Irritable Bowel Syndrome: Questions and Answers for Effective Care

 

Irritable bowel syndrome (IBS) is a heterogeneous group of conditions related to specific biologic and cellular abnormalities that are not fully understood. Psychological factors do not cause IBS, but many people with IBS also have anxiety or depressed mood, a history of adverse life events, or psychosocial stressors. Physicians must understand the fears and expectations of patients and how they think about their symptoms and should also respond empathetically to psychosocial cues. Anxiety related to the unpredictability of symptoms may have a greater effect on quality of life than the symptoms themselves. Patients in generally good health who have ongoing or recurrent gastrointestinal symptoms and abnormal stool patterns most likely have IBS or another functional gastrointestinal disorder. Patients who meet symptom-based criteria and have no alarm features may be confidently diagnosed with few, if any, additional tests. Patients may not completely understand the diagnostic process; asking about expectations and carefully explaining the goals and limitations of testing leads to more effective care. There is no definitive treatment for IBS, and recommended treatments focus on symptom relief and improved quality of life. Trusting patient-physician interactions are essential to help patients understand and accept an IBS diagnosis and to actively engage in effective self-management.

Irritable bowel syndrome (IBS), although common, is not completely understood and is often unrecognized and underdiagnosed.1 Patients may not accept the diagnosis, believing that IBS is a label that connotes a psychological disorder or implies that a cause for their distress has not yet been found.2,3 Primary care physicians and specialists may hesitate to share the diagnosis for the same reasons or, believing IBS to be a diagnosis of exclusion, may be reluctant to make the diagnosis without exhaustive testing.4,5

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Physicians can foster the continuous trusting relationships necessary for effective care of patients with IBS by sharing a clear diagnosis and responding appropriately to the diverse explanatory models used by patients. This includes addressing patient concerns and expectations.2,1014

C

Consensus recommendation based on consistent evidence from qualitative patient surveys

IBS can be diagnosed using symptom-based clinical criteria and limited testing; in the absence of alarm features, exhaustive testing is not necessary.13,14,24,43

C

Evidence-based guidelines and retrospective evidence (favorable findings may also be related to a low pretest probability of organic disease in the populations studied)

Initial interventions for IBS should focus on the most troublesome symptoms or their triggers and on improving quality of life.7,8,35

C

Consensus recommendation based on expert opinion and consistent evidence from qualitative patient surveys

Gluten-free diets and low FODMAP diets should be instituted only for clear indications and under appropriate guidance from a dietitian.7,8

C

Evidence-based guidelines: evidence of benefit, but the evidence was low quality; little or no data regarding long-term outcomes or harms


FODMAP = fermentable oligosaccharides, disaccharides, monosaccharides, and polyols; IBS = irritable bowel syndrome.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Physicians can foster the continuous trusting relationships necessary for effective care of patients with IBS by sharing a clear diagnosis and responding appropriately to the diverse explanatory models used by patients. This includes addressing patient concerns and expectations.2,1014

C

Consensus recommendation based on consistent evidence from qualitative patient surveys

IBS can be diagnosed using symptom-based clinical criteria and limited testing; in the absence of alarm features, exhaustive testing is not necessary.13,14,24,43

C

Evidence-based guidelines and retrospective evidence (favorable findings may also be related to a low pretest probability of organic disease in the populations studied)

Initial interventions for IBS should focus on the most troublesome symptoms or their triggers and on improving quality of life.7,8,35

C

Consensus recommendation based on expert opinion and consistent evidence from qualitative patient surveys

Gluten-free diets and low FODMAP diets should be instituted only for clear indications and under appropriate guidance from a dietitian.7,8

C

Evidence-based guidelines: evidence of benefit, but the evidence was low quality; little

The Authors

show all author info

JOHN M. WILKINSON, MD, FAAFP, is an associate professor of family medicine at the Mayo Clinic Alix School of Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minn....

MARGARET C. GILL, MD, MS, is an assistant professor of family medicine at the Mayo Clinic Alix School of Medicine, Mayo Clinic College of Medicine and Science.

Address correspondence to John M. Wilkinson, MD, FAAFP, Mayo Clinic Alix School of Medicine, Mayo Clinic College of Medicine and Science, 200 1st St. SW, Rochester, MN 55905 (email: wilkinson.john@mayo.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

show all references

1. Hungin APS, Chang L, Locke GR, et al. Irritable bowel syndrome in the United States: prevalence, symptom patterns and impact. Aliment Pharmacol Ther. 2005;21(11):1365–1375....

2. Stenner PH, Dancey CP, Watts S. The understanding of their illness amongst people with irritable bowel syndrome: a Q methodological study. Soc Sci Med. 2000;51(3):439–452.

3. Dixon-Woods M, Critchley S. Medical and lay views of irritable bowel syndrome. Fam Pract. 2000;17(2):108–113.

4. Spiegel BMR, Farid M, Esrailian E, et al. Is irritable bowel syndrome a diagnosis of exclusion?: a survey of primary care providers, gastroenterologists, and IBS experts. Am J Gastroenterol. 2010;105(4):848–858.

5. Linedale EC, Chur-Hansen A, Mikocka-Walus A, et al. Uncertain diagnostic language affects further studies, endoscopies, and repeat consultations for patients with functional gastrointestinal disorders. Clin Gastroenterol Hepatol. 2016;14(12):1735–1741.e1.

6. Schmulson MJ, Ortiz-Garrido OM, Hinojosa C, et al. A single session of reassurance can acutely improve the self-perception of impairment in patients with IBS. J Psychosom Res. 2006;61(4):461–467.

7. Lacy BE, Pimentel M, Brenner DM, et al. ACG clinical guideline: management of irritable bowel syndrome. Am J Gastroenterol. 2021;116(1):17–44.

8. Moayyedi P, Andrews CN, MacQueen G, et al. Canadian Association of Gastroenterology clinical practice guideline for the management of irritable bowel syndrome (IBS). J Can Assoc Gastroenterol. 2019;2(1):6–29.

9. Owens DM, Nelson DK, Talley NJ. The irritable bowel syndrome: long-term prognosis and the physician-patient interaction. Ann Intern Med. 1995;122(2):107–112.

10. Spiegel BMR, Gralnek IM, Bolus R, et al. Clinical determinants of health-related quality of life in patients with irritable bowel syndrome. Arch Intern Med. 2004;164(16):1773–1780.

11. Casiday RE, Hungin APS, Cornford CS, et al. Patients' explanatory models for irritable bowel syndrome: symptoms and treatment more important than explaining aetiology. Fam Pract. 2009;26(1):40–47.

12. Casiday RE, Hungin APS, Cornford CS, et al. GPs' explanatory models for irritable bowel syndrome: a mismatch with patient models? Fam Pract. 2009;26(1):34–39.

13. Lacy BE, Mearin F, Chang L, et al. Bowel disorders. Gastroenterology. 2016;150(6):1393–1407.

14. Drossman DA. Functional gastrointestinal disorders: history, pathophysiology, clinical features and Rome IV. Gastroenterology. 2016;150(6):1262–1279.

15. Bharucha AE, Chakraborty S, Sletten CD. Common functional gastroenterological disorders associated with abdominal pain. Mayo Clin Proc. 2016;91(8):1118–1132.

16. Williams RE, Black CL, Kim H-Y, et al. Determinants of healthcare-seeking behaviour among subjects with irritable bowel syndrome. Aliment Pharmacol Ther. 2006;23(11):1667–1675.

17. Yawn BP, Locke GR III, Lydick E, et al. Diagnosis and care of irritable bowel syndrome in a community-based population. Am J Manag Care. 2001;7(6):585–592.

18. Salmon P, Dowrick CF, Ring A, et al. Voiced but unheard agendas: qualitative analysis of the psychosocial cues that patients with unexplained symptoms present to general practitioners. Br J Gen Pract. 2004;54(500):171–176.

19. Bijkerk CJ, de Wit NJ, Stalman WAB, et al. Irritable bowel syndrome in primary care: the patients' and doctors' views on symptoms, etiology and management. Can J Gastroenterol. 2003;17(6):363–368.

20. Costanzo C, Verghese A. The physical exam as ritual: social sciences and embodiment in the context of the physical examination. Med Clin North Am. 2018;102(3):425–431.

21. Rolfe A, Burton C. Reassurance after diagnostic testing with a low pre-test probability of serious disease: systematic review and meta-analysis. JAMA Intern Med. 2013;173(6):407–416.

22. Spiegel BMR, Gralnek IM, Bolus R, et al. Is a negative colonoscopy associated with reassurance or improved health-related quality of life in irritable bowel syndrome? Gastrointest Endosc. 2005;62(6):892–899.

23. Camilleri M. Peripheral mechanisms in irritable bowel syndrome. N Engl J Med. 2012;367(17):1626–1635.

24. Sood R, Camilleri M, Gracie DJ, et al. Enhancing diagnostic performance of symptom-based criteria for irritable bowel syndrome by additional history and limited diagnostic evaluation. Am J Gastroenterol. 2016;111(10):1446–1454.

25. Irvine AJ, Chey WD, Ford AC. Screening for celiac disease in irritable bowel syndrome: an updated systematic review and meta-analysis. Am J Gastroenterol. 2017;112(1):65–76.

26. Smalley W, Falck-Ytter C, Carrasco-Labra A, et al. AGA clinical practice guideline on the laboratory evaluation of functional diarrhea and diarrhea-predominant irritable bowel syndrome in adults (IBS-D). Gastroenterology. 2019;157(3):851–854.

27. Brandler J, Camilleri M. Pretest and post-test probabilities of diagnoses of rectal evacuation disorders based on symptoms, rectal exam, and basic tests: a systematic review. Clin Gastroenterol Hepatol. 2020;18(11):2479–2490.

28. Camilleri M, Chedid V. Actionable biomarkers: the key to resolving disorders of gastrointestinal function. Gut. 2020;69(10):1730–1737.

29. Vijayvargiya P, Gonzalez Izundegui D, Calderon G, et al. Fecal bile acid testing in assessing patients with chronic unexplained diarrhea: implications for healthcare utilization. Am J Gastroenterol. 2020;115(7):1094–1102.

30. Choung RS, Locke GR III, Zinsmeister AR, et al. Psychosocial distress and somatic symptoms in community subjects with irritable bowel syndrome: a psychological component is the rule. Am J Gastroenterol. 2009;104(7):1772–1779.

31. Vakil N, Stelwagon M, Shea EP, et al. Symptom burden and consulting behavior in patients with overlapping functional disorders in the US population. United European Gastroenterol J. 2016;4(3):413–422.

32. Choung RS, Saito YA, Schleck CD, et al. The natural history of chronic unexplained gastrointestinal disorders and gastroesophageal reflux during 20 years: a US population-based study. Mayo Clin Proc. 2021;96(3):563–576.

33. Sibelli A, Chalder T, Everitt H, et al. A systematic review with meta-analysis of the role of anxiety and depression in irritable bowel syndrome onset. Psychol Med. 2016;46(15):3065–3080.

34. Spiller R, Garsed K. Postinfectious irritable bowel syndrome. Gastroenterology. 2009;136(6):1979–1988.

35. Addante R, Naliboff B, Shih W, et al. Predictors of health-related quality of life in irritable bowel syndrome patients compared with healthy individuals. J Clin Gastroenterol. 2019;53(4):e142–e149.

36. Chang JY, Almazar AE, Richard Locke G III, et al. Quantifying Rome symptoms for diagnosis of the irritable bowel syndrome. Neurogastroenterol Motil. 2018;30(9):e13356.

37. Palsson OS, Baggish J, Whitehead WE. Episodic nature of symptoms in irritable bowel syndrome. Am J Gastroenterol. 2014;109(9):1450–1460.

38. Bradley S, Alderson S, Ford AC, et al. General practitioners' perceptions of irritable bowel syndrome: a Q-methodological study. Fam Pract. 2018;35(1):74–79.

39. Quigley EMM, Shanahan F. The language of medicine: words as servants and scoundrels. Clin Med (Lond). 2009;9(2):131–135.

40. North CS, Downs D, Clouse RE, et al. The presentation of irritable bowel syndrome in the context of somatization disorder. Clin Gastroenterol Hepatol. 2004;2(9):787–795.

41. Patel P, Bercik P, Morgan DG, et al. Irritable bowel syndrome is significantly associated with somatisation in 840 patients, which may drive bloating. Aliment Pharmacol Ther. 2015;41(5):449–458.

42. Wilkinson JM, Cozine EW, Loftus CG. Gas, bloating, and belching: approach to evaluation and management. Am Fam Physician. 2019;99(5):301–309. Accessed March 29, 2021. https://www.aafp.org/afp/2019/0301/p301.html

43. Engsbro AL, Begtrup LM, Haastrup P, et al. A positive diagnostic strategy is safe and saves endoscopies in patients with irritable bowel syndrome: a five-year follow-up of a randomized controlled trial. Neurogastroenterol Motil. 2021;33(3):e14004.

44. Burgers K, Lindberg B, Bevis ZJ. Chronic diarrhea in adults: evaluation and differential diagnosis. Am Fam Physician. 2020;101(18):472–480. Accessed March 29, 2021. https://www.aafp.org/afp/2020/0415/p472.html

45. El-Serag HB, Pilgrim P, Schoenfeld P. Systemic review: natural history of irritable bowel syndrome. Aliment Pharmacol Ther. 2004;19(8):861–870.

46. Jellema P, van der Windt DAWM, Schellevis FG, et al. Systematic review: accuracy of symptom-based criteria for diagnosis of irritable bowel syndrome in primary care. Aliment Pharmacol Ther. 2009;30(7):695–706.

47. Camilleri M. Management options for irritable bowel syndrome. Mayo Clin Proc. 2018;93(12):1858–1872.

48. Böhn L, Strörsrud S, Liljebo T, et al. Diet low in FODMAPs reduces symptoms of irritable bowel syndrome as well as traditional dietary advice: a randomized controlled trial. Gastroenterology. 2015;149(6):1399–1407.e2.

49. Rao SSC, Yu S, Fedewa A. Systematic review: dietary fibre and FODMAP-restricted diet in the management of constipation and irritable bowel syndrome [published correction appears in Aliment Pharmacol Ther. 2015;42(4):490]. Aliment Pharmacol Ther. 2015;41(12):1256–1270.

50. Black CJ, Yuan Y, Selinger CP, et al. Efficacy of soluble fibre, anti-spasmodic drugs, and gut-brain neuromodulators in irritable bowel syndrome: a systematic review and network meta-analysis. Lancet Gastroenterol Hepatol. 2020;5(2):117–131.

51. Camilleri M, Ford AC, Mawe GM, et al. Chronic constipation. Nat Rev Dis Primers. 2017;3:17095.

52. Lavö B, Stenstam M, Nielsen AL. Loperamide in treatment of irritable bowel syndrome—a double-blind placebo controlled study. Scand J Gastroenterol Suppl. 1987;130:77–80.

53. Efskind PS, Bernklev T, Vatn MH. A double-blind placebo-controlled trial with loperamide in irritable bowel syndrome. Scand J Gastroenterol. 1996;31(5):463–468.

54. Garsed K, Chernova J, Hastings M, et al. A randomised trial of ondansetron for the treatment of irritable bowel syndrome with diarrhoea. Gut. 2014;63(10):1617–1625.

55. Ford AC, Lacy BE, Harris LA, et al. Effect of antidepressants and psychological therapies in irritable bowel syndrome: an updated systematic review and meta-analysis. Am J Gastroenterol. 2019;114(1):21–39.

56. Ashraf W, Park F, Lof J, et al. An examination of the reliability of reported stool frequency in the diagnosis of idiopathic constipation. Am J Gastroenterol. 1996;91(1):26–32.

57. Kessel N. Reassurance. Lancet. 1979;1(8126):1128–1133.

58. Ford AC, Moayyedi P. Meta-analysis: factors affecting placebo response rate in the irritable bowel syndrome. Aliment Pharmacol Ther. 2010;32(2):144–158.

59. Kaptchuk TJ, Friedlander E, Kelley JM, et al. Placebos without deception: a randomized controlled trial in irritable bowel syndrome. PLoS One. 2010;5(12):e15591.

60. Wilkins T, Pepitone C, Alex B, et al. Diagnosis and management of IBS in adults. Am Fam Physician. 2012;86(5):419–426. Accessed March 25, 2021. https://www.aafp.org/afp/2012/0901/p419.html

61. Hadley SK, Gaarder SM. Treatment of irritable bowel syndrome. Am Fam Physician. 2005:72(12):2501–2508. Accessed March 25, 2021. https://www.aafp.org/afp/2005/1215/p2501.html

62. Viera AJ, Hoag S, Shaughnessy J. Management of irritable bowel syndrome. Am Fam Physician. 2002;66(10):1867–1875. Accessed March 25, 2021. https://www.aafp.org/afp/2002/1115/p1867.html

 

 

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