Updated: 11/30/2019

Irritable Bowel Syndrome

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Snapshot
  • A 34-year-old female presents to the emergency department with complaints of intermittent abdominal pain for the past 3 months. She states that the pain has gotten progressively worse over the past 2 weeks. She denies any abdominal trauma, hematochezia, heartburn, or melena. She works as a corporate lawyer and is currently undergoing a divorce, which has been a large source of stress for her. She does not recall any signficiant precipitating factor but endorses improvement of the pain following defecation. Physical examination was largely unremarkable with mild diffuse abdominal tenderness. 
Introduction
  • Overview
    • idiopathic functional gastrointestinal disorder characterized by chronic abdominal pain and altered bowel habits
    • patients often present as teens or in their 20’s
  • Epidemiology
    • demographics
      • prevalence in North America estimated to be around 10-15%  
      • higher prevalence in women (14%) compared to men (9%)
  • Pathophysiology 
    • pathophysiology is uncertain as it is likely a disorder resulting from interaction from several factors
      • gastrointestinal tract motor abnormalities (e.g., abnormal transit time) are detectable in some patients
      • hypersensitization of visceral afferent nerves in the gut
      • alterations in particular immune cells and markers
      • suggested genetic susceptibility
      • psychosocial factors may influence the expression of symptoms
  • Associated conditions
    • 50% of patients have comorbid psychiatric disease (e.g., major depression)
    • fibromyalgia
    • chronic fatigue syndrome
    • GERD and functional dyspepsia
Presentation
  • Symptoms
    • chronic abdominal pain with periodic exacerbations 
      • can be exacerbated with stress or meals
      • may be relieved with defecation
    • non-bloody diarrhea  
    • constipation
  • Physical exam
    • abdominal distension
    • mild abdominal tenderness
Imaging
  • Abdominal imaging (e.g., radiograph)
    • done in patients with constipation
    • assess for stool accumulation and determine severity
  • Colonoscopy 
    • indicated if patients have alarm features
      • age of onset > 50 years
      • rectal bleeding/melena
      • weight loss
      • abnormal CBC
      • family history of inflammatory bowel disease (IBD) or colorectal cancer
Studies
  • Serum labs 
    • done primarily to exclude alternative diagnosis
    • CBC, CRP, and fecal calprotein
    • serologic testing for celiac disease if diarrhea present  
Differential 
  • Celiac disease   
    • distinguishing factors
      • positive serologic tests for celiac disease
  • Inflammatory bowel disease
    • distinguishing factors
      •  lesions present on colonoscopy
Treatment
  • Lifestyle modifications 
    • avoidance of gas-producing foods 
    • high fiber and low fat diet 
    • psychiatric support and continuity of care 
  • Medical treatment 
    • laxatives (e.g., polyethylene glycol) are indicated in patients with moderate to severe IBS with constipation
    • antidiarrheal agents (e.g., loperamide) are indicated in patients with moderate to severe IBS with diarrhea
    • antispasmodics (e.g., dicyclomine) are used on an as needed basis for IBS-related abdominal pain
    • bile acid sequestrants in patients with moderate to severe IBS with diarrhea (second-line)
    • tricyclic antidepressants for patients with coexisting depression and persistent abdominal pain despite antispasmodic use (second-line)
 Complications
  • Dehydration
  • Electrolyte imbalance
  • Bowel impaction
  • Hemorrhoids  
 

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