First, I have to try to convince you that the topic of irritable bowel syndrome (IBS) is important for us as mental health clinicians.
Why is irritable bowel syndrome important?
Here are some reasons why:
– Irritable bowel syndrome affects about 10 % of the population in North America and Europe, so it is VERY common (Lovell and Ford, 2012). By the way, it is more common in women than in men when it is at least moderately severe, and the difference between men and women is a lot more when the illness is severe (Drossman, 2016).
– Persons with irritable bowel syndrome frequently also suffer from anxiety disorders and depressive disorders (Staudacher et al., 2021).
For example, persons with irritable bowel syndrome are about 5 times more likely than others to also have generalized anxiety disorder and persons with generalized anxiety disorder are about 5 times more likely than others to also have irritable bowel syndrome (Lee et al., 2009). The presence of irritable bowel syndrome is also associated with obsessive-compulsive disorder (Staudacher et al., 2021).
– Irritable bowel syndrome is often associated with a big decrease in the person’s quality of life (Lacy et al., 2021).
What is irritable bowel syndrome?
Irritable bowel syndrome is a chronic gastrointestinal condition that can vary in severity from mild to debilitating (Sultan and Malhotra, 2017). It is one of a long list of conditions grouped together as “disorders of gut-brain interaction” or “functional gastrointestinal disorders”. Just a couple of examples of other disorders in this category are cyclic vomiting syndrome and cannabinoid hyperemesis syndrome (Drossman, 2016). In irritable bowel syndrome, there is a “complex bidirectional dysregulation of gut-brain interaction (Staudacher et al., 2021). The irritable bowel syndrome symptoms affect the person’s emotional state and vice versa (Staudacher et al., 2021).
The key symptoms of irritable bowel syndrome are (Sultan and Malhotra, 2017):
– Recurrent abdominal pain
– Constipation, diarrhea or both
The abdominal pain is often of a cramping type. It is often affected by meals and defecation; both of these may lead to either improvement in or worsening of the pain.
Other symptoms that are commonly present include:
– Abnormal stool frequency (more than 3 bowel movements per day OR less than 3 bowel movements per week)
– Cramping pain and urgency to defecate are often present before the bowel movement
– Feeling of incomplete evacuation (“tenesmus”) after defecation
– Excessive gas production (flatulence and/or belching)
Other than the symptoms, discussed above, here are some other things to know about the clinical manifestations of irritable bowel syndrome (Sultan and Malhotra, 2017).
– Typically, the abdominal symptoms vary in intensity over time. Often, the symptoms get worse when the person is under stress.
– Often, persons with irritable bowel syndrome also have other medical and psychiatric conditions like anxiety disorders, depressive disorders, chronic fatigue syndrome, fibromyalgia, etc.
If certain clinical features are present, other diagnoses need to be considered. These clinical features have been referred to as “alarm features” (Sultan and Malhotra, 2017). These alarm features include:
– Family history of colon cancer
– Family history of inflammatory bowel disease
Onset and course
– Onset of symptoms after the age of about 50 years
– Recent use of antibiotics
– Recent onset with progressive symptoms rather than a waxing and waning course
– Significant, unintentional weight loss
– Waking up at night frequently due to gastrointestinal symptoms
– Blood in the stool
– Presence of an abdominal mass
– Occult blood in the stool
– Enlarged lymph nodes
It is important to realize that irritable bowel syndrome is diagnosed based on history and not on laboratory tests.
The widely-accepted Rome IV diagnostic criteria for irritable bowel syndrome define it as:
1. Recurrent abdominal pain (on average, on at least one day per week for at least 3 months), and
2. At least two of the following:
– The pain is related to defecation
– There is a change in stool frequency
– There is a change in the appearance of the stool
The symptoms should have started at least 6 months ago. And, the criteria above should have been met in the previous 3 months.
Should laboratory tests be done to rule anything out?
1. Blood tests for celiac disease should be done in persons with diarrhea-predominant irritable bowel syndrome as recommended by both American and Canadian practice guidelines (Lacy et al., 2021; Moayyedi et al., 2019). Note: If the testing for celiac disease is negative once, it does not need to be repeated.
2. Fecal calprotectin and C-reactive protein should be checked if the diagnosis of irritable bowel syndrome is not clear and inflammatory bowel disease needs to be ruled out, (Lacy et al., 2021).
Other tests only need to be done if the history suggests that the diagnosis may be something other than irritable bowel syndrome. See “Alarm features” above.
Persons with irritable bowel syndrome are not more likely than others to have food allergies (Lacy et al., 2021). Testing for food allergies to try to identify triggers for irritable bowel syndrome symptoms is not recommended (Moayyedi et al., 2019).
The importance of identifying a particular patient’s symptom pattern is that it guides treatment choices to a great extent (Lacy et al, 2021).
– Constipation-predominant (IBS-C): >25% hard stools and <25% loose stools
– Diarrhea-predominant (IBS-D): >25% loose stools and <25% hard stools)
– Mixed bowel habits (IBS-M): >25% loose stools and >25% hard stools. These patients have diarrhea at times and hard stools at other times.
– Unclassified (IBS-U): <25% loose stools and <25% hard stools
But, we should also keep in mind that a particular patient’s symptom patterns can change over time (Sultan and Malhotra, 2017).
Next, please see the following article on this website;
Alammar N, Stein E. Irritable Bowel Syndrome: What Treatments Really Work. Med Clin North Am. 2019 Jan;103(1):137-152. doi: 10.1016/j.mcna.2018.08.006. PMID: 30466670.
Black CJ, Ford AC. Best management of irritable bowel syndrome. Frontline Gastroenterol. 2020 May 28;12(4):303-315. doi: 10.1136/flgastro-2019-101298. PMID: 34249316; PMCID: PMC8231425.
Black CJ, Yuan Y, Selinger CP, Camilleri M, Quigley EMM, Moayyedi P, Ford AC. Efficacy of soluble fibre, antispasmodic drugs, and gut-brain neuromodulators in irritable bowel syndrome: a systematic review and network meta-analysis. Lancet Gastroenterol Hepatol. 2020 Feb;5(2):117-131. doi: 10.1016/S2468-1253(19)30324-3. Epub 2019 Dec 16. PMID: 31859183.
Cassell B, Gyawali CP, Kushnir VM, Gott BM, Nix BD, Sayuk GS. Beliefs about GI medications and adherence to pharmacotherapy in functional GI disorder outpatients. Am J Gastroenterol. 2015 Oct;110(10):1382-7. doi: 10.1038/ajg.2015.132. Epub 2015 Apr 28. PMID: 25916226; PMCID: PMC5051635.
Chen M, Tang TC, Qin D, Yue L, Zheng H. Pharmacologic Treatments for Irritable Bowel Syndrome: an Umbrella Systematic Review. J Gastrointestin Liver Dis. 2020 Jun 3;29(2):199-209. doi: 10.15403/jgld-817. PMID: 32530987.
Drossman DA. Functional Gastrointestinal Disorders: History, Pathophysiology, Clinical Features and Rome IV. Gastroenterology. 2016 Feb 19:S0016-5085(16)00223-7. doi: 10.1053/j.gastro.2016.02.032. Epub ahead of print. PMID: 27144617.
Drossman DA, Hasler WL. Rome IV-Functional GI Disorders: Disorders of Gut-Brain Interaction. Gastroenterology. 2016 May;150(6):1257-61. doi: 10.1053/j.gastro.2016.03.035. PMID: 27147121.
Lacy BE, Patel NK. Rome Criteria and a Diagnostic Approach to Irritable Bowel Syndrome. J Clin Med. 2017 Oct 26;6(11):99. doi: 10.3390/jcm6110099. PMID: 29072609; PMCID: PMC5704116.
Lacy BE, Pimentel M, Brenner DM, Chey WD, Keefer LA, Long MD, Moshiree B. ACG Clinical Guideline: Management of Irritable Bowel Syndrome. Am J Gastroenterol. 2021 Jan 1;116(1):17-44. doi: 10.14309/ajg.0000000000001036. PMID: 33315591.
Lee S, Wu J, Ma YL, Tsang A, Guo WJ, Sung J. Irritable bowel syndrome is strongly associated with generalized anxiety disorder: a community study. Aliment Pharmacol Ther. 2009 Sep 15;30(6):643-51. doi: 10.1111/j.1365-2036.2009.04074.x. Epub 2009 Jun 23. PMID: 19552631.
Lovell RM, Ford AC. Global prevalence of and risk factors for irritable bowel syndrome: a meta-analysis. Clin Gastroenterol Hepatol. 2012 Jul;10(7):712-721.e4. doi: 10.1016/j.cgh.2012.02.029. Epub 2012 Mar 15. PMID: 22426087.
Lacy BE, Mearin F, Chang L, Chey WD, Lembo AJ, Simren M, Spiller R. Bowel Disorders. Gastroenterology. 2016 Feb 18:S0016-5085(16)00222-5. doi: 10.1053/j.gastro.2016.02.031. Epub ahead of print. PMID: 27144627.
Moayyedi P, Andrews CN, MacQueen G, Korownyk C, Marsiglio M, Graff L, Kvern B, Lazarescu A, Liu L, Paterson WG, Sidani S, Vanner S. Canadian Association of Gastroenterology Clinical Practice Guideline for the Management of Irritable Bowel Syndrome (IBS). J Can Assoc Gastroenterol. 2019 Apr;2(1):6-29. doi: 10.1093/jcag/gwy071. Epub 2019 Jan 17. PMID: 31294724; PMCID: PMC6507291.
Staudacher HM, Mikocka-Walus A, Ford AC. Common mental disorders in irritable bowel syndrome: pathophysiology, management, and considerations for future randomised controlled trials. Lancet Gastroenterol Hepatol. 2021 May;6(5):401-410. doi: 10.1016/S2468-1253(20)30363-0. Epub 2021 Feb 13. PMID: 33587890.
Sultan S, Malhotra A. Irritable Bowel Syndrome. Ann Intern Med. 2017 Jun 6;166(11):ITC81-ITC96. doi: 10.7326/AITC201706060. PMID: 28586906.
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