Irritable Bowel Syndrome
Irritable Bowel Syndrome: Excerpt from The 5-Minute Pediatric Consult
Edisio Semeao, MD
Irritable Bowel Syndrome - BASICS
Irritable Bowel Syndrome - description
- Irritable bowel syndrome (IBS) is the best known and one of the most common functional GI tract disorders.
- These disorders are characterized by chronic and/or recurrent GI tract symptoms not explained by structural abnormalities, infection, or metabolic changes on routine testing.
- Terms such as spastic colon, nervous colon, and spastic colitis have also been used to describe IBS. Spastic colitis, however, is inaccurate because these patients do not have evidence of inflammation of their colon (colitis) at colonoscopy.
- Patients with IBS have a constellation of symptoms that include:
- Chronic abdominal pain, usually lower abdomen
- Altered bowel pattern:
- Constipation
- Diarrhea
- Alternating constipation and diarrhea
Irritable Bowel Syndrome - epidemiology
- 60–70% of patients with IBS are women
- More common in adolescents in the pediatric population
- Poses a significant health care burden, with a total cost of $30 billion in 1999–2000
- There is no known genetic predisposition for developing IBS.
Irritable Bowel Syndrome - prevalence
- IBS is a prevalent disorder that occurs in 10–20% of the US population.
- It is more prevalent than hypertension, asthma, diabetes, and ischemic heart disease.
- Up to 28% of referrals for gastroenterology consults are for IBS.
- In adults, IBS is the 7th most common cause of visits to primary care physicians.
- 50% of patients present with symptoms before age 35, and 33% can trace their symptoms back into childhood.
Irritable Bowel Syndrome - pathophysiology
- Most commonly, IBS is thought to be a disorder of GI function relating to motility, sensation, and/or perception.
- The pathogenesis of IBS is believed to be multifactorial, with a variety of factors influencing the gut–brain axis at various levels.
- These factors interact to cause the symptoms of IBS and include:
- Predisposing factors (social, cultural, environmental) include genetics, early life experiences, gender, intergenerational illness behavior
- Precipitating factors (physiologic) may be associated with IBS but not directly a cause: Stress, infection/inflammation, bacterial flora, intestinal motility
- Perpetuating factors (behavioral) further amplify the GI dysfunction in patients with IBS and include depression, anxiety, panic disorder, somatization, poor social support, and maladaptive behavior.
- There are no actual histologic, microbiologic, or biochemical abnormalities noted in patients with IBS.
Irritable Bowel Syndrome - DIAGNOSIS
Irritable Bowel Syndrome - signs & symptoms
- There are no specific diagnostic tests or pathognomonic signs or symptoms for the diagnosis of IBS.
- Over the past several years investigators have developed symptom-based, consensus diagnostic criteria for IBS, and the latest version (Rome III) has allowed for a confident diagnosis of this disorder based on a cluster of symptoms, minimal diagnostic evaluation, and the absence of “red flags.”
- Rome III criteria: The signs and symptoms for the diagnosis of IBS may occur on a recurrent basis and need not be continuous. At least 3 months, with onset at least 6 months previously of recurrent abdominal pain or discomfort associated with 2 or more of the following:
- Improvement in the abdominal pain after a bowel movement
- An increasing number of stools with the start of the pain
- Change in the form and appearance of the stool with the onset of pain
Irritable Bowel Syndrome - history
- Evaluation of these patients needs to include a careful and detailed history, including a description of the symptoms, with assessment if they recur on a regular basis.
- Detailed diet and travel history
- Inciting and exacerbating factors
- Characteristics of abdominal pain:
- Sharp, dull, crampy, or burning
- Usually periumbilical or lower abdominal in nature, but not necessarily
- Starts after a meal and rarely awakens a patient from sleep
- Patients, especially children, describe associated symptoms, such as pallor, nausea, anorexia, and fatigue with the abdominal pain
- Presence or absence of abdominal distention
- Presence of increased belching and/or flatulence
- Change in bowel habits: Presence of alternating diarrhea and constipation:
- Patients tend to have one predominant form.
- Most patients experience relief of pain after a bowel movement.
- Patients with constipation may go several days to a week without any stool passage.
- In some instances, mucus may be described in this group of patients. However, blood is a rare finding and is usually associated with local/anal irritation or fissure secondary to diarrhea or constipation.
- Red flags:
- Prolonged, unexplained fevers
- Significant, unexplained weight loss, anorexia
- Family history of colorectal cancer or GI disorders
- Onset in older patients
- Joint complaints
- Nocturnal symptoms that awaken a patient
- Recent major change in the nature or severity of the symptoms
Irritable Bowel Syndrome - physical exam
- Findings, including those from rectal exam, are usually completely normal.
- There is usually no evidence of weight loss or growth failure.
- Red flags: Abdominal mass or other abnormal finding
Irritable Bowel Syndrome - tests
- There are no specific tests for the diagnosis of IBS. The use of various tests may be indicated to evaluate for organic disease based on the presence of “red flags” in the history or the physical exam.
- Confine testing to basic screening tests so that patients are not left with the impression that there is a significant organic disease present.
- Tests may include:
- Lactose breath test: Presence of lactose intolerance
- Stool cultures for routine specimen, Clostridium difficile, and ova and parasites: Exclude infectious etiologies for symptoms.
- Gastric emptying, antral-duodenal, and anal-rectal manometry are special tests.
Irritable Bowel Syndrome - lab
There are no laboratory tests that are diagnostic for IBS. Routine CBC, ESR, urinalysis, electrolytes, liver function tests, albumin, amylase, lipase, celiac antibodies, and thyroid studies are performed to exclude other diseases.
Irritable Bowel Syndrome - imaging
Abdominal x-ray or CT scan may exclude an intra-abdominal process.
Irritable Bowel Syndrome - diag proced-surgery
Upper endoscopy and/or colonoscopy: Indications include:
- Bleeding
- Profuse diarrhea
- Weight loss
- Iron deficiency anemia
- Abnormal laboratory or radiographic studies
- Extraintestinal manifestations of inflammatory bowel disease
Irritable Bowel Syndrome - pathological findings
Red flags from testing that would raise concern about the diagnosis of IBS include:
- Anemia
- Leukocytosis
- Elevated ESR or C-reactive protein
- Positive fecal occult blood
- Positive stool cultures
- Positive serology for celiac disease
- Abnormal histology on endoscopy/colonoscopy
Irritable Bowel Syndrome - differencial diagnosis
- Common disorders that need to be considered are those that may present with recurrent abdominal pain and altered bowel patterns, including:
- Chronic inflammatory conditions of the bowel (Crohn disease, ulcerative colitis, indeterminate colitis, celiac disease)
- Infectious disorders (parasites, bacterial)
- Lactose intolerance
- Complications of constipation (megacolon, encopresis, intermittent sigmoid volvulus)
- Drug-induced diarrhea or constipation
- Gynecologic disorders
- Neoplasms
- Psychiatric disorders
- Patients fulfilling Rome III criteria for IBS rarely (<1% probability) have an underlying illness. In contrast, IBS is so prevalent that there may be a co-occurrence with other disorders that can modify and/or amplify the clinical features of IBS. Common disorders include celiac disease and lactose intolerance.
Irritable Bowel Syndrome - TREATMENT
Irritable Bowel Syndrome - initial stabilization
- The best (but at times the most difficult) treatment for IBS is reassurance of both the parents and the child.
- The symptoms should be addressed, but the patient and/or parents should be made aware that the symptoms are not dangerous to the child.
- Avoid downplaying patients’ clinical symptoms, because it will make their acceptance of the treatment plan more difficult.
Irritable Bowel Syndrome - general measures
- For patients with mild symptoms of IBS, reassurance, education, and lifestyle changes such as avoiding identified triggers may be adequate for management.
- In patients with more severe or complex symptoms, a multidisciplinary approach including pharmacotherapy and psychosocial intervention may be needed.
Irritable Bowel Syndrome - medication
Irritable Bowel Syndrome - first line
- Bulking agents: Fiber supplementation in the diet is a usual 1st step in therapy that prolongs stool transit time and absorption.
- Laxatives: Unproven benefits, no real trials, and frequent complications
- Antispasmodics: Dicyclomine (Bentyl) and hyoscyamine (Levsin) may aid in pain relief, but overall efficacy in global symptom control is not proven.
Irritable Bowel Syndrome - second line
- Tricyclic antidepressants: Pain relief is somewhat effective but may have unwanted side effects.
- Newer therapies:
- 5-Hydroxytryptamine (HT)Withdrawn from the US market due to increased risk of heart attack or stroke in March 2007, and then in July 2007 approved for restricted use in patients for whom other treatment options are considered unsafe or ineffective.
- 5-HT5-HTDextofisopam—nonserotonergic, decreases stimulated autonomic function via its action on a hypothalamic receptor
Research therapies:
- MD-11100—guanylate cyclase-C agonist. This new agent acts on intestinal epithelium and has been shown to promote intestinal secretions and transit and decrease visceral pain in animal models.
Psychotherapy: Patients are taught a variety of techniques and exercises to use during the episodes of pain that allow them to focus on other subjects, not on the pain.
Overall, the most effective intervention may be to combine therapies that will target specific symptoms and arms of the gut–brain axis to globally control the symptoms from IBS.
Irritable Bowel Syndrome - FOLLOW UP
Irritable Bowel Syndrome - complications
- A large number of the complications that arise from IBS include depression and anxiety, causing a decreased quality of life.
- Patients with IBS show a significant amount of absenteeism from both school and work.
Irritable Bowel Syndrome - patient monitoring
There is no standard or specific follow-up needed for patients with IBS. They should continue with routine care, and one should ensure effective communication between the patient and physician to review the clinical symptoms and evaluate for any changes in the symptoms that may indicate another underlying problem.
Irritable Bowel Syndrome - bibliography
- Camilleri M. Treating irritable bowel syndrome: Overview, perspective and future therapies. Br J Pharmacol. 2004;141:1237–1248.
- Cremonini F, Talley N. Irritable bowel syndrome: Epidemiology, natural history, health care seeking and emerging risk factors. Gastroenterol Clin North Am. 2005;34:189–204.
- Drossman D. The functional gastrointestinal disorders and the Rome III process. Gastroenterology. 2006;130:1377–1390.
- Milla PJ. Irritable bowel syndrome in childhood. Gastroenterology. 2001;120:287–290.
- Staiano A, Corazziari E. Irritable bowel syndrome: Contrasts and comparisons between children and adults. J Pediatr Gastroenterol Nutr. 2001;32(suppl 1):S32–S34.
Irritable Bowel Syndrome - CODES
Irritable Bowel Syndrome - icd9
564.1 Irritable bowel syndrome
Irritable Bowel Syndrome - FAQ
- Q: Evidence of microscopic colitis may be consistent with the diagnosis of IBS?
- A: There should be no histologic or laboratory abnormalities.
- Q: Patients with IBS may have a coexisting GI disorder?
- A: Frequently, patients may be diagnosed with lactose intolerance or celiac disease. In these instances, both disorders need to be treated to alleviate the symptoms.
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Book Source Details
- Book Title: The 5-Minute Pediatric Consult
- Author(s): M. William Schwartz MD; et al.
- Year of Publication: 2008
- Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: The 5-Minute Pediatric Consult
Authors: M. William Schwartz MD; et al.
Publisher: Lippincott Williams & Wilkins
Copyright: 2008
ISBN: 0-7817-7577-9
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