GASTROENTEROLOGY-HEPATOLOGY DIVISION

INTERNAL MEDICINE DEPARTEMENT

FK-USU/ADAM MALIK HOSPITAL
 "The bowels are at one time constipated,
another lax, in the same person. How the
disease has two such different symptoms I do
not profess to explain.
(Cumming, London Med Gaz, 1849.)
Other names:
Mucous colitis
Spastic colitis
Nervous colon
Irritable colon
 Abdominal discomfort that is
Relieved with defecation
Associated with altered stool frequency
Associated with altered stool consistency
 Altered Bowel Motility
Abnormal timing & pattern of contractions w/ food or
stress
Visceral Hypersensitivity
Abnormal excitability of neurons & pathways
Psychosocial Factors
May affect perceptions or central signal processing
Neurotransmitter Imbalance
Increased serotonin levels?
Infection/Inflammation
Inflammatory cytokines may affect bowel
sensitization
 To date, no single conceptual
model can explain all cases of the
syndrome.
NEJM 2001; 344:1846-1850
 A pattern of symptoms indicative of
some disease
Different causes for same problem?
Different problems with similar
manifestations?
 Irritable Bowel Syndrome
Defined by Factor Analysis.
Dig Dis Sci 1995; 40: 2647-55.
Six Manning criteria:
Frequent stools with
abdominal pain
Looser stools with pain
Relief of pain with
defecation
Abdominal distension
Passage of mucus
A feeling of incomplete
evacuation after defecation
Validation study
1344 students
Measured prevalence of 22
GI Sx in past 6 months
Factor analysis:
3 three Manning symptoms
clustered together among both
sexes and racial groups
More frequent bowel
movements with the onset
of pain
Looser stools with the onset
of pain
Relief of pain with
defecation
3 Manning symptoms did not
cluster with each other or with
the first three symptoms.
Bloating
Mucus
Feeling of incomplete
evacuation
 Incidence/prevalence
Prevalence 3 - 22% world-wide
Reason for 20 - 50% of gastroenterology
visits
$8 billion in medical expenses per year in
the USA
26% prevalence among children with
recurrent abdominal pain
Predominant age
40% onset before age 35
50% onset age 35 - 50
Predominant gender
Female > Male (2:1) in the US
 What is the differential diagnosis for IBS?
 Inflammatory bowel Endocrine tumors (very
disease uncommon)
Crohn's disease or ulcerative Gastrinoma
colitis Carcinoid
Medications Colorectal carcinoma
Laxatives Adenocarcinoma
Constipating medications Villous adenoma
Infections Intestinal pseudo-
Parasitic, bacterial, viral, and obstruction
opportunistic Diabetes
Malabsorption syndromes Scleroderma
Celiac disease Lactose intolerance
Pancreatic insufficiency
Endocrine disorders
Psychiatric disorders
Depression
Hypothyroidism Anxiety
Hyperthyroidism
Somatization disorder
Diabetes
Addison's disease
Manning Rome III
IBS diagnosed if 3 of the Abdominal pain or
following are present: discomfort for at least 3
Abdominal pain days per month for the past
3 months, with at least two
Pain relief with of:
defecation Improved with
Increased stool defecation
frequency with pain Onset associated with
Looser stools with change in stool
pain frequency
Onset associated with
Mucus in stools
change in stool form
Feeling of incomplete
evacuation
Further evaluation is mandated:
Weight loss

Evidence of bleeding or anemia

Signs of infection

Age over 50 at the onset of symptoms

 Manning Criteria:
2 of 6 present
84-94% Sensitivity & 55-76%
Specificity
3 of 6 present
63-90% Sensitivity & 70-93%
Specificity
Rome 1:
65% Sensitivity & 100% Specificity
 Constipation Predominant
Diarrhea Predominant
Abdominal Pain Predominant

Severity
Mild
Can be ignored if the patient does not think about it
Moderate
Cannot be ignored but does not affect patient's
lifestyle
Severe/very severe
Affects patient's lifestyle
 What tests are needed for IBS?
 Constipation predominant IBS
CBC, TSH, Electrolytes, Sigmoidoscopy
Diarrhea predominant IBS
CBC, TSH, ESR, Electrolytes,
Sigmoidoscopy
Abdominal pain predominant IBS
CBC
 Meta-analysis of 6 studies
Prevalence of disease if IBS criteria met:
Colitis/inflammatory bowel disease = 0.5% - 1.0%
Colorectal cancer = 0% - 0.5%
Celiac disease = 4.7%
Gastrointestinal infection = 0% - 1.7%
Thyroid dysfunction = 6%
Lactose malabsorption = 22% - 26%
Endoscopy, ultrasound, and barium studies only
detected organic disease in 1% of patients.
CBC and chemistries were unhelpful.

Am J Gastroenterol 2002; 97:2812-9.

 Warrant a more thorough diagnostic
evaluation.
Weight loss
Evidence of bleeding or anemia
Signs of infection
Age over 50 at the onset of symptoms
 Bottom line:
There is insufficient evidence to
recommend the routine performance of a
standardized battery of diagnostic tests in
patients who meet symptom-based
criteria for IBS.

Am J Gastroenterol 2002; 97:2812-9.

 Positive Manning or Rome 3?
Absence of alarm symptoms?
Symptom Pattern?
Also explore
Dietary fiber and food intolerances
Family history of intestinal disease or
malignancy
Family stress
Abuse history?
Depression or anxiety
Effect of symptoms on daily life
 What are important parts of the
management of IBS?
 Strong physician-patient relationship
Education, reassurance
Dietary
Reduce EtOH, caffeine, fat (?????)
Explore triggers
Lifestresses
Foods
Symptom-specific medications
Pain predominant
Diarrhea predominant
Constipation predominant
1. Provide information about IBS and normal GI
functioning, discuss the role of stress.
2. Analyze the patient's illness in terms of
symptoms, circumstances of first onset, symptom
triggers, contributing factors, and consequences.
3. Teach relaxation techniques.
4. Teach patients to identify irrational thoughts
regarding their GI problems.
5. Discuss ways people cope with the problems
that chronic illness brings to daily life.
6. Discuss ways to manage difficulties the
individual may have in social situations caused
by GI problems.
Ann Int Med 133: 136. JFP 52: 942
Improved Pain Good evidence for
Amitryptiline Tegaserod for
Improved Constipation constipation*
Ispaghula (Psyllium) Alosetron for
Ondansetron women with
Improved Diarrhea diarrhea IBS *
Ispaghula (Psyllium) Fair evidence for
Amitryptiline TCAs for Pain
Ondansetron Loperamide for
Diarrhea
Bulk for
Constipation
Antispasmodics for
Global Symptoms
 Constipation- predominant IBS
Guar gum, fiber, exercise, episodic use of
antispasmodics, peppermint oil, and adequate
fluid intake.
Diarrhea-predominant IBS
Loperamide, episodic use of antispasmodic
agents, peppermint oil, and dietary
manipulation
Patients with pain-predominant or severe IBS
TCAs and psychotherapy should be
considered.
 Perform a symptom-directed history and exam
Use lab testing judiciously if indicated
Defer further testing or imaging unless clearly
indicated
Begin education on the interaction of
emotional factors, coping styles, environmental
stressors and physiologic factors in IBS
Begin working to establish a strong physician-
patient relationship
Consider a trial of dietary adjustments
Consider pharmacologic interventions based
on the patients symptom pattern