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Irritable Bowel Syndrome
Irritable Bowel Syndrome
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Epidemiology
Prevalence: 10–20% in North America and Europe (accounts for 20–50% of referrals to gastroenterologists)
Sex: In Western countries, women are 1.5–2 times more likely to be affected than men.
Age: highest prevalence in individuals aged 20–39 [1]
References:[1][2][3][4]
Epidemiological data refers to the US, unless otherwise specified.
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Pathophysiology
IBS is a functional gastrointestinal disorder without a specific organic cause. The pathophysiological processes leading to IBS are multifaceted and not yet fully
understood. The most common findings associated with IBS are:
Altered gastrointestinal motility
Visceral hypersensitivity/hyperalgesia
Altered permeability of the gastrointestinal mucosa
Psychosocial aspects
References:[3][5][6][7]
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Clinical features
IBS is characterized by chronic abdominal pain and changes in bowel habits – both of which are typical, but not specific, symptoms of the condition.
Abdominal pain
o Frequency, intensity, and localization generally vary widely from patient to patient
o Typically related to defecation
Altered bowel habits: diarrhea and/or constipation
Other gastrointestinal symptoms
o Nausea, reflux, early satiety
o Passing of mucus, abdominal bloating
Extraintestinal symptoms
o Generalized somatic symptoms (e.g., pain or fatigue, as in fibromyalgia)
o Disturbed sexual function
o Dysmenorrhea
o Increased urinary frequency and urgency
Physical examination: normal
Red flag symptoms: nighttime diarrhea and abdominal pain, fever, bloody stools, weight loss and acute onset of symptoms!
References:[2][3]
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Subtypes and variants
Four different patterns are seen in the presentation of irritable bowel syndrome:
IBS-D (diarrhea is the predominant symptom)
IBS-C (constipation is the predominant symptom)
IBS-M (mixed diarrhea and constipation)
IBS-A (alternating diarrhea and constipation)
References:[3]
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Diagnostics
IBS is a clinical diagnosis based on the patient's history (Rome IV criteria) and symptoms. However, any suspected differential diagnoses should be ruled out
before making a definitive diagnosis.
Patient history
Rome IV criteria for irritable bowel syndrome: diagnosis can be made if the following criteria are present
o Recurrent abdominal pain on average at least 1 day per week during the previous 3 months that is associated with 2 or more of the following:
Pain related to defecation
Change in stool frequency
Change in stool form or appearance
Other symptoms consistent with IBS (see "Symptoms/clinical findings")
A family history of inflammatory bowel disease, celiac disease, or colorectal cancer is unusual in patients with IBS.
Ruling out organic disease
If no other differential diagnosis is suspected, laboratory tests and imaging are generally not recommended for individuals under the age of 50 if they show
typical signs of IBS and lack any alarming signs, such as iron-deficiency anemia, weight loss, or a family history of organic gastrointestinal diseases.
References:[2][3][8]
Colorectal Right-sided carcinomas: melena, diarrhea
Weight loss Often no pain
carcinoma Left-sided carcinomas: constipation
Other differential diagnoses to consider
Bacterial or viral gastroenteritis
Hypothyroidism/hyperthyroidism
Celiac disease
Lactose intolerance
Bacterial overgrowth syndrome (i.e., SIBO)
References:[3]
The differential diagnoses listed here are not exhaustive.
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Treatment
General measures
Regular consultations and reassurance that the disease, although chronic, is benign
Lifestyle changes
o Dietary adjustments
Plenty of fluid
High-fiber foods
Avoidance of:
Gas-producing foods (e.g., beans, onions, prunes)
Fermentable, short-chain carbohydrates (e.g., foods with high fructose content: honey, apples, corn syrup)
Lactose
Gluten
o Physical activity
o Stress management (identification of stress factors, avoidance techniques, relaxation therapy)
Psychological therapy (patients with psychological conditions): e.g., cognitive-behavioral therapy
Medical therapy
Medical therapy of IBS is symptom-directed:
Diarrhea
o Antidiarrheals (loperamide)
o Rifaximin
Constipation
o Soluble fibers/bulk-forming laxatives (psyllium)
o Osmotic laxatives (polyethylene glycol)
o Lubiprostone (chloride channel activator)
Cramping/pain
o Antispasmodics (dicyclomine, hyoscyamine)
o Tricyclic antidepressants (e.g., amitriptyline, nortriptyline)