patients with Shigella infection
HeatherAdministrator
03/04/05 12:03 PM
* Surgical Treatment of Chronic Functional Constipation?
HeatherAdministrator
03/04/05 11:24 AM
* Chronic constipation in children
HeatherAdministrator
02/19/05 05:53 PM
* Intestinal infection and irritable bowel syndrome.
HeatherAdministrator
02/19/05 05:36 PM
* Overlap of GI symptom complexes in a US community
HeatherAdministrator
02/06/05 02:35 PM
* Magnetic pill tracking: a novel non-invasive tool for investigation of human digestive motility
HeatherAdministrator
02/06/05 02:27 PM
* The value of a general therapeutic approach in subjects with irritable bowel syndrome
HeatherAdministrator
02/06/05 02:22 PM
* Is Constipation Associated with Decreased Physical Activity in Normally Active Subjects?
HeatherAdministrator
02/06/05 02:18 PM
* High interdigestive and postprandial motilin levels in patients with the irritable bowel syndrome
HeatherAdministrator
02/06/05 02:12 PM
* 10% to 20% of older adults have IBS
HeatherAdministrator
01/23/05 05:05 PM
* Diagnostic Criteria for Irritable Bowel Syndrome - Family Practice Doctors Unaware of Guidelines
HeatherAdministrator
01/07/05 06:20 PM
* Stress Increases Visceral Sensitivity in IBS Patients
HeatherAdministrator
01/07/05 06:13 PM
* Treatment of irritable bowel syndrome with colonic pacing
HeatherAdministrator
01/07/05 05:53 PM
* Irritable bowel syndrome: colonoscopy painful and difficult?
HeatherAdministrator
01/07/05 05:50 PM
* Suicide in IBS patients emphasizes need for improvements in treatment
HeatherAdministrator
01/07/05 05:47 PM
* New Risk for Asthma, Allergy Found in the Gut
HeatherAdministrator
01/07/05 04:53 PM
* Salt intake and smoking play major roles in GERD
HeatherAdministrator
12/20/04 02:11 PM
* Constipation and Laxative Use Found to Increase Colon Cancer Risk
HeatherAdministrator
12/20/04 01:30 PM
* Link Between Irritable Bowel Syndrome (IBS), Alcoholism and Mental Illness
HeatherAdministrator
12/20/04 01:24 PM
* Complementary and alternative medicine in gastroenterology
HeatherAdministrator
12/20/04 01:16 PM
* Advances in the Treatment of Chronic Constipation
HeatherAdministrator
11/28/04 02:55 PM
* Symptom patterns in functional dyspepsia and irritable bowel syndrome
HeatherAdministrator
11/28/04 02:34 PM
* Obese Women Face Higher Risk of Colorectal Cancer
HeatherAdministrator
11/08/04 04:48 PM
* Obesity is Associated With Increased Risk of Gastrointestinal Symptoms
HeatherAdministrator
10/24/04 07:42 PM
* Stress Therapy Can Help Irritable Bowel
HeatherAdministrator
10/24/04 07:38 PM
* Relationship Between Colon Ischemia, Irritable Bowel Syndrome
HeatherAdministrator
10/11/04 04:15 PM
* Clinical Update on the Treatment of Constipation in Adults
HeatherAdministrator
10/11/04 03:34 PM
* Racial Differences in the Impact of Irritable Bowel Syndrome on Health-Related Quality of Life
HeatherAdministrator
10/11/04 03:25 PM
* What Differentiates Chronic Constipation From IBS With Constipation?
HeatherAdministrator
09/26/04 03:25 PM
* Treatment options in irritable bowel syndrome
HeatherAdministrator
09/26/04 02:57 PM
* Diagnostic approach to suspected irritable bowel syndrome
HeatherAdministrator
09/12/04 03:38 PM
* Dyssynergic Defecation: Demographics, Symptoms, Stool Patterns, and Quality of Life
HeatherAdministrator
09/12/04 03:35 PM
* Small Intestinal Bacterial Overgrowth - A Framework for Understanding IBS
HeatherAdministrator
08/30/04 01:46 PM
* New views - and some respect - for IBS
HeatherAdministrator
08/30/04 01:25 PM
* Categorization of dysmotility in patients with chronic constipation
HeatherAdministrator
08/08/04 02:54 PM
* Prevalence of IBS according to different diagnostic criteria
HeatherAdministrator
08/08/04 02:50 PM
* Irritable Bowel Can Follow Dysentery
HeatherAdministrator
08/08/04 02:37 PM
* Irritable Bowel Syndrome Remains a Difficult Condition to Manage
HeatherAdministrator
07/24/04 02:09 PM
* Intolerance to visceral distension in functional dyspepsia or irritable bowel syndrome
HeatherAdministrator
07/24/04 02:17 PM
* Bacillary dysentery as a causative factor of irritable bowel syndrome and its pathogenesis
HeatherAdministrator
07/24/04 01:42 PM
* Irritable Bowel Syndrome Linked to High Rates of Various Surgeries
HeatherAdministrator
07/11/04 02:15 PM
* Drug-Free Ways to Treat IBS
HeatherAdministrator
07/11/04 01:47 PM
* Irritable Bowel Syndrome - An Evidence-Based Approach to Diagnosis
HeatherAdministrator
06/27/04 01:14 PM
* Biases Affect Treatment of IBS
HeatherAdministrator
06/04/04 06:45 PM
* Moms with Bowel Symptoms Take Baby to Doctor More
HeatherAdministrator
05/25/04 11:53 AM
* Natural History of Irritable Bowel Syndrome
HeatherAdministrator
05/10/04 02:36 PM
* Intestinal Gas May Contribute to IBS Symptoms
HeatherAdministrator
05/10/04 02:29 PM
* Are Your Bowels Irritable? IBS Awareness Month is Here
HeatherAdministrator
04/09/04 07:11 PM
* Heartburn May Not Reflect Gastroesophageal Reflux Disease Severity
HeatherAdministrator
03/30/04 02:43 PM
* A link between irritable bowel syndrome and fibromyalgia
HeatherAdministrator
03/30/04 01:46 PM
* Diverticular Disease: Electrophysiologic Study and a New Concept of Pathogenesis
HeatherAdministrator
03/09/04 11:48 AM
* New Syndrome Connects Gallbladder Dysfunction And Chronic Diarrhea
HeatherAdministrator
03/09/04 11:45 AM
* Researchers Pioneer Accessible, Cost-Effective Treatments for IBS
HeatherAdministrator
03/08/04 06:48 PM
* Splitting IBS: from original Rome to Rome II criteria
HeatherAdministrator
02/10/04 02:35 PM
* Utilization patterns and net direct medical cost to Medicaid of IBS
HeatherAdministrator
02/10/04 02:34 PM
* Family practitioners' attitudes and knowledge about IBS
HeatherAdministrator
02/10/04 02:32 PM
* The Effect of Somatization on Gastrointestinal and Extraintestinal Symptoms of IBS
HeatherAdministrator
01/26/04 03:26 PM
* Surgery and IBS
HeatherAdministrator
01/26/04 03:21 PM
* IBS Subgroups by Bowel Habit Predominance
HeatherAdministrator
01/26/04 03:13 PM
* Visceral perception thresholds in irritable bowel syndrome
HeatherAdministrator
01/07/04 11:56 AM
* Electric activity of the colon in irritable bowel syndrome
HeatherAdministrator
01/07/04 11:52 AM
* Irritable Bowel Syndrome's Possible Genetic Link
HeatherAdministrator
01/07/04 11:40 AM
* Intestinal gas distribution determines abdominal symptoms
HeatherAdministrator
12/16/03 12:27 PM
* Faecal incontinence - Many treatment options now exist
HeatherAdministrator
12/16/03 12:17 PM
* Abnormal Colonic Propagated Activity in Patients with Constipation
HeatherAdministrator
12/16/03 12:07 PM
* Colonic Propulsive Impairment in Intractable Slow-Transit Constipation
HeatherAdministrator
12/16/03 12:03 PM
* Overlapping upper and lower GI symptoms in IBS patients with constipation or diarrhea
HeatherAdministrator
12/01/03 05:51 PM
* Familial aggregation of irritable bowel syndrome
HeatherAdministrator
12/01/03 05:49 PM
* Outlook affects bowel disorder patients
HeatherAdministrator
11/18/03 03:30 PM
* Doctors unmoved by bowel misery
HeatherAdministrator
11/18/03 03:28 PM
* Travelers' Diarrhoea Can Trigger Irritable Bowel
HeatherAdministrator
11/04/03 03:21 PM
* Mind-Body Technique Eases Kids' Gut Pain
HeatherAdministrator
10/30/03 11:17 AM
* Molecular Alterations In Patients With Irritable Bowel Syndrome
HeatherAdministrator
10/20/03 03:46 PM
* Three in Four People With IBS Also Have Functional Dyspepsia
HeatherAdministrator
10/15/03 03:28 PM
* Infectious Gastroenteritis Linked to Irritable Bowel Syndrome
HeatherAdministrator
09/30/03 02:27 PM
* Association Between Pain Episodes & High Amplitude Pressure Waves in IBS
HeatherAdministrator
09/16/03 03:54 PM
* Constipation and its management
HeatherAdministrator
09/16/03 03:41 PM
* Contributions of suggestion, desire, and expectation to placebo effects in IBS patients
HeatherAdministrator
09/16/03 03:28 PM
* Do published guidelines for evaluation of IBS reflect practice?
HeatherAdministrator
08/30/03 02:40 PM
* Cognitive-behavioral therapy versus education and desipramine versus placebo for IBS
HeatherAdministrator
08/12/03 12:54 PM
* Distinctive features of postinfective irritable bowel syndrome
HeatherAdministrator
07/28/03 03:18 PM
* UCLA/CURE Neuroenteric Disease Program Newsletter
HeatherAdministrator
07/23/03 10:38 AM
* Bacterial Overgrowth in IBS
HeatherAdministrator
07/18/03 12:15 PM
* Diagnosis of irritable bowel syndrome.
HeatherAdministrator
07/18/03 11:54 AM
* Eradication of small intestinal bacterial overgrowth reduces symptoms of IBS
HeatherAdministrator
07/18/03 11:44 AM
* Antibiotics increase functional abdominal symptoms.
HeatherAdministrator
07/18/03 11:41 AM
* Treatment of the irritable bowel syndrome.
HeatherAdministrator
07/15/03 11:02 PM
* Extraintestinal symptoms in IBS and IBD
HeatherAdministrator
07/15/03 06:21 PM
* Postinfectious irritable bowel syndrome.
HeatherAdministrator
07/15/03 06:19 PM
* Dieting severity and GI symptoms in college women.
HeatherAdministrator
07/15/03 01:13 PM
* Functional GI disorders and eating disorders - Relevance of the association
HeatherAdministrator
07/15/03 11:14 AM
* Features of eating disorders in patients with IBS
HeatherAdministrator
07/15/03 11:12 AM
* New and Important Insights Into IBS
HeatherAdministrator
07/14/03 03:24 PM
* The Irritable Bowel Syndrome-Fibromyalgia Connection
HeatherAdministrator
07/14/03 03:19 PM
* Update on Treatment of Functional Gastrointestinal Disorders
HeatherAdministrator
07/14/03 02:55 PM
* Irritable bowel syndrome in primary care: The patients’ and doctors’ views
HeatherAdministrator
07/14/03 02:43 PM
* Inflammatory bowel disease and irritable bowel syndrome: separate or unified?
HeatherAdministrator
07/14/03 02:32 PM

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