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Do published guidelines for evaluation of IBS reflect practice?
      08/30/03 02:40 PM
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Do published guidelines for evaluation of Irritable Bowel Syndrome reflect practice?

BMC Gastroenterol. 2001; 1 (1): 11

Barbara P. Yawn, ,1 Eva Lydick, ,2 G Richard. Locke,3 Peter C. Wollan,1 Susan L. Bertram,1 and Margary J. Kurland1

1Department of Research, Olmsted Medical Center, Rochester, Minnesota, USA 2SmithKline Beecham Pharmaceuticals, Division of Epidemiology, Collegeville, Pennsylvania, USA 3Gastroenterology Outcomes Research Unit, Mayo Clinic, Rochester, Minnesota, USA

Received July 25, 2001; Accepted October 26, 2001; Published October 26, 2001.

Background
The only US guidelines listed in the National Guideline Warehouse for the diagnosis of Irritable Bowel Syndrome (IBS) are the expert opinion guidelines published by The American Gastroenterology Association. Although the listed target audience of these guidelines includes family physicians and general internists, the care recommended in the guidelines has not been compared to actual primary care practice. This study was designed to compare expert opinion guidelines with the actual primary care provided and to assess outcomes in the 3 years following the IBS diagnosis.

Methods
This is a retrospective medical record review study using a random sample of incident IBS cases from all Olmsted County, Minnesota providers diagnosed between January 1, 1993 and December 31, 1995. Data was collected on all care and testing provided to the subjects as well as 3-year outcomes related to the IBS diagnosis.

Results
Of the 149 IBS patients, 99 were women and the mean age was 47.6 years. No patient had all of the diagnostic tests recommended in the guidelines. 42% had the basic blood tests of CBC and a chemistry panel. Sedimentation rate (2%) and serum thyroxine level (3%) were uncommon. Colon imaging studies were done in 41% including 74% of those over the age of 50. In the 3 years following the diagnosis, only one person had a change in diagnosis and no diagnoses of gastro-intestinal malignancies were made in the cohort.

Conclusions
Primary care practice based diagnostic evaluations for IBS differ significantly from the specialty expert opinion-based guidelines. Implementation of the specialty guidelines in primary care practice would increase utilization with apparent limited improvement in diagnostic outcomes.


Irritable bowel syndrome is a gastro-intestinal (GI) disorder of unknown etiology often described as a functional bowel problem. [1-3] The diagnosis of IBS rests on the occurrence of a set of symptoms and the exclusion of other GI pathology. [4-7] The only published US guidelines for evaluation of patients with possible IBS have been developed by the American Gastroenterological Association (AGA).[3] Due to the lack of higher levels of evidence, the guidelines are based on expert opinion and are likely to reflect the clinical experience of these specialists with the small percent (6 to 8%)[8] of all IBS patients seen by gastroenterologists in the US. [9] Little has been written about the potential implications of implementing the only currently available IBS diagnostic guidelines[10] or how the guidelines compare to existing community practice.

Using a community population-based sample of subjects with an incident diagnosis of IBS, we reviewed the GI-related health care utilization and diagnostic evaluations completed around the time of first (incident) IBS diagnosis and compared those evaluations to the AGA guidelines for the diagnosis of IBS. In addition, we evaluated the utilization implications of implementing the AGA guidelines in this patient population. The purpose of the study is not to validate the guidelines but to see how they compare to current primary care practice and to understand the potential implications of full guideline implementation.


Setting
Olmsted County is a metropolitan statistical area (MSA) of 135,000 people 90 miles south of Minneapolis, Minnesota. The population is estimated to be 92 percent white non-Hispanic. [11] Olmsted County has local resources for primary, and specialty care. Previous studies estimate that over 98 percent of all Olmsted County residents' health care is delivered within Olmsted County [11] by the Mayo Medical Center (MMC), the Olmsted Medical Center (OMC) or the single solo practice family physician's office in Rochester.

Data Collection
The cohort was identified using the database of the Rochester Epidemiology Project (REP)[11,12] that collects all diagnoses made within all Olmsted County medical facilities and links all people in Olmsted County to all sources of health care they use. All people with a diagnosis of functional or irritable bowel syndrome (564.1) or spastic colon – psychogenic (306.4) during 1993–1995 were identified from the database. Broad criteria were used for the search to increase sensitivity at the risk of reducing specificity. This type of search strategy was possible since final subject selection relied on medical record review rather than only administrative data. [13] The initial search identified 1245 potential cases (a combination of incident and prevalent cases) of which 36 (2.9%) had previously refused general record review research authorization and thus could not be included in the study according to Minnesota statute.[14] The goal was to identify 150 subjects for in-depth review using data from all sources of medical care each individual has used within the county. The sample size was selected based on the desire to have a sufficient sample to provide estimates of compliance with individual elements of the guidelines with confidence intervals of +/- 5% for those tests with very high and very low compliance and +/-8% for those near 50% compliance. This is a descriptive study and therefore no other types of sample size calculations were made.

The 1245 people identified by the initial search of the REP database, were put into a random order and the medical records of potential subjects' were screened until the final cohort of 150 patients who met the inclusion criteria were identified. A total of 416 potential IBS subjects were screened to identify the final incident cohort of 150 subjects who had lived in Olmsted County for at least 3 years and had no previous diagnoses of IBS listed in any medical records in the county. The minimum of 3 years of residency within Olmsted County was used to improve the likelihood that review of the complete available medical records would identify prevalent rather than incident cases of IBS. The assurance that patients represented an incident diagnosis of IBS was especially important in this study comparing diagnostic evaluations completed to the recommended guidelines for initial evaluation. Potential subjects from the group of 416 were excluded during screening primarily for 1 of 3 reasons: they were prevalent rather than incident cases of IBS (n = 67), no actual diagnosis of IBS was documented in any of the subject's medical records (n = 41) or they had been an Olmsted County resident for < 3 years (n = 93). Another 65 people had a group of miscellaneous reasons for exclusion including incident diagnosis date outside the window of this study, age < 16 at diagnosis, and missing records.

All medical records of the 150 subjects in the final cohort (those meeting the eligibility criteria) were reviewed in detail to abstract data on demographic characteristics, visits for gastro-intestinal or abdominal problems, and non-GI symptom-related visits from 10 years before the first IBS diagnosis to 3 years after. GI symptom-related visits were those in which any symptom, sign or complaint referable to the GI tract was recorded. This included such complaints as diarrhea, abdominal pain, constipation, change in stool habits, and vomiting. All other visits were considered non-GI related. Information on the presenting complaint, specialty of physician seen, tests ordered and site of the visit (emergency department, office, or hospital) was recorded. Data collection began at the earliest visit that occurred 10 years or less before the incident IBS diagnosis. Long term data were available for most patients (mean = 7.3 years, median 7 years) and were used to assure that there was no previous diagnosis of IBS. The data of most interest for this comparison of diagnostic evaluations completed and the testing recommended in the guidelines were visits in 2 years before the diagnosis of IBS. Diagnostic outcomes were assessed during the 3 years after the incident diagnosis. These data were present in 100% of subjects.

Data analysis
One subject revoked general research authorization (required by Minnesota statute) during data analysis and thus the analysis was completed for the remaining 149 subjects. Descriptive information is presented as summary statistics.

Health care utilization was stratified into 2 major time periods: a) the 60 days surrounding the incident IBS diagnosis (30 days before to 30 days after) called the immediate diagnostic period; and b) the 2 years prior to the diagnosis, excluding the 30 days before termed the extended diagnostic period. For referral to a GI specialist we also included the 1 year after the diagnosis since referral for non-urgent conditions may take a considerable period of time. The designation of the 60-day "diagnostic period" was based on the clinical judgement of the authors and was felt to reflect the usual time required to complete a diagnostic evaluation. The percent of subjects using each of the recommended services was calculated for the diagnostic period and then for the extended immediate diagnostic period (included the 2 year period prior to the incident diagnosis). The extended window of time was important for such tests as colonoscopy that may not be repeated within 2 years of a normal examination.

Comparisons of test utilization between age groups, genders and those who did and did not have a gastroenterologist involved in their care were made using the Wilcoxon rank-sum test. Chi-square tests were used to compare frequencies of events.

The potential impact of fully implementing the AGA guidelines (Table 1) was assessed. The additional tests that would be needed for full implementation was calculated by subtracting the tests provided in this study from tests that would need to be completed if all subjects' evaluations met the guidelines. Diagnostic outcomes (e.g. changes in diagnoses from IBS to another GI disease in the 3 years following first IBS diagnosis) is reported as a single percent of total diagnosis.

This study was approved by the Olmsted Medical Center and the Mayo Medical Center Institutional Review Boards. The funding agency had no role in study design or right of approval of manuscripts submitted for publication. The author who worked for the funding agency was one of the epidemiologist members of the design team and reviewed the final draft of the manuscript.

Two thirds of the 149 subjects (n = 99) were women. The mean age of the subjects at the time of diagnosis was 47.6 years (s.d. 17.8 years and range 16 to 91 years) and was the same for men and women. Most of the IBS diagnoses (94%) were made by family physicians and general internists with 13% of subjects seeing a gastroenterologist at any time in the period 2 years before to 1 year after the diagnosis.

Table 2 summarizes the percent of people having each test or group of tests that are recommended for diagnostic evaluation by the AGA guidelines. In this cohort, testing did not vary significantly by sex. Only the completion of some type of colon imaging (flexible sigmoidoscopy, colonoscopy or barium enema) varied by age with 74% (n = 46) of those 50 and older at diagnosis versus 38% (n = 33) of those younger than 50 at diagnosis having one of the tests documented. Since the guidelines were developed by a panel of gastroenterologists, the compliance with the guidelines in those subjects seeing a GI specialist was also calculated (n = 19). All types of colon imaging were more common in those with GI specialty visits [79% (n = 15) versus 50% (n = 64), p > 0.05] but only the increase in flexible sigmoidoscopies reached statistical significance [53%, (n = 10) versus 19%, (n = 25), p < 0.05]. The only other diagnostic tests that were statistically more likely to be completed in those seen by a gastroenterologist were stool testing for ova and parasites [53%, (n = 10) versus 16%, (n = 21), p < 0.05] and fecal occult blood [26%, (n = 5) versus 9% (n = 12), p < 0.05].

The final column of Table 2 reflects the additional number of people (and percent of the subjects) who would require each category of test to comply with the AGA guidelines [3] for diagnosis of IBS.

In those subjects with primarily diarrhea (n = 82), the guidelines suggest a small bowel radiograph and a lactose/dextrose H2 breath test. Twelve subjects (15%) had a small bowel radiograph and none had H2 breath testing. For those with abdominal pain (n = 110) the guidelines recommend a plain film of the abdomen. Thirteen of these patients (12%) had a flat plate.

In the three years after the diagnosis of IBS, only one subject had any change in diagnosis from IBS to another condition related to the symptoms. This 23-year old subject was diagnosed with inflammatory bowel disease approximately one year after the initial IBS diagnosis. No subject was diagnosed with any type of GI-related malignancy and there were no deaths in the cohort.

The evaluation of IBS in this community population-based cohort of primary care patients differed significantly from that recommended by the AGA guidelines [3] for IBS evaluation. The evaluation of GI-related signs and symptoms appeared to be based primarily on history and physical examination with minimal specific testing or imaging of the GI tract. The inclusion of a GI specialist in the subject's care increased but did not guarantee compliance with the AGA guidelines.

The diagnostic guidelines developed and published by the AGA are available in several formats including as part of the guideline warehouse sponsored by the Agency for Health Care Research and Quality (AHRQ) www.guidelines.gov/ibs where they are listed as applicable to family medicine, internal medicine, gastroenterology and primary care. Physicians who are familiar with the medical literature will know that almost all elements of the IBS guideline required expert opinion since little other evidence was available. Unfortunately, the level of evidence used is not clearly stated. [15] Furthermore, the AGA guidelines were developed by a panel limited to gastroenterologist physicians. However, gastroenterologists see only a minority of IBS patients.[8] Over 94% of the subjects in this sample were initially evaluated by family physicians and general internists with only 13% ever seeing a gastroenterologist in the 7 years before or 3 years after the incident IBS diagnosis. Therefore, subspecialty developed guidelines may not be appropriate for the majority of IBS care especially when the guidelines have to be based primarily on opinion which likely reflects only the experience of physicians included in the guideline development panel.

The complete printed position statement that accompanies the original publication of the AGA guidelines does note the potential lack of applicability to primary care patients (> 85% of all IBS patients) stating "...Primary care patients may be different and may be followed with expectant management". [3] However, expectant management is not specified nor are the specific indications for referral to a specialist presented. The position paper also recognizes that "...there is a risk of overdoing the diagnostic evaluation to rule out organic disease". Within the guideline warehouse www.guidelines.gov these modifiers are missing. No data are presented in any format that provide any rationale for extending the AGA guidelines to primary care practice.

The additional testing that would be required to meet the AGA guidelines [3] is extensive (Table 2) and would likely result in significant increases in health care expenditures. Even if the guidelines were applied only to those visiting a gastroenterologist (assumed to be 13% of subjects in our study), additional health care utilization would be required. The anticipated gain in improved diagnostic accuracy appears to be limited since in this cohort only one diagnosis was changed from IBS in the 3 years of follow up after the incident IBS diagnosis.

The value of completing all of the additional testing recommended by the guidelines cannot be completely assessed with this data set. However, the outcome of no new GI malignancies in the three years of follow up of this cohort is comparable to other studies of prognosis in IBS [16] and suggests additional testing would be of limited value in identifying life threatening conditions. The value of the additional testing or referrals on the patient's quality of life or other health conditions is not known and requires additional research. The format of that additional research might be similar to the studies for other guidelines such as the study of the cost implications of implementing guidelines that recommend radiographs for evaluation of low back pain. [17] Such a study for IBS guidelines would need to assess the added value of the extensive work-up recommended by the specialty guidelines in a larger population over a longer period of time and could be compared to the outcomes (including patient satisfaction) of a group assigned to more limited evaluation as completed in this study. It would be important to determine if the additional tests or referrals would identify other diseases, serve to more fully reassure the patient or simply have become what patients and specialist expect to occur with a GI specialty visit. [18]

Failure to comply with one aspect of the guidelines is worth specific mention. While subjects over age 50 were more likely to have colon-imaging studies, 25% of them had no colon imaging studies or assessment of fecal occult blood. This is not consistent with the published evidence based U.S. Preventive Services Task Force (USPSTF) guidelines for routine screening and preventive care related to colon cancer for asymptomatic people 50 years and older and appear to represent missed screening opportunities. [19,20] The addition of a GI specialist in the patient's care increased but did not guarantee compliance with the USPSTF guidelines for screening studies of the colon.

The AGA[3] had little evidence of any higher level than expert opinion on which to base IBS guidelines. The disparity between the testing family physicians and general internists choose to evaluate potential IBS and that recommended in the guidelines highlights the potential impact of using subspecialty experts to define recommended care in a primary care condition with limited research based evidence. If indeed gastroenterologists do see a sicker or otherwise different group of people with IBS than seen by family physicians and general internists then more extensive evaluation by gastroenterologists would be appropriate to consider. If the GI specialty patients are no more likely to have other diseases but are just more likely to be dissatisfied with care and need additional reassurance, more testing may not be the most cost effective solution. Alternative considerations such as group therapy, support groups or additional education may be a better use of resources and time. [21] In this population, the disparity between the care given and that recommended reinforces the value of understanding the full spectrum of disease when developing opinion based guidelines as well as the importance of developing evidence based guidelines as opposed to expert opinion based guidelines whenever possible.

This is a relatively small cohort of primary care patients from a single county. Practices in other communities and with patients of more diverse racial and ethnic background may be different. Medical records rarely reflect every thing that happens during any medical encounter. It is possible that additional testing did occur. However, tests often involve people other than the physician, are billable items in the non-capitated care environment we studied and therefore significant amounts of undocumented testing is unlikely. The use of medical records did allow the date of the incident diagnosis to be pinpointed and allowed us to assess diagnostic evaluation in temporal relation to the incident diagnosis making comparison with diagnostic guidelines possible. Our limited sample size may not have been sufficient to allow accurate assessment of missed GI malignancies.

Conclusion
Community based evaluation of IBS differs from the consensus based guidelines developed by specialists. The limited testing done in this population appeared to limit health care expenditures without adversely impacting the recognition of life threatening GI disease. To allow physician assessment of the potential applicability of published guidelines, the guidelines should always be accompanied by information regarding the target population (i.e. primary care patients versus specialty care patients) and the evidence basis of the guidelines.


References
Lynn, RB & Friedman, LS: Irritable bowel syndrome. N Engl J Med 1993, 329:194045.[PubMed][Full Text]

Maxwell, PR, Mendall, MA, & Kumar, D: Irritable bowel syndrome. Lancet 1997, 350:169195.[PubMed][Full Text]

American Gastroenterological Association Medical Position Statement.: Irritable Bowel Syndrome. Gastroenterology 1997, 112:21182137.[PubMed]

Manning, AP, Thomson, P, Heaton, KW, et al. : Toward positive diagnosis of the irritable bowel BMJ 1978, ii:653654.

Talley, NJ, Phillips, SF, Melton, LJ, III, et al. : Diagnostic value of the Manning criteria in irritable bowel syndrome Gut 1990, 31:7781.[PubMed]

Vanner, SJ, Depew, WT, Paterson, WG, et al. : Predictive value of the Rome criteria for diagnosing the irritable bowel syndrome Am J Gastroenterol 1999, 94:29127.[PubMed][Full Text]

Beck, E & Hurwitz, B: Irritable bowel syndrome Occas Pap R Coll Gen Pract 1992, 58:3235.[PubMed]

Everhart, JE & Renault, PF: Irritable bowel syndrome in office-based practice in the United States. Gastroenterology 1991, 100:9981005.[PubMed]

Harvey, RF, Salih, SY, & Read, AE: Organic and functional disorders in 2000 gastroenterology outpatients Lancet 1983, i:632634.[PubMed]

Thompson, WG: Irritable bowel syndrome: a management strategy. Bailliere's Clin Gastroenterology 1999, Pages:453460.

Melton, LJ, III: History of the Rochester Epidemiology Project. Mayo Clin Proc 1996, 71:266274.[PubMed]

Kurland, LT & Molgaard, CA: The patient record in epidemiology. Scientific American 1981, 245:5463.[PubMed]

Mark, DH: Race and the Limits of Administrative Data (editorial) JAMA 2001, 285:33738.[PubMed][Full Text]

Yawn, BP, Yawn, RA, Geier, GR, et al. : The impact of requiring patient authorization for use of data in medical records research. J Fam Pract 1998, 47:361365.[PubMed]

Shaneyfelt, TM, Mayo-Smith, MF, & Rothwangle J, J: Are Guidelines Following Guidelines? The Methodological Quality of Clinical Practice Guidelines in the Peer-Reviewed Medical Literature. JAMA 1999, 281:19001905.[PubMed][Full Text]

Harvey, RF, Mauad, EC, & Brown, AM: Prognosis in the irritable bowel syndrome: a 5-year prospective study. Lancet 1987, i:963965.[PubMed]

Suarez-Almazor, ME, Belseck, E, Russell, AS, & Mackel, JV: Use of lumbar radiographs for the early diagnosis of low back pain. Proposed guidelines would increase utilization. JAMA 1997, 277:17826.[PubMed]

Thompson, WG, Heaton, KW, Smyth, GT, et al. : Irritable bowel syndrome in general practice: prevalence, characteristics, and referral. Gut 2000, 46:7882.[PubMed][Full Text]

U.S. Preventive Services Task Force.: Guide to Clinical Preventive Services 2nd ed. Alexandria, VA: International Medical Publishing 1996, xxlii, 519:521529.

Helm, JF & Sandler, RS: Colorectal cancer screening. Medical Clinics of North America 1999, 83:140322.[PubMed]

Bertram S, S, Kurland, M, Lydick, E, Locke, GR, III, & Yawn, BP: The Patient's Perspective of Irritable Bowel Syndrome. JFP 2001, 50:521525.

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=59674

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* IBS - it's the pain and the stigma
HeatherAdministrator
08/28/09 01:16 PM
* Wasington state retailers required to make bathrooms available to people with IBS and IBD
HeatherAdministrator
05/13/09 01:06 PM
* Development of an educational intervention for patients with Irritable Bowel Syndrome
HeatherAdministrator
02/06/09 12:20 PM
* Prevalence of Functional Gastrointestinal Disorders in Patients With Fibromyalgia and the Role of Psychologic Distress
HeatherAdministrator
01/22/09 04:47 PM
* Highlights of ACG's New Recommendations on IBS Therapies
HeatherAdministrator
01/09/09 11:10 AM
* Irritable Bowel Syndrome Can Have Genetic Causes
HeatherAdministrator
12/16/08 11:42 AM
* Is IBS part of a cascade of events?
HeatherAdministrator
10/27/08 10:56 AM
* Contributions of Pain Sensitivity and Colonic Motility to IBS Symptom Severity
HeatherAdministrator
10/21/08 02:38 PM
* Subgroup classification in irritable bowel syndrome patients over time
HeatherAdministrator
10/09/08 01:56 PM
* Genetic factors may play a role in IBS
HeatherAdministrator
09/26/08 02:52 PM
* Genetics of Irritable Bowel Syndrome
HeatherAdministrator
08/27/08 12:43 PM
* Irritable bowel syndrome: an international study of symptoms in eight countries
HeatherAdministrator
08/07/08 12:42 PM
* Gallstones, cholecystectomy and irritable bowel syndrome
HeatherAdministrator
04/22/08 04:01 PM
* Abdominal Bloating in Employed Adults: Prevalence, Risk Factors, and Association With Other Bowel Disorders
HeatherAdministrator
04/22/08 02:07 PM
* IBS is keeping me hostage!
HeatherAdministrator
03/14/08 11:12 AM
* Abdominal Bloating and Distension in Functional Gastrointestinal Disorders
HeatherAdministrator
02/28/08 03:16 PM
* Psychological distress and GI symptoms are related to severity of bloating
HeatherAdministrator
02/28/08 02:40 PM
* Irritable Bowel Syndrome's Possible Genetic Link
HeatherAdministrator
02/04/08 10:43 AM
* Patients with allergies appear to have a higher incidence of irritable bowel syndrome (IBS)
HeatherAdministrator
02/04/08 10:19 AM
* Train operator suffering from irritable bowel syndrome sues for lost wages
HeatherAdministrator
12/06/07 02:45 PM
* IBS may not affect small bowel transit time, but age does
HeatherAdministrator
10/24/07 01:56 PM
* Diagnostic work-up of IBS
HeatherAdministrator
10/24/07 12:15 PM
* Neural mechanisms of pelvic organ cross-sensitization.
HeatherAdministrator
10/10/07 11:41 AM
* Incidence and Prognosis of Post-Infectious Irritable Bowel Syndrome
HeatherAdministrator
09/13/07 11:21 AM
* Irritable bowel syndrome and the Rome III criteria: for better or for worse?
HeatherAdministrator
08/28/07 04:15 PM
* Quality of Life in Patients With IBD and IBS Differs Between Subjects Recruited from Clinic or the Internet
HeatherAdministrator
08/09/07 11:31 AM
* Fecal microbiota of irritable bowel syndrome patients differs significantly from that of healthy subjects
HeatherAdministrator
08/02/07 03:08 PM
* Irritable bowel syndrome and bloating
HeatherAdministrator
08/02/07 03:02 PM
* IBS And Restless Legs Syndrome Linked
HeatherAdministrator
08/02/07 02:50 PM
* Overlapping upper and lower gastrointestinal symptoms in irritable bowel syndrome patients
HeatherAdministrator
06/20/07 01:49 PM
* Bacterial Overgrowth Apparently NOT Important in IBS
HeatherAdministrator
06/06/07 10:51 AM
* Irritable bowel syndrome: patients' attitudes, concerns and level of knowledge
HeatherAdministrator
05/23/07 02:32 PM
* Influence of genetics on irritable bowel syndrome
HeatherAdministrator
05/23/07 02:25 PM
* Diarrhea-predominant irritable bowel syndrome and possible microscopic colitis
HeatherAdministrator
05/11/07 03:37 PM
* Breath Methane Levels Correlate With Constipation in IBS
HeatherAdministrator
04/28/07 10:13 AM
* 7 common myths – and facts – about IBS
HeatherAdministrator
04/11/07 04:17 PM
* Symptomatic overlap between irritable bowel syndrome and microscopic colitis
HeatherAdministrator
03/18/07 04:48 PM
* Reactions to a guided self-management intervention in a randomised controlled trial for IBS
HeatherAdministrator
03/18/07 04:39 PM
* Audit of Subtypes of Functional Constipation in a Gastroenterology Referral Center
HeatherAdministrator
03/18/07 04:26 PM
* New insights into the pathogenesis and pathophysiology of irritable bowel syndrome
HeatherAdministrator
03/01/07 01:17 PM
* Overly Anxious and Driven People Prone to Irritable Bowel Syndrome
HeatherAdministrator
03/01/07 12:37 PM
* Paid Participants Sought for Online IBS University Research Study
HeatherAdministrator
02/26/07 11:43 AM
* Physical activity and intestinal gas clearance in patients with bloating.
HeatherAdministrator
02/04/07 04:11 PM
* Familial Aggregation in Constipated Subjects
HeatherAdministrator
01/21/07 04:12 PM
* Participate in a research study looking at attitudes and opinions about people who have IBS
HeatherAdministrator
12/29/06 04:15 PM
* Most important barriers to the optimal management of patients with IBS-C and chronic constipation
HeatherAdministrator
12/01/06 01:23 PM
* Traveler's Diarrhea May Boost Risk of Irritable Bowel Syndrome
HeatherAdministrator
10/14/06 02:28 PM
* Irritable Bowel Syndrome Linked to Migraine, Fibromyalgia, and Depression
HeatherAdministrator
10/14/06 02:24 PM
* Restricted Fetal Growth Linked to Irritable Bowel Syndrome
HeatherAdministrator
10/14/06 02:21 PM
* The Science of IBS - Postinfectious IBS and Small Intestinal Bacterial Overgrowth
HeatherAdministrator
09/30/06 03:23 PM
* The Science of IBS - Environment and Genetics
HeatherAdministrator
09/17/06 02:36 PM
* Making a Positive Diagnosis of IBS
HeatherAdministrator
08/19/06 11:56 AM
* IBS -- Review and What's New - Abstract and Introduction
HeatherAdministrator
08/05/06 03:58 PM
* Treatment of Functional Diarrhea
HeatherAdministrator
07/17/06 01:54 PM
* Prevalence and Incidence of Chronic Constipation
HeatherAdministrator
07/05/06 05:35 PM
* Rome III Diagnostic Criteria
HeatherAdministrator
06/12/06 04:16 PM
* Determinants of Healthcare-Seeking Behaviour in IBS
HeatherAdministrator
06/04/06 11:48 AM
* Genetic cause for irritable bowel syndrome
HeatherAdministrator
05/29/06 01:48 PM
* Cytokines May Provide Marker for Irritable Bowel Syndrome
HeatherAdministrator
05/14/06 05:04 PM
* Introduction to IBS Constipation - the Problem
HeatherAdministrator
05/14/06 04:57 PM
* Gender, Age, Society, Culture, and the Patient's Perspective in IBS
HeatherAdministrator
05/13/06 03:16 PM
* What IBS Patients Need - But Don't Get - From Their Physicians
HeatherAdministrator
05/08/06 04:37 PM
* Antibiotic use and irritable bowel syndrome (IBS).
HeatherAdministrator
04/15/06 04:02 PM
* Older Versus Younger Patients with Irritable Bowel Syndrome
HeatherAdministrator
04/15/06 03:11 PM
* Prevalence of irritable bowel syndrome and depression in fibromyalgia
HeatherAdministrator
04/15/06 03:04 PM
* Intestinal serotonin signalling in irritable bowel syndrome
HeatherAdministrator
04/15/06 02:59 PM
* Gender-related differences in visceral perception in health and irritable bowel syndrome
HeatherAdministrator
04/15/06 02:47 PM
* Role of Stress, Infection, Inflammation in IBS
HeatherAdministrator
03/16/06 12:22 PM
* Pathophysiologic Mechanisms of IBS
HeatherAdministrator
03/16/06 12:16 PM
* Gum Chewing Stimulates Bowel Activity and Reduces Surgical Recovery Time
HeatherAdministrator
03/04/06 01:04 PM
* A bulging midriff roughly doubles women's chances of gallstone surgery
HeatherAdministrator
03/04/06 12:56 PM
* Lifestyle Factors and Symptoms of Gastro-oesophageal Reflux
HeatherAdministrator
02/18/06 01:42 PM
* IBS Patients Show Greater Brain Response to Subliminal Gut Stimuli
HeatherAdministrator
02/18/06 01:32 PM
* Discrepancies between Patient-Reported Outcomes and Clinician-Reported Outcomes in IBS
HeatherAdministrator
02/01/06 12:15 PM
* Distension technique influences the relationship between colonic and rectal hypersensitivity in IBS
HeatherAdministrator
02/01/06 12:04 PM
* Stability of Irritable Bowel Syndrome Using a Rome II-Based Classification
HeatherAdministrator
01/18/06 04:27 PM
* Digestive Woes May Keep the Overweight From Exercising
HeatherAdministrator
01/18/06 04:00 PM
* Possible role of nitric oxide in visceral hypersensitivity in patients with irritable bowel syndrome
HeatherAdministrator
01/08/06 05:03 PM
* A Survey on Patient Educational Needs in Irritable Bowel Syndrome
HeatherAdministrator
01/08/06 04:53 PM
* Gut motor function: immunological control in enteric infection and inflammation
HeatherAdministrator
12/21/05 12:41 PM
* Post-infectious Irritable Bowel Syndrome
HeatherAdministrator
12/19/05 04:55 PM
* Clinical Insights in IBS-C and Chronic Constipation
HeatherAdministrator
12/08/05 12:37 PM
* New Studies Gauge Knowledge, Attitudes and Preferences of Patients with Irritable Bowel Syndrome
HeatherAdministrator
11/12/05 01:30 PM
* The Genetics of Irritable Bowel Syndrome
HeatherAdministrator
11/12/05 01:10 PM
* Irritable Bowel Syndrome Study Shows That Targeted Antibiotics Lead To Long-lasting Improvement
HeatherAdministrator
11/12/05 01:00 PM
* Colonic Immune Activity and Blood T Lymphocytes in Patients With Irritable Bowel Syndrome
HeatherAdministrator
10/28/05 11:48 AM
* Brain activation responses to auditory stimuli in IBS
HeatherAdministrator
10/28/05 11:42 AM
* Functional Constipation Linked to Obesity in Children
HeatherAdministrator
10/11/05 01:43 PM
* Childhood Abdominal Pain May Progress to Adult Irritable Bowel Syndrome
HeatherAdministrator
10/11/05 01:36 PM
* Bronchial Hyperresponsiveness in Irritable Bowel Syndrome
HeatherAdministrator
10/11/05 01:16 PM
* The Impact of Somatization on the Use of Gastrointestinal Health-Care Resources in Patients with IBS
HeatherAdministrator
09/22/05 04:51 PM
* Abdominal Bloating - Four Factors
HeatherAdministrator
09/22/05 04:47 PM
* Abdominal Bloating
HeatherAdministrator
09/22/05 04:46 PM
* Guidelines for the Management of Dyspepsia
HeatherAdministrator
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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