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New Insights Into the Pathogenesis of Irritable Bengi G. et al. Vol. 5, issue 10, October issue, 2017 Medical Research Archives REVIEW ARTICLE NEW INSIGHTS INTO THE PATHOGENESIS OF IRRITABLE BOWEL SYNDROME Göksel Bengi1, İlkay Şimşek1 Affiliations: 1 Dokuz Eylul University, Medicine Faculty, Department of Gastroenterology, İzmir, Turkey * Corresponding author: Göksel Bengi, E-mail: [email protected] Abstract: Irritable Bowel Syndrome is one of the most frequently seen functional bowel diseases. Despite its high prevalence, the etiology and pathogenesis of IBS could not still be explained completely and diagnosing is quite difficult in some cases. IBS, being a multisymptomatic functional gastrointestinal system disease, has a broad clinical spectrum and in general, the symptoms are associated with gastrointestinal dysmotility and visceral hypersensitivity. The true diagnosis is based on four key factors: medical history, physical examination, minimal laboratory tests and colonoscopy or other appropriate tests in some cases. However, a homogeneous pathophysiological pattern has not been defined for IBS and this situation, with a high degree of probability, reflects that IBS is a multifactorial disorder that involves abnormalities in brain-gut interactions, visceral hypersensitivity, intestinal motility and secretion, psychosocial factors, composition of the gut microbiota, disturbed intestinal permeability and low grade immune activity. Key Words: Irritable, bowel, gastrointestinal, IBS Irritable Bowel Syndrome is one of the most predominant, constipation predominant, frequently seen functional bowel diseases mixed type and the ungroupable. characterized by recurrent abdominal pains Constipation predominant IBS diagnosis and change in bowel habits (IBS-C) is made if more than 25% of bowel (diarrhea/constipation). IBS is a long-term movements are type 1 or type 2 and less than illness in which patients suffer from chronic 25% is type 6 or 7. Whereas in the diarrhea- or recurrent gastrointestinal symptoms predominant IBS (IBS-D); while more than despite the fact that routine clinical 25% of the bowel movements are type 6 or investigations are normal. Although regional type 7, less than 25% are type 1 or type 2. In variation exists, the prevalence of IBS ranges mixed-type IBS (IBS-M); in more than 25% from 10–15% in population-based studies in of the bowel movements type 1 or type 2 and North America and Europe. The prevalence again in more than 25% type 6 or type 7 of IBS is most common between 20 and 40 coexistence is seen. The patients that do not years of age with a significant female fall into any of these three categories are predominance (1). Irritable bowel syndrome included to the unsubtyped group (IBS-U). is divided into four sub-groups by evaluation And in time, inter-type transitions may be of the patient’s stool according to BSFS observed in 75% of these patients. IBS is (Bristol Stool Form Scale) as diarrhea- associated with decreased quality of life, Copyright 2017 KEI Journals. All Rights Reserved Bengi G. et al. Medical Research Archives, vol. 5, issue 10, October 2017 issue Page 2 of 15 impaired social function and loss of work amendment was the vague nature of the term productivity. Onset of symptoms is most ‘’discomfort’’ and the word ‘’discomfort’’ not common in young adults and IBS has a existing in every language or expressing global prevalence of around 11% (2). different meanings in different languages. Despite its high prevalence, the etiology and Besides that, it is not clear whether the pathogenesis of IBS can still not be discrimination between discomfort and pain is explained completely and diagnosing is quite qualitative or quantitative, the knowledge about difficult in some cases (3). IBS, being a the meaning of the word discomfort multisymptomatic functional gastrointestinal significantly varies among individuals and it is system disease, has a broad clinical spectrum thought to cover too many symptoms. The and in general, the symptoms are associated other major amendment contained the with gastrointestinal dysmotility and visceral modification made on the symptom frequency hypersensitivity (4). In this compilation, we threshold. Compared to the period indicated as will mention the diagnosis and main minimum 3 days in a month in Rome III, in pathophysiological bases of IBS. Rome IV, occurrence of abdominal pain at least 1 day in a week on average during the Diagnostic criteria and clinical previous month is regarded necessary. It is symptoms of IBS: possible for both amendments to decrease the IBS prevalence in population-based studies; Since the pathophysiology of IBS could not however, since most of the IBS patients be completely understood and the routine recognize pain as one of the main symptoms investigations show normal results, IBD (7) and appearance of the symptoms in most diagnosis is based on the combination of of the IBS patients in clinical samplings in a altered bowel habits and abdominal pain frequency higher than once a week (8), according to the Rome IV criteria (5). neither of these amendments will According to that, IBS diagnosis can be significantly affect the IBS prevalence in made when a patient has recurrent clinical populations. Besides that, with the abdominal pain complaint associated with 2 aim of emphasizing that a significant or more of the following criteria: (1) related proportion of IBS patients actually report with defecation; (2) associated with change worsening in pain with defecation and/or stool in defecation frequency; (3) associated with frequency and/or change in stool form, since it change in appearance of stool. Because of was regarded necessary for abdominal pain to the relationship with motility disorder, be described with the wording ‘’…related visceral hypersensitivity, change in mucosa with defecation…’’ (Rome IV) instead of function and immune function, bowel ‘’….recovering with defecation….’’ (Rome microbiota changes and the change III), a minor amendment made on the appearing in the central nervous system definition of the main IBS criteria was also (CNS) process, the Rome IV criteria were included to Rome IV. expanded according to this concept of these bowel-brain interaction disorders. In clinical practice, there are limited aspects in respect of use of Rome Criteria. These criteria When compared with the Rome III (6) criteria, may leave the patients who can be treated two changes in IBS diagnostic criteria stand successfully however who do not meet the out in Rome IV. First of these is exclusion of criteria out of scope. The subject patients’ abdominal discomfort from the scope of remaining out of scope may be originating identification criteria and this means that from the symptom duration being shorter than abdominal pain is not a prerequisite for IBS 6 months, symptoms appearing in frequency diagnosis anymore. The basis underlying this lower than 1 in a week or inability of meeting Copyright 2017 KEI Journals. All Rights Reserved http://journals.ke-i.org/index.php/mra Bengi G. et al. Medical Research Archives, vol. 5, issue 10, October 2017 issue Page 3 of 15 2 of the 3 criteria. Besides that, some patients Faecal calprotectin is a non-invasive may have two or even more FGIDs and these screening method for intestinal mucosal concurrent symptoms are not included in the inflammation and it is seen to be more scope of Rome IV Criteria (9). effective than the standard test application such as C-reactive protein (14). It is accepted Premonitory symptoms suggest existence of an that IBS patients are under risk in respect of organic disease; however, some authors believe concurrent celiac disease existence. It is that the accuracy level provided by these estimated that celiac disease may develop in remains insufficient (10). The IBS patients’ a proportion reaching 4.7% of the patients complaining also of various other meeting IBS criteria (15). gastrointestinal (for example dyspepsia) symptoms and nongastrointestinal symptoms Stool analysis may prove to be useful in respect like migraine, fibromyalgia, chronic fatigue, of diarrhea symptom especially in developing chronic pelvic pain, sexual dysfunction, eating countries. When presence of warning disorders, food intolerances and other disorders symptoms or premonitory symptoms do not that provide additional support to diagnosis is a exist, colonoscopy for screening purposes situation worthy of notice. should be made if the patient is over the age of 50 . The correlation between IBS and small Some diseases such as inflammatory bowel intestinal bacterial overgrowth (SIBO) has disease (IBD), microscopic colitis, celiac been validated in many researches. This disease, lactulose and fructose intolerance, validation has been made mostly by using colon cancer, enteric infections, food allergy breath tests, however in about 60% of the and intolerance as well as neuroendocrine patients with IBS and diarrhea, quantitative tumors may show similarity to IBS and microbiological assessment of the duodenal therefore some diagnostic tests may be needed aspirate that confirmed SIBO was also used. for diagnosis. It can be seen that a series of Hydrogen glucose breath test is the most various diagnostic methods including common non-invasive SIBO diagnostic manometry, colonoscopy and enteroclysis method (16). (11,12) along with stool cultures and blood tests provide benefit in respect of excluding Different IBS biomarkers have been defined the organic disease. Routine laboratory and tested; however none of these is a practical analyses like complete blood
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