Irritable bowel syndrome in general practice: an overview

BACKGROUND: Irritable bowel syndrome (IBS) is a functional gastrointestinal disorder that is frequently seen in gastroenterological practice. Population-based studies have shown that at any point in time IBS symptoms are present in about 3%-22% of the general Western population. In general practice, half of all new patients have functional disorders and IBS is responsible for about five consultations per week. General practitioners (GPs) manage the majority of IBS patients, but most knowledge (and research) is based on the smaller percentage of patients managed in secondary care. There is a paucity of literature on differences or similarities between these two groups with regard to clinical characteristics or diagnostic approach. METHODS: The literature published in English about IBS in general practice was reviewed. CONCLUSIONS: Irritable bowel syndrome is frequently encountered in primary care. Primary care IBS patients, compared to secondary care patients, are likely to be young, female and to have less severe symptoms. But this is only true for some symptoms; for example, non-abdominal complaints are equally reported in both groups. The disorder can be diagnosed safely using internationally agreed symptom-based criteria, such as the Rome II criteria. Additional diagnostic measures will be necessary to support the diagnosis in only a minority of situations. Many primary care IBS patients can be managed given adequate reassurance and education, frequently without additional pharmacological treatment.     

Irritable bowel syndrome

Patients with irritable bowel syndrome (IBS) are highly prevalent among subjects seeking medical attention at the general practitioner or specialist level. While IBS lacks any disease associated excess mortality, this disorders is relevant to the affected subjects due to the considerable burden with regard to the symptoms and an impaired quality of life. Furthermore, this disease has a substantial impact on society due to the economical consequences. In recent years substantial progress has been achieved regarding our pathophysiological understanding. However, as usual, there has been a substantial delay between the discovery of disease mechanisms and its translation into improved patient care. For diagnosing IBS standardized criteria have been established (i. e. Rome II- or the DGVS-criteria). Regarding treatment, life style advice such as avoidance of specific nutrients that precipitate or aggravate or the "little psychotherapy" (addressing patients concerns and anxiety regarding the symptoms) are considered essential. However, the overall response rate is disappointing. Evidence-based pharmacological interventions include herbal preparations, spasmolytics, low dose tricyclic antidepressants and 5-HT-3-receptor antagonists and 5-HT-4-receptor agonists. At present no cure for patients with IBS exists. Thus, all currently available treatments target palliation of symptoms. This, however, may change in the future.     

Irritable bowel syndrome

Irritable bowel syndrome is a frequent functional disorder of gastrointestinal tract. Its high incidence represents an important socioeconomic concern. The diagnosis of irritable bowel syndrome is indirect and requires exclusion of an organic lesion within as well as outside the gastrointestinal tract. No algorithms--so called treatment guidelines--are available for pharmacological or non-pharmacological treatment of the irritable bowel syndrome. Long-term and comprehensive care of patients with functional diseases is an important component of the management of patients with irritable bowel syndrome.     

Irritable bowel syndrome

Conceptually, the irritable bowel syndrome (IBS) has been considered a brain-gut functional disorder, but this paradigm is under serious challenge. There is increasing evidence that organic disease of the gastrointestinal tract can be identified in subsets of patients who fulfil the Rome criteria for IBS. Evidence for subtle inflammatory bowel disease, serotonin dysregulation, bacterial overgrowth and central dysregulation continue to accumulate. The underlying causes of IBS remain to be adequately identified, but postinfectious IBS is a clear-cut entity. Furthermore, a genetic contribution to IBS also seems likely. Diagnosis continues to be based on the symptom profile and the absence of alarm features. A heightened awareness of coeliac disease masquerading as IBS is becoming accepted. Management remains largely based on symptomatic rather than on disease-modifying therapy, but this is likely to change in the near future. Here, recent advances in the pathophysiology and management of IBS are considered.     

Irritable bowel syndrome

Patients with different irritable bowel symptoms and normal subjects were compared to determine whether subtypes of irritable bowel syndrome (IBS) could be distinguished on the basis of colonic motility or psychological test scores. A provocative test involving stepwise distension of the rectosigmoid area revealed two types of colonic motility. Slow contractions having durations of at least 15 sec and occurring at irregular intervals were more frequent in IBS patients than in normals but did not differentiate constipation from diarrhea. Fast contractions having durations of less than 15 sec and occurring in runs at frequencies of 6–9 cpm were more frequent in patients with diarrhea than in normals or constipated IBS patients. Constipated patients showed no more fast contractions than normals. Severity of bowel symptoms was correlated with the overall amount of motility (motility index) in patients with diarrhea but not in patients with constipation. Patients with IBS showed significantly elevated levels on the following psychological traits: anxiety, interpersonal sensitivity, depression, hostility, and somatization of affect. However, there were no significant trait differences between patients with diarrhea and those with constipation. Also, there was no correlation between amount of psychopathology and either colonic motility or severity of symptoms in the whole group of IBS patients.     

Irritable bowel syndrome

Opinion Statement I believe there are four essential elements in the management of patients with irritable bowel syndrome (IBS): to establish a good physician-patient relationship; to educate patients about their condition; to emphasize the excellent prognosis and benign nature of the illness; and to employ therapeutic interventions centering on dietary modifications, pharmacotherapy, and behavioral strategies tailored to the individual. Initially, I establish the diagnosis, exclude organic causes, educate patients about the disease, establish realistic expectations and consistent limits, and involve patients in disease management. I find it critical to determine why the patient is seeking assistance (eg, cancer phobia, disability, interpersonal distress, or exacerbation of symptoms). Most patients can be treated by their primary care physician. However, specialty consultations may be needed to reinforce management strategies, perform additional diagnostic tests, or institute specialized treatment. Psychological co-morbidities do not cause symptoms but do affect how patients respond to them and influence health care-seeking behavior. I find that these issues are best explored over a series of visits when the physician-patient relationship has been established. It can be helpful to have patients fill out a self-administered test to identify psychological co-morbidities. I often use these tests as a basis for extended inquiries into this area, resulting in the initiation of appropriate therapies. I encourage patients to keep a 2-week diary of food intake and gastrointestinal symptoms. In this way, patients become actively involved in management of their disease, and I may be able to obtain information from the diary that will be valuable in making treatment decisions. I do not believe that diagnostic studies for food intolerances are cost-effective or particularly helpful; however, exclusion diets may be beneficial. I introduce fiber supplements gradually and monitor them for tolerance and palatability. Synthetic fiber is often better-tolerated than natural fiber, but must be individualized. In my experience, excessive fiber supplementation often is counterproductive, as abdominal cramps and bloating may worsen. Antidiarrheal agents are very effective when used correctly, preferably in divided doses. I use them in patients in anticipation of diarrhea and especially in those who fear symptoms when engaged in activities outside the home. I encourage patients to make decisions as to when and how much to use. However, almost always, a morning dose before breakfast is used (loperamide, 2 to 6 mg) and, perhaps again later in the day when symptoms of diarrhea are prominent. I prefer antispasmodics to be used intermittently in response to periods of increased abdominal pain, cramps, and urgency. For patients with daily symptoms, especially after meals, agents such as dicyclomine before meals are useful. For patients with infrequent but severe episodes of unpredictable pain, sublingual hyoscyamine often produces rapid relief and instills confidence. In general, I recommend that oral antispasmodics be used for a limited period of time rather than indefinitely, and generally for periods of time when symptoms are prominent.     

肠易激综合征

肠易激综合征 (ｉｒｒｉｔａｂｌｅｂｏｗｅｌｓｙｎｄｒｏｍｅ ,ＩＢＳ)是一种身心疾患 ,主要表现为胃肠功能紊乱 ,具有与排便相关或排便习惯改变相关的腹痛 ,并伴有不正常排便及腹胀的症状。临床上分为腹泻型、便秘型和混合型。1　流行病学ＩＢＳ相当常见 ,而且是世界性的。近年英美进行大样本调查中ＩＢＳ分别占普通人群的 2 2 %和 11.6 %。国内缺少大样本的调查。最初北京文碧珍、潘其英等调查了北京地区 2 33例非患者人群 ,发现具有腹痛而便后缓解者占2 2 .8% ,有腹痛而便后不缓解者占 6 % ,经常排稀便者占6 .4% ,有排便费力、粪便干结…     

Irritable bowel syndrome

The diagnosis of irritable bowel syndrome requires the exclusion of any associated organic disease: a positive diagnosis would avoid expensive and potentially dangerous diagnostic procedures. A scoring system has been proposed for positive diagnosis where more than 44 points excluded organic digestive disease. The aim of this study was to determine the usefulness of this scoring system in a different setting. Patients (1257) consecutively referred to our medical division were admitted to the study and 270 of these, complaining of abdominal symptoms, were scored on the Kruis system method. The positive predictive value (53.8% for men and 81.5% for women) and the sensitivity (46.7% and 59.5%) did not appear to be adequate. The negative predictive value (91.6% and 87.3%) and the specificity (93.5 and 95.4%) gave higher results, but two cases of neoplasia and nine cases of other organic digestive diseases were not identified or suggested. We believe that this scoring system may be useful only as a first step in a diagnostic flow chart.     

Irritable bowel syndrome: toward an understanding of severity.

Irritable bowel syndrome (IBS) is a chronic disorder with symptoms that range in severity from mild and intermittent to severe and continuous. Although severity is a guiding factor in clinical decision making related to diagnosis and treatment, current guidelines related to IBS do not address the issue of severity. Recent data suggest that severity as a multidimensional concept, not fully explained by intensity of symptoms, has important clinical implications including health care utilization and health-related quality of life. Components of IBS severity include symptom intensity, time of assessment, whether the patient or physician makes the severity determination, the type of scale used to measure severity, and the degree of disability or impairment. Currently no consensus definition of IBS severity exists, although 2 validated scales of IBS severity have recently been published. Review of the literature suggests that the prevalence of severe or very severe IBS is higher than previously estimated with a range from 3%-69%. Individual IBS symptoms are important but are not sufficient to explain severity. Rather, severity has multiple components including health-related quality of life, psychosocial factors, health care utilization behaviors, and burden of illness. However, studies have not been adequately designed to determine the relative values of these factors in IBS severity.     

Irritable bowel syndrome in Nigerians

Twenty-six Nigerians with irritable bowel syndrome are reported. Twenty-three patients (88.46%) belong either to the middle or upper socioeconomic class; 16 patients (61.5%) had predominantly constipation. Six of the patients (23.1%) had their first symptoms before the age of 15 years. No sex preference is shown by this study. The most common symptoms are flatulence and abdominal pain, which is relieved by bowel motion, belching, and/or passage of flatus. Cow's milk, stress, and a local diet of beans are the most common aggravating factors, while another local high-fiber diet of cassava was found helpful in reducing the intensity and frequency of symptoms in some patients.     

Irritable bowel syndrome: current approach to symptoms, evaluation, and treatment

There are frequent advances in knowledge about the clinical presentation, pathophysiology, and treatment of irritable bowel syndrome. It is important for clinicians to be aware of available therapies and the supporting evidence for those therapies to increase patient satisfaction. This is best achieved with a collaborative and long-term clinician-patient relationship and mutual commitment to modify therapy and try new modalities until the greatest relief of symptoms and improvement in health-related quality of life is achieved. This article reviews symptoms, comorbidities, gender differences, and measure of severity in irritable bowel syndrome and current and evidence-based approaches to evaluation and treatment, and the new symptom-based Rome III diagnostic criteria are reviewed and explained.