Irritable Bowel Syndrome (IBS) is an important disease entity because of its high prevalence, substantial morbidity and enormous costs. IBS is a common disorder, with up to 1 in 10 individuals worldwide affected, prevalence estimates for IBS have varied anywhere from 1% to 45% worldwide. People in the community under 50 years of age have a higher prevalence of IBS. Gender-Specific prevalence rates for IBS are higher in women as compare with men. Patients with IBS experience constipation, diarrhea or a mixture of these symptoms.
IBS patients are classified as per their predominant symptoms:
Constipation (IBS –C)
Diarrhea (IBC –D)
Mixed (IBS – M)
Physical examination in patients with IBS is usually normal. In Gastroenterology clinics, more than one third of patients have functional gastrointestinal disorder, IBS being the most common diagnosis. The diagnosis of IBS rests on a careful history and physical examination; that diagnostic tests often are not needed represents an important conceptual advance. IBS is characterized by the presence of abdominal discomfort or pain associated with disturbed defecation. Bloating is often present, but this not considered an essential symptom for diagnosis.
DIAGNOSIS:
Presently we follow Rome IV criteria for diagnosing IBS:
Rome IV criteria for diagnosing IBS include: Recurrent abdominal pain, on average at least 1 day/week in the last 3 months, associated with two or more of the following criteria:
Related to defecation.
Associated with a change in frequency of stool.
Associated with a change in form (appearance) of stool.
The criteria should be fulfilled for the last 3 months with symptom onset at least 6 months before diagnosis.
IBS is a functional GI disorder. Rome IV defines “Functional GI disorder as a disorder of Gut – Brain interaction”. It is a group of disorders classified by gastrointestinal symptoms related to any combination of the following:
Motility disturbance, visceral hypersensitivity, Altered mucosal and Immune function, Altered gut microbiota, and Altered central Nervous system processing. All this to say that changes in many different body processes can lead to a functional GI disorder. Rome IV emphasizes that the best management for functional GI disorders requires a bio-psychosocial approach. This approach takes into consideration.
Early life influence: Genetics, Culture, Environment
Psychosocial factors: Stress; Personality; psychological state, coping, social support.
Physiology: Motility, Sensation, Immune function, Microflora, Food diet.
RISK FACTORS
The best accepted risk factor for IBS is bacterial gastroenteritis. The risk of post-infection IBS has been reported to be increased with depression, adverse life events and hypochondriasis, female gender, younger age and prolonged duration of diarrhea following initial attack. Other risk factors for IBS include an affluent childhood environment, premenopausal and post-menopausal estrogen use, recent antibiotic use, food intolerance, extraintestinal Somatic symptoms, and poor quality of life. IBS runs in families and low birth weight is also a risk factor of IBS. Children of a parent with IBS may see physicians more often than those who do not have and parent with IBS.
There was a good evidence for a decrease in health-related QOL (Quality of Life) in patients with moderate to severe IBS, to a degree comparable with other chronic disorders such as depression or Gastroesophageal reflux disorder (GERD). IBS is associated with substantial costs because of days lost from work, excess physician visits, diagnostic testing & use of medications. Patients with IBS miss 3 times as many days from work as do those without bowel symptoms.
SYMPTOMS OF IBS:
• Abdominal discomfort or Pain
• Constipation and Diarrhea
• Bloating and visible Distension
• Non Colonic symptoms like Epigastric discomfort or Pain (Dyspepsia). Headache, Backache, impaired Sleep, Chronic Fatigue, Pelvic pain, Musculoskeletal Pain syndromes are also associated with IBS.
• Retention of gas following its infusion into the small intestine is greater in patients with IBS than it is in healthy controls. Many patients with IBS attribute their symptoms to certain foods, with wheat, dairy products, Citrus fruits, Potatoes, Onions & Chocolate most commonly implicated. It has been suggested that colonic flora could be abnormal in a subset of patients with IBS, resulting in production of excess gas & development of symptoms. Depression, anxiety & Somatization are most common psychiatric conditions that coexist in IBS.
TREATMENT
• Education & support: IBS, a life-long disorder, needs a strong patient-physician relationship. In terms of providing optimal reassurance, it is important first to educate patients & then to actively reassure them.
• Diet & Lifestyle: Data from various studies show that soluble fiber (Ispaghula) is of global benefit. Fiber supplements should begin at a fiber supplements should begin at a low dose & be increased very slowly. Recent interest has surrounded the potential role of fermentable Oligosaccharides, Disaccharides, Monosaccharides & Polyols (FODMAPs) in generating symptoms in IBS, via their fermentation & osmotic effects. It has been seen that low FODMAPs diet improves clinical response compared with general dietary advice in patients with Diarrhea-predominant IBS (IBS D). In contrast a High-FODMAP diet significantly worsens the symptoms in IBS patients.
Low FODMAP Diet Includes:
Grapes, Strawberry, Corn, Tomato, Banana, Carrot, Rice, Cucumber, Orange, Fish, Green-Bean, lemon, Ginger, Black Tea, Spinach, Capsicum, Kiwi Fruit.
High FODMAP Diet includes:
Custard, Chickpeas, Canned Fruit, Lentils, Fruit Juice, Apricot, Watermelon, Mango, Pears, Apple, Onion, Cauliflower, Honey, Peas, Beetroot, Milk & its products, Ice-Cream, Cabbage, Wheat.
MEDICATION
• Anticholinergic a Antispasmodic Agents like Dicyclomine, hyoscyamine Continue to be used commonly for IBS.
• Laxatives-used for IBS-C
• Antidiarrheal agents (Loperamide) – efficacious in IBS-D patients.
• Serotonin- Receptor Drugs (Alosetron) efficacious in women with severe IBS-D.
• Antidepressants & Anxiolytics appear to be efficacious in IBS
• Antibiotics – Rifaximin (550mg tds) for two weeks, helped in global symptoms and bloating.
• Probiotics: found to be helpful by improving colonic microbiota
• Psychological treatments: Psychotherapy, hypnotherapy & cognitive behavioral therapy have been proposed as useful treatments for IBS.
In conclusion IBS is a chronic functional disorder of the gastrointestinal tract with symptoms of abdominal pain and altered bowel habits that include diarrhea, constipation, or both. Patients who suffer from IBS often have an impaired quality of life. Patients who suffer from IBS often respond to lifestyle, diet modifications (Low FODMAP Diet) & drugs. In clinical practice, once a diagnosis of IBS has been made, it usually requires no revision despite prolonged follow-up. Some IBS patients have spontaneous improvement over time, but IBS usually is a relapsing disorder. The presence of excessive psychological distress or anxiety, as well as a long duration of complaints, tends to indicate a poorer prognosis.
Author is Post DM Senior Resident Department of Gastroentrology SKIMS, Soura
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