In the Clinic

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Downloaded From: http://annals.org/ by McGill University, Teresa Rudkin on04/08/2016 Jennifer F. Wilson Science Writer David Goldmann,MD Christine Laine,MD,MPH Section Editors The contentof CME Questions Patient InformationPage Practice Improvement Treatment Diagnosis PIER education resourcesofthe © 2007 AmericanCollegeofPhysicians judgment. The informationcontainedhereinshouldneverbeusedasasubstituteforclinical resources referencedineachissueof primary resourcesformoredetailcanconsulthttp://pier.acponline.org andother MKSAP of sciencewritersandphysicianwriters.Editorialconsultantsfrom the ACP’s MedicalEducationandPublishing Divisionandwiththeassistance editors develop Knowledge andSelf-AssessmentProgram). Syndrome Irritable Bowel in theclinic (Physicians’ InformationandEducationResource) provide expertreviewofthecontent.Readerswhoareinterestedinthese In theClinic In theClinic American CollegeofPhysicians is drawnfromtheclinicalinformationand from theseprimarysourcesincollaborationwith In theClinic Annals ofInternalMedicine . MKSAP (ACP), including page ITC7-16 page ITC7-15 page ITC7-14 page ITC7-8 page ITC7-2 PIER (Medical and in the clinic rritable bowel syndrome (IBS) is a common but poorly understood disorder that interferes with normal colon function, resulting in abdominal I pain, bloating, constipation, and diarrhea. No specific biological bio- marker, physiologic abnormality, or anatomical defect has been discovered. Psychosocial stress may exacerbate symptoms. IBS is 1 of 28 adult and 17 pediatric functional gastrointestinal disorders. These disorders are symptom-based and not explained by other pathologically defined diseases. IBS appears to be linked to motor and sensory physiology and brain–gut interaction (1). Emerging theories suggest that alteration of intestinal bacteria may also play a role in the condition. IBS affects as many as 1 in 5 U.S. adults, occurs more often in women than in men, and begins before the age of 35 in about half of all people who develop the disorder. IBS is recognized worldwide, but prevalence varies geographically. Diagnosis What symptoms should prompt a individual patient’s symptom clinician to consider IBS? pattern can change over time, it Symptoms of IBS vary from person is debatable whether symptom to person, but clinicians should pattern clearly demarcates consider IBS if abdominal discom- patients with different IBS fort or pain associated with bowel subtypes. dysfunction is present. Other symptoms that suggest IBS include Certain clinical features, often prominent gastrocolic reflex, alter- called alarm features or red flag nating constipation and diarrhea, symptoms, suggest that the diagno- and excess gas and sis is something other than IBS (2) flatulence. Gas- (see Box). Alarm features include trointestinal symp- Alarm Features That Suggest toms that wax and Possible Organic Disease weight loss, noctur- wane for more nal awakening be- Symptoms cause of gastroin- than 2 years and • Weight loss those that are exac- • Frequent nocturnal awakenings testinal symptoms, erbated by psy- due to gastrointestinal blood in the stool, chosocial stress symptoms family history of should raise suspi- • Fever colon cancer or in- cion for IBS • Blood mixed in stool flammatory bowel over other History disease, recent use diagnoses. • New onset, progressive of antibiotics, and symptoms fever. Three general pat- • Onset of symptoms after age 50 terns of bowel • Recent antibiotic use What are the symptoms are • Family history of colon cancer or accepted diagnostic 1. Drossman DA. The inflammatory bowel disease functional gastroin- common in IBS: criteria for IBS? testinal disorders and Physical Findings the Rome III process. diarrhea-predomi- • Abdominal mass History is the main Gastroenterology. nant, constipation- diagnostic tool for 2006;130:1377-90. • Stool positive for occult blood [PMID: 16678553] predominant, and • Enlarged lymph nodes IBS. There are 2 2. Longstreth GF. Irrita- mixed (alternating sets of symptom- ble bowel syndrome. Diagnosis in the diarrhea and con- based diagnostic cri- managed care era. Dig Dis Sci. stipation). Determining a patient’s teria to help discriminate IBS from 1997;42:1105-11. predominant symptom pattern can other disorders: the Manning crite- [PMID: 9201069] 3. Manning AP, Thomp- be useful in guiding management ria and the Rome criteria (Table 1). son WG, Heaton KW, because the different subgroups These criteria were developed for Morris AF. Towards positive diagnosis of respond differently to the various use in clinical studies, but can be the irritable bowel. Br Med J. 1978;2:653-4. therapeutic options. Because an helpful in clinical settings. [PMID: 698649]

Downloaded From: http://annals.org/ by McGill University, Teresa Rudkin on 04/08/2016 Manning and colleagues (3) pro- recommends that clinicians base posed the first widely used IBS cri- classification of IBS symptoms as When Rome criteria have been teria in 1978 based on the symp- diarrhea-prominent; constipation- satisfied, warning symptoms toms listed in Table 1. prominent; or mixed, based on stool consistency. Rome criteria are are absent; the history and In 1989, a group of experts met in dynamic, and future studies are Rome and developed another set of physical examination suggest consensus-based criteria known as needed to confirm the validity of IBS; and the occult blood test, the Rome criteria to assist in the recent changes intended to increase diagnosis of IBS and other func- the usefulness of the criteria in re- complete blood count, and tional gastrointestinal disorders (4). search and clinical settings (1). erythrocyte sedimentation The Rome criteria, which are also When diagnostic criteria are satis- rate are normal, the risk for displayed in Table 1, were based on a broader array of symptoms than fied; warning symptoms are absent; overlooking organic disease the history and physical examina- the Manning criteria and explicitly may be as low as 1% to 3%. considered both duration and fre- tion suggest IBS; and the occult quency of symptoms. In 1999, the blood test, complete blood count same group of experts developed (CBC), and erythrocyte sedimenta- the Rome II criteria, a modified tion rate (ESR) are normal, the risk version of the earlier criteria in- for overlooking organic disease may tended to be more adaptable to be as low as 1% to 3%. Thus, ex- clinical practice (5). pert consensus is that physicians should limit evaluation to fulfill- The group released the most recent ment of the Rome or Manning version of the Rome criteria, Rome criteria if no alarm symptoms are III, in 2006. Rome III did not present. change the basic diagnostic criteria for IBS but modified the time frame Even without exclusion of alarm features, for symptoms and description of the presence of at least 3 of the 6 Manning IBS subtyping (6). Rome III speci- criteria has an average sensitivity of ap- fies that symptoms must have begun proximately 60% and specificity of approx- at least 6 months before the diag- imately 80%. The criteria’s sensitivity and nosis can be established and that specificity vary by study; however, the diag- patients have fulfilled the Rome nostic accuracy is known to be better in criteria for at least 3 months before women, younger patients, and when more IBS can be diagnosed. Rome III criteria are fulfilled (7).

Table 1. Symptom Criteria for Irritable Bowel Syndrome 4. Thompson WG, Dote- wall G, Drossman DA, Rome III* et al. Irritable bowel Recurrent abdominal pain or discomfort at least 3 days per month in the past 3 months syndrome: guidelines for the diagnosis. associated with 2 or more of the following: Gastroenterol Int. 1. Improvement with defecation 1989;2:92-95. 5. Thompson WG, 2. Onset with change in frequency of stool Longstreth GF, Dross- man DA, et al. Func- 3. Onset associated with a change in the form and appearance of stool tional bowel disorders and functional *Criteria must be fulfilled for at least the past 3 months with symptom onset at least 6 months before abdominal pain. Gut. diagnosis. 1999;45 Suppl 2:II43- 7. [PMID: 10457044] 6. Longstreth GF, † Manning Thompson WG, Chey WD, et al. Functional Pain relief with defecation, often bowel disorders. Gas- Looser stools at pain onset, often troenterology. 2006;130:1480-91. More frequent stools at pain onset, often [PMID: 16678561] 7. Talley NJ, Phillips SF, Visible abdominal distention Melton LJ, et al. Diag- Mucus per rectum nostic value of the Manning criteria in ir- Feeling of incomplete evacuation ritable bowel syndrome. Gut. †To establish IBS diagnosis, patient must meet 3 or more criteria. 1990;31:77-81. [PMID: 2318433]

Downloaded From: http://annals.org/ by McGill University, Teresa Rudkin on 04/08/2016 Tolliver and coworkers showed that the fulfill the Rome criteria, and have Rome criteria had a positive predictive val- no alarm features, a presumptive ue of 98.5%—out of 196 patients, they ex- diagnosis of IBS can be made with- cluded 1 case of colon cancer, 1 of colitis, out endoscopy but should be and 1 of peptic ulcer (8). reevaluated depending on the Vanner and colleagues prospectively stud- course of symptoms over time. Be- ied 95 patients who met the Rome criteria cause patients with IBS have ab- and lacked red flags and found the positive normally sensitive gastrointestinal predictive value was 98% (9). tracts, they may find endoscopy more uncomfortable than do pa- Investigators conducted interviews with a large, community-based sample of U.S. tients without this condition. Rec- women diagnosed with IBS, and they tal and colonic balloon studies have found that Rome I was significantly more shown hypersensitivity of the intes- sensitive than Rome II (84% vs. 49%; P < tines in 55% to 93% of patients 0.001). Only 58% of patients who had IBS with IBS (11). Thus, normal according to Rome I criteria had IBS ac- endoscopy can be particularly in- cording to Rome II criteria; 17.7% did not dicative of IBS when it causes more meet the criteria for either Rome I or II (10). pain than expected or when it re- produces the patient’s symptoms. What is the utility of the physical examination in diagnosing IBS? Blood Tests The physical examination is usually A CBC and an ESR are reasonable normal in IBS, except for mild ab- to evaluate for anemia, elevated dominal tenderness or a palpable, sedimentation rate, or leukocytosis tender loop of colon. However, because these findings are not com- neither is sensitive or specific for patible with IBS. Serum amylase IBS. Physical findings that are not and liver enzyme levels may be use- associated with IBS but that are ful if pancreatic or biliary disease is notable because they indicate the suspected. need to seek other diagnoses include fever, weight loss, lymph Evaluation of Stool Samples node enlargement, abdominal mass, Evaluation of stool for Clostridium and hepatosplenomegaly. The difficile may be helpful if the patient physical examination should in- has recently taken antibiotics. Ex- clude testing the stool for occult amination of stool for ova and par- blood. asites may be helpful in patients with diarrhea-predominant symp- Which diagnostic tests are useful toms, especially if travel history in diagnosing IBS? 8. Tolliver BA, Herrera suggests potential exposure to para- JL, DiPalma JA. Eval- There are no specific diagnostic uation of patients sites. In general, bacterial cultures who meet clinical tests for IBS. Tests that may be are unlikely to be helpful in the di- criteria for irritable helpful for ruling out diagnoses bowel syndrome. agnosis of chronic diarrhea. How- Am J Gastroenterol. other than IBS include endoscopy, 1994;89:176-8. ever, there is a form of IBS in blood tests, evaluation of stool [PMID: 8304298] which patients develop typical IBS 9. Vanner SJ, Depew samples, and imaging studies. Clin- WT, Paterson WG, et symptoms after resolution of an al. Predictive value of icians should use these tests with the Rome criteria for acute episode of dysentery. This diagnosing the irrita- discretion depending on the pa- ble bowel syndrome. tient’s age, history, and symptom condition may take 6 months to re- Am J Gastroenterol. solve and can lead to chronic IBS. 1999;94:2912-7. pattern, and on the presence of [PMID: 10520844] Factors associated with post infec- 10. Chey WD, Olden K, alarm features for organic disease. Carter E, et al. Utility tious IBS include age, female sex, of the Rome I and Endoscopy severity of infection, and possibly Rome II criteria for irritable bowel syn- Flexible sigmoidoscopy may be psychological predisposition. drome in U.S. women. Am J Gas- helpful in excluding colitis or Awareness of the condition can troenterol. obstructive lesions of the colon. limit the search for persistent 2002;97:2803-11. [PMID: 12425552] However, if patients are young, infection.

Downloaded From: http://annals.org/ by McGill University, Teresa Rudkin on 04/08/2016 Stool collection over a 24-hour pe- no definitive data support routine riod for quantification of volume performance of any diagnostic may be helpful in patients who re- tests in patients with potential port large-volume or watery diar- IBS. Clinicians should consider rhea. Normal stool volume is 200 symptom patterns when trying to mL or less per day. Volumes over exclude serious diagnoses that can 350 to 400 mL suggest etiologies masquerade as IBS. other than IBS. Patients with Constipation-Prominent Measurement of fecal calprotectin Symptoms in stool samples can help to identi- In patients with constipation, clini- fy patients with intestinal inflam- cians should consider partial mation as an organic cause of colonic obstruction or non-IBS symptoms mimicking IBS. In one causes of colonic dysmotility. study, the positive predictive value Nonobstructive causes of colonic of fecal calprotectin for organic dis- symptoms may be because of dys- ease was 76% and the negative pre- motility secondary to medications, dictive value was 89% (12). neurologic disease, hypothyroidism, pelvic floor dysfunction, or colonic A spot or 24-hour fecal fat test can inertia (colon transit > 5 days). The show malabsorption. Screening for diagnosis is not IBS if colonic dys- celiac sprue with antigliadin and motility is present without pain or antiendomysial antibodies is both if there is another explanation for sensitive and specific (13). If no fat symptoms, such as neurologic dis- malabsorption is detected, clini- order, pelvic floor disorder, or cians may still consider these anti- colonic inertia (transit through body tests in patients with unex- colon > 72 hours, with predomi- plained anemia or weight loss. nantly right colon delay). In pa- Imaging Studies tients younger than 45 years of age Imaging studies should be used ju- with mild, chronic constipation- diciously, but the following tests predominant symptoms, normal may help to exclude conditions that CBC, and no alarm features, treat- could mimic IBS. A flat and up- ment with fiber or an osmotic right abdominal radiograph during laxative should be offered before an episode of pain may show un- additional diagnostic testing. recognized bowel obstruction, aerophagia, or retained stool. A Patients with Diarrhea-Predominant 11. Mertz H, Naliboff B, Symptoms Munakata J, Niazi N, small bowel barium radiograph can Mayer EA. Altered The differential in patients with rectal perception is a diagnose ileal and jejunal Crohn biological marker of diarrhea-predominant symptoms patients with irrita- disease, and dilatation or diverticula ble bowel syndrome. favoring small bowel overgrowth. includes inflammatory bowel dis- Gastroenterology. ease, infection, malabsorption, and 1995;109:40-52. Computed tomography (CT) scan- [PMID: 7797041] ning will have low yield if there are effects of medication and diet. For 12. Tibble JA, Sigthors- younger patients with mild, chronic son G, Foster R, For- no alarm symptoms. gacs I, Bjarnason I. diarrhea-predominant symptoms, Use of surrogate markers of inflam- What is the differential diagnosis clinicians should consider flexible mation and that clinicians should consider sigmoidoscopy, CBC, and exami- Rome criteria to distinguish organic when evaluating a patient for nation of stools for ova and para- from nonorganic intestinal disease. possible IBS? sites. For patient older than 45 Gastroenterology. The differential diagnosis of a pa- years or those with refractory, 2002;123:450-60. [PMID: 12145798] tient presenting with symptoms of severe, or new-onset symptoms, 13. Bürgin-Wolff A, Gaze evaluating the entire colon may be H, Hadziselimovic F, IBS is extensive (Table 2). Thus, et al. Antigliadin and some clinicians feel obligated to warranted to exclude neoplasm. antiendomysium an- tibody determina- perform a wide variety of diagnos- However, clinicians must keep in tion for coeliac dis- tic tests before attributing a pa- mind that non-IBS disease is ease. Arch Dis Child. 1991;66:941-7. tient’s symptoms to IBS. However, unlikely if the patient satisfies [PMID: 1819255]

Downloaded From: http://annals.org/ by McGill University, Teresa Rudkin on 04/08/2016 Table 2. Differential Diagnosis of Irritable Bowel Syndrome* Disease Clinical Characteristics Diagnostic Strategy Constipation-predominant symptoms Strictures due to inflammatory Obstipation Colonoscopy vs. barium enema and bowel disease, diverticulitis, flexible sigmoidoscopy ischemia, or cancer Colonic inertia Very infrequent bowel movements Sitzmark transit study Pelvic floor dysfunction† Straining, self-digitation Rectal examination, balloon expulsion study, anoretal manometry, defecography Neurologic disease† Concurrent Parkinson disease, History and neurologic examination autonomic dysfunction (Shy-Drager), multiple sclerosis Medication† Opiates, cholestyramine, calcium- Medication history channel blockers, anticholinergic medications Hypothyroidism† Other hypothyroid symptoms and signs Serum thyroid-stimulating hormone

Diarrhea-predominant symptoms Crohn disease Diarrhea may be from Colonoscopy, small bowel barium radiograph inflammatory exudate, motility changes, small bowel overgrowth, or bile salt malabsorption Ulcerative colitis Likely to have rectal bleeding Colonoscopy Microscopic colitis† Generally middle-aged and older Colonoscopy/flexible sigmoidoscopy and biopsy women with autoimmune disease (especially thyroiditis) Parasites Giardia lamblia (stream and well O + P x 3, stool Giardia antigen, water); Ascaris lumbricoides, metronidazole trial Entamoeba histolytica (travel to developing world); Strongyloides stercoralis (travel to developing world, Kentucky, or Tennessee) Clostridium difficile Recent antibiotics taken Stool ELISA, flexible sigmoidoscopy for pseudomembranes Other bacteria IBS after dysentery may persist for Compatible history, possible initial months after infection with bacteria positive stool culture Small bowel overgrowth Due to severe small bowel Abdominal radiograph, small bowel barium dysmotility, partial obstruction, radiograph, lactulose breath hydrogen test, blind loop, or jejunal diverticulosis antibiotic trial Sprue† (gluten-sensitive enteropathy) May present with diarrhea, usually Usually steatorrhea, positive gliadin, steatorrhea endomysial serum antibodies; endoscopy with small bowel biopsy is gold standard Lactose intolerance† Symptoms worse with lactose Avoidance trial, lactose breath test consumption Postgastrectomy syndrome Postprandial symptoms History of problems worse after gastric surgery HIV enteropathy May have chronic GI infections, Clinical suspicion, HIV test, low CD4 such as with cryptosporidium, CMV, Blastocystis hominis, amoeba Gastrointestinal endocrine tumor Carcinoid, gastrinoma, VIPoma Urine 5HIAA, fasting gastrin (followed by secretin stimulation test), serum VIP

Pain-predominant symptoms Aerophagia, bloating Patient may be anxious (nervous air Abdominal radiograph with pain swallowing), can be exacerbated by antireflux surgery Intermittent small bowel More likely with history of previous Abdominal radiograph with pain, small abdominal surgeries bowel barium radiograph

Downloaded From: http://annals.org/ by McGill University, Teresa Rudkin on 04/08/2016 Table 2. Differential Diagnosis of Irritable Bowel Syndrome* (continued) Disease Clinical Characteristics Diagnostic Strategy Crohn disease Small intestine or colon involvement Small bowel barium radiograph colonoscopy Acute intermittent porphyria Rare; may have elevated liver Serum and urine porphyrins, especially enzymes and neurologic symptoms porphobilinogen, and delta aminolevulinic acid

Ischemia Intestinal angina especially in Mesenteric angiogram vasculopaths, food aversion, weight loss, pain 15–40 min after meals Chronic pancreatitis Alcohol abuse, pain usually more Abdominal radiograph for calcifications, CT persistent than with usual IBS scan, ERCP, endoscopic ultrasonography Lymphoma of Gl tract Generally, weight loss CT scan, small bowel radiograph Endometriosis Menstrual-associated symptoms, Laparoscopy pelvic symptoms

*CMV = cytomegalovirus; CT = computed tomography; ELISA = enzyme-linked immunosorbent assay; ERCP = endoscopic retrograde cholangiopancre- atography; GI = gastrointestinal; IBS = irritable bowel syndrome; O + P = ova and parasites; VIPoma = vasoactive intestinal peptide-producing tumor. †Unlikely alone to cause abdominal pain.

Rome criteria and lacks alarm endometriosis (in general cyclic symptoms. with menses).

Patients with Pain-Predominant Clinicians should use clinical judg- Symptoms ment to modify these general In patients with refractory, pain- guidelines to allow less or more predominant symptoms, a flat and evaluation. upright abdominal radiograph dur- Under what circumstances should ing a pain episode can be helpful in clinicians consider consultation revealing unrecognized bowel ob- with a gastroenterologist? struction, aerophagia, or retained Gastroenterologists often work stool. Serum amylase and liver en- with primary care physicians and zyme levels may diagnose pancreat- patients to diagnose IBS and to ex- ic and biliary disease if symptoms clude relevant disorders. Consulta- suggest these diagnoses. CT scan- tion is warranted in the following ning for neoplasms will have low cases of diagnostic uncertainty: when patients do not fit Rome or yield if there are no alarm symp- Manning criteria, when patients toms. Other rare conditions that have alarm symptoms, and when may cause pain-predominant patients do not respond to initial abdominal symptoms with some management. Consultation is also bowel dysfunction include intestinal necessary if specialized diagnostic angina (generally associated with procedures, such as endoscopy, weight loss and occult blood) and are needed.

Diagnosis... Clinicians should base the diagnosis of IBS on history and physical examination, paying careful attention to fulfillment of the Rome or Manning criteria and exclusion of alarm features. Patients who fulfill the criteria and have no alarm features may need no additional testing other than a complete blood count and test for fecal occult blood to establish a presumptive diagnosis of IBS. Diagnostic testing should be judicious and focus on exclusion of specific non-IBS conditions that are consistent with the individual patient’s clinical presentation.

CLINICAL BOTTOM LINE

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Is dietary modification effective in A systematic review studied the role of 14. Prior A, Whorwell PJ. the management of IBS? bulking agents in IBS (wheat bran, corn Double blind study fiber, calcium polycarbophil, ispaghula of ispaghula in irrita- Dietary modification is not proven ble bowel syndrome. to reduce IBS symptoms, and ma- husk, and psyllium) and concluded that Gut. 1987;28:1510-3. they were no more effective than placebo [PMID: 3322956] jor exclusion diets are not recom- 15. Müller-Lissner SA. Ef- mended. However, it may be in providing global symptom relief of IBS . fect of wheat bran However, the authors deemed all of the tri- on weight of stool reasonable to consider dietary and gastrointestinal als inadequate because of methodological transit time: a meta modification for individual cases in flaws or small sample size (16). analysis. Br Med J which specific foods seem to trigger (Clin Res Ed). 1988;296:615-7. symptoms. In addition, common- Are there nonpharmacologic [PMID: 2832033] 16. Brandt LJ, Bjorkman sense dietary recommendations di- interventions aside from diet D, Fennerty MB, et al. rected at the predominant symptom Systematic review that are useful in the on the management can help to minimize symptoms. management of IBS? of irritable bowel syndrome in North Clinicians should talk with patients In addition to advice about diet, America. Am J Gas- about their dietary habits to: troenterol. important nonpharmacologic as- 2002;97:S7-26. pects of IBS care include reassur- [PMID: 12425586] • Evaluate for lactose intolerance 17. Colwell LJ, Prather • Evaluate consumption of caf- ance, education with advice about CM, Phillips SF, Zins- trigger avoidance, stress manage- meister AR. Effects of feine, fructose, or artificial an irritable bowel ment, and exercise. Clinicians must syndrome educa- sweeteners, all of which can tional class on have laxative effects reassure patients that their symp- health-promoting toms are not because of a life- behaviors and symp- • Inquire about laxative-contain- toms. Am J Gas- threatening disorder and assist troenterol. ing herbal products 1998;93:901-5. • Determine whether patients them in developing effective self- [PMID: 9647015] management strategies. Patients do 18. Owens DM, Nelson with gas and bloating are drink- DK, Talley NJ. The irri- ing excess carbonated beverages, better and use health care more ef- table bowel syndrome: long-term drinking with a straw, or chew- ficiently when it is acknowledged prognosis and the that their symptoms are not imag- physician-patient in- ing gum, all of which can lead a teraction. Ann Intern person to swallow too much air ined, that the symptoms have physi- Med. 1995;122:107- 12. [PMID: 7992984] • Advise against excess intake of ologic causes that are poorly under- 19. Creed F, Craig T, fats, which can lead to gas stood but real, and that they can Farmer R. Functional abdominal pain, psy- retention themselves control some symptom chiatric illness, and life events. Gut. • Advise avoidance of certain car- triggers. 1988;29:235-42. bohydrates, such as beans, cab- [PMID: 3345935] bage, broccoli, and cauliflower, In an uncontrolled study, advice about diet 20. Bennett EJ, Tennant and exercise, stress management, and ap- CC, Piesse C, Bad- if they trigger symptoms. They cock CA, Kellow JE. may be difficult to digest and propriate use of medications was associat- Level of chronic life ed with alleviation of IBS symptoms in 80% stress predicts clini- lead to fermentation and gas in cal outcome in irrita- of patients (17). ble bowel syndrome. the colon. Gut. 1998;43:256-61. [PMID: 10189854] Retrospective analysis of outpatient charts 21. Drossman DA, San- Inadequate dietary fiber may cause at a referral center showed a correlation dler RS, McKee DC, Lovitz AJ. Bowel pat- constipation, and clinicians often between patient education, including dis- terns among sub- encourage patients with constipation- cussion of psychosocial stressors, and re- jects not seeking health care. Use of a predominant IBS to increase fiber duced future visits(18) . questionnaire to intake. Studies suggest that fiber is identify a population with bowel dysfunc- helpful for relief of constipation, It may be helpful to ask patients to tion. Gastroenterolo- gy. 1982;83:529-34. but not for relief of pain (14, 15). complete daily diaries of symptoms, [PMID: 7095360] Fiber is not effective for patients including entries for stressors, 22. Drossman DA, Leser- man J, Nachman G, with diarrhea-predominant IBS mood, events, thoughts, and diet. et al. Sexual and Clinicians should use the diary physical abuse in and may even exacerbate symp- women with func- toms. Achieving constipation relief information to help patients under- tional or organic gastrointestinal dis- with fiber may require high-dose stand the role of psychosocial stres- orders. Ann Intern therapy, which patients are often sors and to help them develop self- Med. 1990;113:828- 33. [PMID: 2240898] unable to tolerate. management strategies.

Downloaded From: http://annals.org/ by McGill University, Teresa Rudkin on 04/08/2016 What is the role of psychotherapy include antispasmodics, laxatives, in the care of patients with IBS? antidiarrheals, antidepressants, and Psychosocial stressors are associated antibiotics. IBS drugs are described with symptoms (19–21). Patients in Table 3. Limited effectiveness of with IBS are more likely to have conventional treatment options is had early life or current trauma, frustrating for patients but also including losses or abuse (22), and common. are more likely to have generalized anxiety disorder and worry (23). In a study of 350 IBS patients, more than Psychological distress is associated half of patients (55%) taking prescription drugs for IBS felt that they were ineffective 23. Hazlett-Stevens H, with IBS after dysentery (24). Psy- Craske MG, Mayer chological therapy to minimize or only somewhat effective, more than EA, Chang L, Naliboff BD. Prevalence of ir- anxiety can reduce symptoms. 60% reported adverse effects from these ritable bowel syn- medications, and 40% of patients taking drome among uni- One randomized, controlled trial (RCT) versity students: the over-the-counter medications reported roles of worry, neu- involving patients whose symptoms had that they were ineffective (29). roticism, anxiety not improved with sensitivity and visceral anxiety. J Psy- standard medical treat- The U.S. Food and chosom Res. ment for at least 6 2003;55:501-5. Stress management options Drug Administra- [PMID: 14642979] months showed that include the following: tion (FDA) has ap- 24. Gwee KA, Leong YL, two thirds of the pa- Graham C, et al. The • Stress reduction training and role of psychological tients receiving psy- proved only 2 drugs relaxation therapies, such as to treat IBS: and biological fac- chotherapy had less di- meditation tors in postinfective tegaserod maleate, a gut dysfunction. arrhea but not less • Counseling and support Gut. 1999;44:400-6. 5-HT –receptor ag- constipation; they also • Regular exercise, such as 4 [PMID: 10026328] onist that increases 25. Guthrie E, Creed F, had less intermittent walking or yoga Dawson D, Tomen- pain, but those with • Changes to the stressful intestinal motility, son B. A controlled constant abdominal trial of psychological situations in your life and alosetron hy- treatment for the ir- pain did not improve • Adequate sleep drochloride, a ritable bowel syn- (25). drome. Gastroen- • Hypnotherapy. 5-HT3–receptor an- terology. tagonist medication 1991;100:450-7. Other research has [PMID: 1985041] that decreases ab- 26. North of England IBS found that pscho- dominal sensitivity. However, Research Group. The therapy also results in decreased use cost-effectiveness of tegaserod was taken off the market psychotherapy and of health care resources. So while paroxetine for severe in March 2007 because of safety irritable bowel syn- psychotherapy has costs on the drome. Gastroen- concerns, and use of alosetron has terology. front end, it may reduce long-term been restricted. 2003;124:303-17. medical costs (26). However, trials [PMID: 12557136] 27. Talley NJ, Owen BK, of psychological treatment in IBS Antispasmodics Boyce P, Paterson K. Antispasmodics are indicated on Psychological treat- have methodological inadequacies, ments for irritable mostly because of difficulties in an as-needed basis as a first-line bowel syndrome: a critique of con- creating a true control group or in treatment for IBS pain. The 2 trolled treatment tri- adequately blinding trials (27). antispasmodics available in the als. Am J Gastroen- terol. Consequently, it has not been de- United States, dicyclomine and 1996;91:277-83. hyoscyamine, block the action of [PMID: 8607493] finitively determined whether psy- 28. Jailwala J, Imperiale chotherapy is any more beneficial acetylcholine at parasympathetic TF, Kroenke K. Phar- macologic treat- for IBS than other interventions. sites in secretory glands, smooth ment of the irritable muscle, and the central nervous bowel syndrome: a systematic review of Which pharmacologic therapies system. The effect is reduced con- randomized, con- are effective in IBS? tractions in the colon. The drugs trolled trials. Ann Intern Med. The choice of drug therapy de- are particularly helpful when taken 2000;133:136-47. [PMID: 10896640] pends on an individual’s symptoms, before meals if postprandial ur- 29. International Foun- and effectiveness varies from pa- gency, diarrhea, and cramping are a dation for Functional Gastrointestinal Dis- tient to patient (28). Drugs used in problem. Adverse reactions increase orders. IBS in the real management of patients with IBS as dose increases. world survey. Mil- waukee, WI: Interna- tional Foundation for Functional Gas- trointestinal Disor- ders; 2002:1-19.

Downloaded From: http://annals.org/ by McGill University, Teresa Rudkin on 04/08/2016 Table 3. Drugs Commonly Used in the Treatment of Irritable Bowel Syndrome* Class/Agent Mechanism of Action Dosing Benefits Side Effects Notes Antispasmodics Reduce contractions Generally given as Reduce pain Dry mouth, somnolence, Effective to blunt (Dicycolime, in colon and small needed, especially constipation, urine gastrocolonic response if hyocsyamine) bowel that may before meals retention, diplopia; side diarrhea/urgency or produce diarrhea effects usually minor postprandial pain; first-line and cramps agents for pain Combination Additive effect of Generally given as Useful for pain, Drowsiness, additive Potential for abuse antispasmodics/ sedative to reduce needed, especially especially if effect with alcohol; minimized by anticholinergic sedatives GI motility before meals patient anxious other side effects similar component Clidinium, and anti- to those of antispasmodics; bromide/ spasmodics do not take before chlordia- alone have driving or tasks zepoxide, failed requiring alertness phenobarbital, hyocsyamine, atropine/ scopolamine Laxatives Draw water into colon Titrate to effect Reduce Hypermagnesemia, Less cramping and probably PEG solution, distention of hyperphosphatemia safer long-term than magnesium colon due to if renal insufficiency; stimulant cathartics (which citrate, sodium retained stool; can cause gas and may cause tachyphylaxis phosphate, PEG-based bloating and “cathartic colon”); sorbitol lavage solutions first-line agents after fiber useful for severe in constipation-predominant constipation when IBS; avoid in IBS with gas a few glasses are and bloating taken at bedtime Antidiarrheals µ-Opiate agonists have Titrate to effect Reduce diarrhea Can cause constipation; No known long-term Loperamide, primarily gut effect but not pain atropine can give dry sequelae from repeated diphenoxylate/ to increase segmenting mouth, urine retention, use; loperamide has no atropine contractions and decrease tachycardia CNS penetration; abuse propulsive ones of diphenoylate prevented by combination with atropine Antidepressants Mechanism is uncertain Lower doses than Reduce pain Anticholinergic effects Tricyclics are first-line Tricyclics, needed to treat with tricyclics, diarrhea agents in patients with pain SSRIs depression with SSRIs and diarrhea, no definitive data on SSRIs Antibiotics Aims to restore Rifaximin 400 mg Symptom Antibiotic resistance; Resistance is less of a Neomycin, normal intestinal 3 times/d for improvement ototoxicity and CNS concern with rifaximin rifaximin bacteria 10 days in correlates with symptoms with because it is not absorbed recent trial normalization of neomycin intestinal bacteria

*CNS = central nervous system; GI = gastrointestinal; IBS = irritable bowel syndrome; PEG = polyethylene glycol; SSRIs = selective serotonin reuptake inhibitors.

For patients who are anxious or for which incorporated only trials of anti- whom antispasmodics alone are not spasmodics that are not approved by the 30. Poynard T, Naveau S, successful, clinicians should consid- FDA (cimetropium bromide, pinaverium Mory B, Chaput JC. Meta-analysis of er a sedative–antispasmodics com- bromide, trimebutine, octilium bromide, smooth muscle re- and mebeverine), found that the drugs laxants in the treat- bination. The risk for abuse of ment of irritable sedative–antispasmodics is low be- were significantly better than placebo bowel syndrome. Al- for improving overall symptoms and iment Pharmacol cause of the small dose of sedatives Ther. 1994;8:499-510. in most formulations and because pain. Patients receiving active drugs had [PMID: 7865642] more adverse effects (6% mean difference; 31. Drossman DA, of the unpleasant anticholinergic Whitehead WE, side effects that occur with dose P < 0.01) than those receiving placebo, but Camilleri M. Irritable the adverse reactions were not serious (30). bowel syndrome: a elevation. technical review for practice guideline Laxatives development. Gas- A meta-analysis of 26 RCTs with antispas- troenterology. modics supports their utility in the man- Expert consensus suggests osmotic- 1997;112:2120-37. [PMID: 9178709] agement of IBS symptoms. The study, type laxatives if fiber is unsuccessful

Downloaded From: http://annals.org/ by McGill University, Teresa Rudkin on 04/08/2016 for initial therapy of constipation Other opioid antidiarrheal agents (31). Osmotic laxatives, like mag- are also likely to be effective. nesium citrate or sodium phos- Diphenoxylate hydrochloride com- phate, are used to rapidly empty bined with atropine sulfate is used the lower intestine and bowel. in IBS to slow gastrointestinal Although not usually used for transit. Diphenoxylate is a consti- long-term or repeated correction of pating meperidine congener that constipation, they are considered reduces excessive gastrointestinal safe and effective for severe consti- propulsion and motility, and at- pation when used daily or as need- ropine discourages abuse by speed- ed. Low-dose daily administration ing up the heart rate. Diphenoxy-

of another type of hyperosmotic late may exacerbate constipation. 32. Andorsky RI, Gold- laxative, polyethylene glycol, in- ner F. Colonic lavage 5-HT Antagonists solution (polyethyl- creases bowel frequency and ene glycol elec- Tegaserod, a 5-HT –receptor ago- trolyte lavage solu- decreases symptoms in chronic 4 nist, was the only drug approved by tion) as a treatment constipation in which fiber supple- for chronic constipa- the FDA for relief of abdominal tion: a double-blind, mentation is not successful (32). placebo-controlled Polyglycol is a large molecule that discomfort, bloating, and constipa- study. Am J Gas- tion in patients with IBS (35). troenterol. causes water to be retained in the 1990;85:261-5. However, on March 30, 2007, the [PMID: 2178398] stool, which softens the stool and 33. Cann PA, Read NW, increases the number of bowel FDA requested that the manufac- Holdsworth CD, turer withdraw tegaserod from the Barends D. Role of movements. loperamide and market because of an association placebo in management of irritable Patients with IBS should avoid between use of the drug and myo- bowel syndrome regular use of stimulant cathartics, cardial infarction and stroke. In an (IBS). Dig Dis Sci. 1984;29:239-47. such as senna, cascara, and phe- analysis of over 18 000 patients, [PMID: 6365490] adverse cardiovascular events 34. Efskind PS, Bernklev nolphthalein. Stimulant cathartics T, Vatn MH. A dou- increase the risk for cramps and occurred in 13 of 11 614 patients ble-blind placebo- controlled trial with tachyphylaxis and may lead to a (0.11%) receiving tegaserod com- loperamide in irrita- pared with 1 of 7031 patients ble bowel syndrome. markedly slow “cathartic colon.” Scand J Gastroen- (0.01%) receiving placebo terol. 1996;31:463-8. Antidiarrheals [PMID: 8734343] (www.fda.gov/cder/drug/advisory/ 35. Talley NJ. Serotonin- Nonabsorbable synthetic opioids tegaserod.htm). ergic neuroenteric modulators. Lancet. can be useful to treat patients with 2001;358:2061-8. diarrhea-predominant IBS. These Alosetron, a 5-HT3–receptor an- [PMID: 11755632] 36. Watson ME, Lacey L, antidiarrheal agents work by pe- tagonist that can provide relief in Kong S, et al. Alos- ripheral μ-opioid receptors to re- diarrhea-predominant IBS, increas- etron improves quality of life in women duce visceral nociception via affer- es colonic compliance, reduces in- with diarrhea-pre- testinal transit, and reduces pain dominant irritable ent pathway inhibition. The effect bowel syndrome. is to reduce propagating contrac- and diarrhea (36). It was withdrawn Am J Gastroenterol. 2001;96:455-9. tions and to increase segmenting from the market in 2000 because of [PMID: 11232690] the occurrence of serious life- 37. Camilleri M, North- contractions in the bowel, which cutt AR, Kong S, et slows transit and allows more time threatening gastrointestinal effects al. Efficacy and safety of alosetron in for water absorption. and was reintroduced in 2002 with women with irritable restricted availability and use. bowel syndrome: a randomised, place- Loperamide is the first-line agent Alosetron carries a 1 in 700 risk of bo-controlled trial. for diarrhea. It can be taken as ischemic colitis and thus should be Lancet. 2000;355:1035-40. needed or on a scheduled basis reserved for women with severe, [PMID: 10744088] 38. Camilleri M, Chey depending on the severity and fre- refractory IBS symptoms causing WY, Mayer EA, et al. quency of symptoms. Two RCTs significant impairment in quality A randomized controlled clinical trial of (33, 34) showed that loperamide of life. Prescribing physicians must the serotonin type 3 is effective for diarrhea; however, register with the manufacturer receptor antagonist alosetron in women it did not significantly relieve pain (phone: 888-825-5249), and patients with diarrhea-predominant irritable in either study. There are no must sign a consent form to begin bowel syndrome. identified safety concerns associated therapy. Three separate double- Arch Intern Med. 2001;161:1733-40. with repeated use of loperamide. blind, randomized, placebo-controlled [PMID: 11485506]

Downloaded From: http://annals.org/ by McGill University, Teresa Rudkin on 04/08/2016 trials have shown that alosetron for anticholinergic side effects. SSRIs diarrhea-predominant IBS had an may trigger episodes in patients 39. Camilleri M, Mayer EA, Drossman DA, et al. overall “adequate response” rate of with diarrhea-predominant IBS Improvement in pain nearly 60%. Improvement over while being helpful for patients and bowel function in female irritable bowel placebo was approximately 15% with constipation. patients with alos- (37–39). etron, a 5-HT3 receptor antagonist. Ali- Antibiotics ment Pharmacol Ther. Antidepressants Alterations in gut flora have been 1999;13:1149-59. [PMID: 10468696] Antidepressants can be helpful in identified in patients with IBS, and 40. Jackson JL, O’Malley PG, Tomkins G, et al. alleviating IBS symptoms. Accord- some hypothesize that intestinal Treatment of func- ing to a recent meta-analysis of 12 bacterial overgrowth may play a tional gastrointestinal disorders with antide- studies, the number needed to treat role in symptoms. The antibiotic pressant medications: neomycin has been shown to im- a meta-analysis. Am J for benefit in 1 person was 3.2 (40). Med. 2000;108:65-72. prove IBS symptoms. This effect [PMID: 11059442] 41. Myren J, Løvland B, Clinicians should consider tricyclic seems to correlate with normaliza- Larssen SE, Larsen S. A antidepressants to reduce pain and tion of intestinal bacterial flora (44, double-blind study of the effect of trim- diarrhea. The mechanism of action 45). However, neomycin effectively ipramine in patients eliminates bacterial overgrowth in with the irritable bow- of these drugs in IBS is unclear, el syndrome. Scand J but it is known that they act prima- only about 25% of patients (45), Gastroenterol. 1984;19:835-43. rily by blocking the uptake of neu- and side effects limit its use. Low [PMID: 6151243] efficacy, side effects, and concerns 42. Greenbaum DS, Mayle rotransmitters at specific presynap- JE, Vanegeren LE, et al. tic nerve endings in the central about antimicrobial resistance also Effects of desipramine apply to other antibiotics that have on irritable bowel syn- nervous system. As a result, they drome compared been previously investigated for prevent synaptic receptor overstim- with atropine and treating bacterial overgrowth (46). placebo. Dig Dis Sci. ulation. The benefit of tricyclics in 1987;32:257-66. For this reason, researchers have [PMID: 3545719] IBS seems to be independent of the 43. Drossman DA, Toner been seeking an antibiotic for IBS BB, Whitehead WE, et anticholinergic effects or antide- that is not systemically absorbed, al. Cognitive-behav- ioral therapy versus pressant effects. The required has minimal adverse effects, and education and de- dosage is less than that required for sipramine versus effectively eliminates bacterial over- placebo for moderate the treatment of depression. Several growth. One drug that meets these to severe functional bowel disorders. Gas- studies have shown benefits for criteria is rifaximin. troenterology. tricyclic use (41–43). Tricyclics 2003;125:19-31. An RCT assigned 87 patients who met the [PMID: 12851867] can be used in combination with 44. Pimentel M, Chow EJ, Rome I criteria for IBS to receive either 400 Lin HC. Eradication of antispasmodics. mg of rifaximin 3 times daily for 10 days or small intestinal bacterial overgrowth re- Use of selective serotonin reuptake placebo. A questionnaire was adminis- duces symptoms of ir- tered before treatment and 7 days after ritable bowel inhibitors (SSRIs) is not well- syndrome. Am J Gas- treatment. The primary outcome was troenterol. studied in patients with IBS, but global improvement in IBS. Patients were 2000;95:3503-6. [PMID: 11151884] early findings suggest that SSRIs then asked to keep a weekly symptom di- 45. Pimentel M, Chow EJ, can improve the quality of life in ary for 10 weeks. Over the 10 weeks of Lin HC. Normalization of lactulose breath patients who have severe IBS with follow-up, rifaximin resulted in greater im- testing correlates with provement in IBS symptoms than placebo. symptom improve- associated psychological stress. This ment in irritable bow- may be primarily a psychological In addition, rifaximin recipients had a low- el syndrome. A dou- er bloating score after treatment. This pre- ble-blind, effect. Patients may also benefit randomized, placebo- liminary, short-duration trial suggests controlled study. Am J from pain alleviation; however, a co- Gastro-enterol. that rifaximin improves IBS symptoms for 2003;98:412-9. hort study that associated paroxetine up to 10 weeks after discontinuation of [PMID: 12591062] with improved quality of life in IBS 46. Attar A, Flourié B, therapy (47). Rambaud JC, et al. An- did not find any association with tibiotic efficacy in What are some possible future small intestinal bacte- alleviated abdominal pain (26). rial overgrowth-relat- treatments for IBS? ed chronic diarrhea: a crossover, randomized SSRIs might be a consideration for Several new drugs are being studied trial. Gastroenterology. older patients or in persons with for the treatment of IBS. IBS thera- 1999;117:794-7. [PMID: 10500060] constipation because they lack py is moving from “symptom-based”

Downloaded From: http://annals.org/ by McGill University, Teresa Rudkin on 04/08/2016 therapy to “hypthesis-based” therapy. Is there evidence to support the Rather than treating symptoms, effectiveness of complementary new IBS approaches aim to treat and alternative medicine treatments for IBS? 47. Pimentel M, Park S, the underlying pathophysiology. Mirocha J, Kane SV, Patients with IBS frequently try Kong Y. The effect of a Trials are currently underway for nontraditional therapies, particu- nonabsorbed oral antibiotic (rifaximin) on treating IBS with renzapride, a larly if traditional approaches to the symptoms of the treatment do not relieve their irritable bowel syn- 5-HT3–receptor antagonist and drome: a randomized symptoms. While some patients trial. Ann Intern Med. a 5-HT4–receptor agonist (48, 49). 2006;145:557-63. Tachykinin antagonists, like sub- have some relief with such thera- [PMID: 17043337] pies, data to support their use are 48. Meyers NL, Tack J, stance P and neurokinin A, might Middleton S, et al. Effi- sparse (54) (Table 4). cacy and safety or also be useful for treating IBS. renzapride in patients Tachykinins are present in the gas- with constipation-pre- What components of care should dominant irritable trointestinal tract and are involved clinicians integrate into follow-up bowel syndrome [Ab- stract]. Gut. in such functions as gastrointestinal of patients with IBS? 2002;51(suppl III): A10. 49. George A, Meyers NL, motility, visceral sensitization, and There are no specific data on which Palmer RMJ. Efficacy autonomic reaction to stress. Stud- to base a recommendation on the and safety of renzapride in patients with ies in animals and healthy humans frequency or the components of constipation-predomi- follow-up for patients with IBS. nant IBS: a phase IIB have yielded promising results study in the UK pri- (50, 51). Neutrophins, a family However, a common-sense ap- mary healthcare set- ting [Abstract]. Gut. of neuropeptides that includes proach includes monitoring for 2003;52:A91. alarm features, progression of 50. Julia V, Morteau O, neutrophin-3, are also undergoing Buéno L. Involvement preclinical study as potential thera- symptoms, and management of of neurokinin 1 and 2 psychosocial stressors. The typical receptors in vis- peutic agents for functional gas- cerosensitive response symptom course in IBS is chronic to rectal distension in trointestinal disorders. Studies have rats. Gastroenterology. and fluctuating. Clinicians should shown that recombinant human 1994;107:94-102. consider additional diagnostic tests [PMID: 7517374] neutrophin-3 increased stool fre- 51. Lördal M, Navalesi G, or referral if alarm features develop Theodorsson E, Maggi quency; facilitated stool passage in CA, Hellström PM. A or if symptoms are refractory and novel tachykinin NK2 patients with constipation; and ac- persistent. Clinicians should em- receptor antagonist prevents motility- celerated gastric, small bowel, and phasize to patients that the long- stimulating effects of colonic transit in healthy persons term prognosis is good. Carefully neurokinin A in small intestine. Br J Pharma- (52, 53). Antibiotics and probiotics explaining the prognosis can sig- col. 2001;134:215-23. [PMID: 11522614] aim to normalize intestinal bacteria. nificantly reduce patient distress. 52. Coulie B, Szarka LA, Camilleri M, et al. Re- combinant human neurotrophic factors accelerate colonic Table 4. Alternative and Complementary Therapies Used by Patients with Irritable transit and relieve Bowel Syndrome constipation in humans. Gastroenterolo- Therapy Proposed Action Notes gy. 2000;119:41-50. [PMID: 10889153] Acupuncture Relief of chronic pain No definitive studies available; results of 53. Coulie B, Lee JS, Ly- existing studies are mixed ford G, et al. Recombi- nant human neu- Hypnosis Relief of chronic pain No definitive studies available rotrophin-3 increases Peppermint oil Natural antispasmodic believed to Ineffective in 2 crossover trials; some noncholinergic smooth muscle con- relax intestinal smooth muscle effect noted in one parallel trial tractility and decreas- Ginger Natural antispasmodic believed to No evidence from high-quality trials es nonadrenergic (NANC) inhibition of relax intestinal smooth muscle myenteric neurons in Aloe Natural antispasmodic believed to No evidence from high-quality trials guinea-pig colon [Ab- stract]. Gastroenterol- relax intestinal smooth muscle ogy. 2000;118:A710. Chinese herbal Natural antispasmodic believed to Global improvement noted in 1 study 54. Spanier JA, Howden CW, Jones MP. A sys- therapy relax intestinal smooth muscle tematic review of al- Probiotics Aim to replenish the beneficial Bifidobacteria infantis showed symptom ternative therapies in the irritable bowel intestinal bacteria that may be improvement in early clinical studies syndrome. Arch lacking in patients with IBS Intern Med. 2003; 163:265-74. [PMID: 12578506]

Downloaded From: http://annals.org/ by McGill University, Teresa Rudkin on 04/08/2016 When should clinicians consider because of increased familiarity with consulting a specialist for the disorder. Clinicians should con- treatment? sider referral to a mental health pro- When management strategies are fessional for patients with refractory not effective, clinicians should con- symptoms leading to impaired quali- sider consulting a gastroenterologist. ty of life or major depression, anxiety Gastroenterologists may have greater disorder, bipolar disorder, or other knowledge of treatment options serious psychological disease.

Treatment… Dietary advice, patient education, and stress management are essen- tial to effective IBS management. Drug therapy should target the individual patient’s symptom pattern, and options include antispasmodics, laxatives, antidiarrheals, 5-HT antagonists, antidepressants, and antibiotics. Of the many nontraditional therapies that patients use to treat IBS, clinical trial data best support a clinical benefit of probiotics.

CLINICAL BOTTOM LINE Practice Improvement Do professional organizations measures in the United States do offer recommendations for the not include any measures specifically care of patients with IBS? related to the care of patients with IBS. In 2003, the American Gastroen- However, the quality of the doctor– terological Association developed patient interaction is paramount in clinical practice guidelines for the care of patients with IBS. IBS based on a comprehensive A survey developed by the Ameri- review (31). can Gastrointestinal Association may be useful for evaluating a pa- Are there performance measures tient’s satisfaction with his or her related to the care of patients care (www.gastro.org/wmspage.cfm with IBS? ?parm1=3266). However, the sur- Current proposed performance vey has not yet been validated.

in the clinic www.pier.acponline.org c IBS module of PIER, an electronic decision support resource designed for rapid access to information at the point of care.

Tool Kit lini www.annals/intheclinic/tools Download copies of the Patient Information sheet that Irritable Bowel appears on the following page for duplication and Syndrome distribution to your patients. ec www.gastro.org/wmspage.cfm?parm1=3266 Patient satisfaction surveys to enable the physician to quantitatively measure the patient care experience as well as physician–patient communication. in th

Downloaded From: http://annals.org/ by McGill University, Teresa Rudkin on 04/08/2016 THINGS PEOPLE SHOULD KNOW In the Clinic Annals of Internal Medicine ABOUT IRRITABLE BOWEL SYNDROME

• IBS causes pain, cramping, bloating, gas, diarrhea, and constipation. Another name for the condition is spastic colitis. • The cause of IBS is believed to be intestines that are overly sensitive to normal intestinal movement, gas, some foods, and stress. • There is no test for IBS, so doctors make the diagnosis by carefully evaluating symptoms and excluding other conditions. • There is no cure, but people with IBS can control symptoms by healthy diet and exercise, managing stress, avoiding things that trigger symptoms, and taking medications to treat symptoms.

Web Sites with Good Information about Irritable Bowel Syndrome MedlinePLUS www.nlm.nih.gov/medlineplus/irritablebowelsyndrome.html National Institute of Diabetes and Digestive and Kidney Diseases http://digestive.niddk.nih.gov/ddiseases/pubs/ibs_ez/ International Foundation for Functional Gastrointestinal Disorders www.aboutibs.org/ Mayo Clinic www.mayoclinic.com/health/irritable-bowel-syndrome/MM00461 (a short video clip that provides information about irritable bowel syndrome)

HEALTH TiPS* Irritable bowel syndrome (IBS) is a common problem that can cause constipation, diarrhea, or both. Sometimes there is stomach pain or gas. IBS comes and goes but never goes away for good. IBS does not cause cancer. What You Can Do: Things to Ask your Doctor: Find out what makes your IBS symptoms What causes IBS? worse Do I need any tests? • Stress at home or work • Some foods Why do I have problems if all my tests are normal? Write down when your IBS symptoms happen How can I deal with stress? • Get help to deal with stress Do I need medicine for my IBS? • Stay away from too much caffeine, soda, fatty foods, and laxatives Why doesn't medicine always work for my IBS? See your doctor often to keep your IBS on What are the side effects of my medicines for track. Next doctor's visit ______IBS?

*HEALTH TiPS are developed by the American College of Physicians Foundation and PIER and are designed to be understood by most patients. Patient Information Patient

Downloaded From: http://annals.org/ by McGill University, Teresa Rudkin on 04/08/2016 CME Questions

1. A 24-year-old woman has a 7-month 3. A 24-year-old woman is evaluated for occult blood. He has no family history history of occasional abdominal bloat- 3-year history of oral ulcers that occur of cancer or inflammatory bowel dis- ing and constipation alternating with frequently, usually at times of stress, ease. He notes that the symptoms intermittent loose stools. She was well and last about 1 week. The ulcers are began when his wife filed for a until 8 months ago, when she devel- unrelated to rash, joint symptoms, or divorce. He denies being depressed. oped diarrhea during a trip to Mexico fever. She notes that over the past 4 What is the most appropriate next that was treated with ciprofloxacin. months they have become larger, recur step in the evaluation and manage- She has not had weight loss, fever, or more frequently, and last longer (2 to ment of this patient? nocturnal symptoms. Her stools are 3 weeks). She attributes a recent 4.4- small in volume, soft, and brown and kg (10-lb) unintentional weight loss to A. Flexible sigmoidoscopy do not contain blood or mucus. pain while eating during outbreaks of B. Symptom diary and follow-up the ulcers. Her medical history is sig- visit Which of the following is most likely C. Abdominal CT scan to be the diagnosis in this patient? nificant for occasional abdominal pain and diarrhea that was previously diag- D. Radiographs of the abdomen A. Clostridium difficile infection nosed as irritable bowel syndrome. She E. Reassurance B. Helicobacter pylori infection has no history of an eating disorder, C. Diverticular disease illicit drug use, blood transfusion, or 5. A 34-year-old woman with a medical D. Postinfectious irritable bowel any previous sexual activity. Her family history of childhood asthma and 2 syndrome history is unrevealing. On examination, normal pregnancies is evaluated for she has 2 mildly tender oral ulcera- abdominal pain and bloating almost 2. A 25-year-old woman has a 7-month tions that she notes have been present daily for the past 3 years since the history of progressively severe consti- for about 6 days. Results of fecal birth of her youngest child. She also pation, generalized abdominal pain, occult blood testing are positive. reports diarrhea, which she describes and bloating that have affected her as 2 to 6 loose bowel movements per ability to work and handle other re- What is the best next step in the day, never feels like her colon is com- sponsibilities. She has approximately management of this patient? pletely evacuated, and reports that one firm bowel movement each week. A. Colonoscopy stool is sometimes watery. She denies Use of over-the-counter fiber products B. HIV serology fever, weight loss, previous lactose has been ineffective. Her weight is C. Hyoscyamine intolerance, family history of cancer stable, and she is otherwise healthy. D. Acyclovir or inflammatory bowel disease, visible Thyroid function tests and measure- E. Biopsy of oral lesions blood or mucus in stools, and anti- ment of serum calcium and serum biotic use. She has been prescribed electrolyte levels are normal. 4. A 28-year-old man is evaluated for 6 dicyclomine, which provides some Which of the following medications is weeks of intermittent abdominal pain relief of pain but not diarrhea. Physi- most appropriate at this time? relieved with bowel movements and cal examination is normal. You believe increased frequency of bowel move- that the patient most likely has irrita- A. Alosetron ments with stool that is softer and ble bowel syndrome. B. A selective serotonin reuptake less well-formed than previously. He inhibitor Which of the following would be the denies fever, upper gastrointestinal most appropriate next step? C. A tricyclic antidepressant symptoms, or recent camping or travel. D. Metronidazole Physical examination is entirely nor- A. Colonoscopy E. Polyethylene glycol mal except for some mild abdominal B. Stool cultures tenderness to deep palpation in all C. Dietary history 4 quadrants. Stool is negative for D. Alosetron E. Fluoxetine

Questions are largely from the ACP’s Medical Knowledge Self-Assessment Program (MKSAP). Go to www.annals.org/intheclinic/ to obtain up to 1.5 CME credits, to view explanations for correct answers, or to purchase the complete MKSAP program.

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