IBS Subgroups by Bowel Habit Predominance
01/26/04 03:13 PM
Loc: Seattle, WA
IBS Subgroups by Bowel Habit Predominance
Lin Chang, MD
Although there are symptom-based Rome II diagnostic criteria for IBS and for the subgroups of IBS with diarrhea and IBS with constipation, the subgroup criteria are not evidence-based and were developed using expert opinion.
A study was performed to develop a symptom-based algorithm to classify patients with IBS into 3 subgroups: IBS with constipation, IBS with diarrhea, and IBS with alternating symptoms. Similar to the methodology used in the previously mentioned IBS study assessing burden of illness, clinical characteristics and gastrointestinal symptoms were gathered in an IBS patient population comprising members of the Intestinal Disease Foundation (n = 1340). Expert opinion was used to define symptom criteria for each subgroup. A hierarchical classification algorithm was developed based on the frequency of patients experiencing a combination of relevant gastrointestinal symptoms (diarrhea, constipation, and other Rome symptom criteria for IBS and functional constipation). The classification of patients with IBS by this algorithm was then compared with that determined by the Rome II criteria for subgroup classification. Of the 657 (49%) members who responded to the survey, 430 (65%) had IBS. The symptom-based algorithm classified 40% with IBS with diarrhea, 33% with IBS with constipation, and 12% with IBS alternating symptoms. Using the Rome II criteria, 31% had IBS with diarrhea, 10% had IBS with constipation, 41% had IBS with alternating symptoms, and 18% were unclassified.
The study authors concluded that the symptom-based algorithm was "more reflective" of the estimated prevalence of IBS subgroups in the general population. A few relevant points should be considered when interpreting these results: (1) the symptoms used in the algorithm consist of more constipation symptoms than diarrhea symptoms, and therefore may bias the classification towards IBS with constipation; (2) there are only symptom-based Rome II criteria for IBS with diarrhea and IBS with constipation, but not IBS with alternating symptoms; therefore, patients who do not meet criteria for IBS with diarrhea or IBS with constipation are in an intermediate group with no absolute criteria -- this may explain the significant number of unclassified IBS patients; and (3) the symptoms used to determine subgroups in the algorithm were based on expert opinion and were not evidence-based.
A study by Locke and colleagues specifically addressed the symptom profile in a community population that self-reported having alternating constipation and diarrhea. Four thousand twenty-nine randomly selected households were sent gastrointestinal symptom questionnaires and 2718 respondents were eligible for the analysis; 9.2%, 2.5%, and 7.6% of respondents reported their usual bowel pattern as constipation, diarrhea, or alternating diarrhea and constipation, respectively. The respondents were not required to meet diagnostic criteria for IBS (ie, presence of chronic or recurrent abdominal pain or discomfort associated with altered bowel habits). In general, self-report of bowel pattern approximated symptom criteria. Eighty-three percent of individuals with self-reported constipation met constipation symptom criteria; 67% of individuals self-reporting diarrhea met criteria for diarrhea. Among those individuals with alternating bowel habits (mean age 54 years, 63% women), 59% met symptom criteria for constipation, 35% met criteria for diarrhea, 20% met criteria for both, and 25% did not meet criteria for either. Predictive symptoms of alternators were incomplete evacuation and the presence of mucus.
Clearly, additional studies need to be performed to more accurately classify patients with IBS into bowel habit subgroups and characterize symptoms in patients with IBS with alternating symptoms (which is lacking in the literature). But first, it should be determined whether subclassifying IBS into these subgroups is even clinically relevant for patient care and research studies, given the fluctuation of IBS symptoms over time.
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