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Am Fam Physician. 2021;103(12):727-736

Patient information: A handout on this topic is available at https://familydoctor.org/condition/irritable-bowel-syndrome-ibs.

This clinical content conforms to AAFP criteria for CME.

Author disclosure: No relevant financial affiliations.

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

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

Most individuals with IBS have relatively mild or intermittent symptoms and can be treated with reassurance, education, dietary advice, and the occasional use of medications.68 As with other chronic conditions affecting patients who may have coexisting psychological issues, the patient-physician relationship is particularly crucial for effective long-term management.9 Physicians must elicit the specific concerns and expectations of patients and understand the ways in which IBS affects patients' lives and the diverse explanatory models that patients use when describing their illness.2,1014 Physicians should be able to discuss and describe IBS and its management in ways that are consistent with patients' beliefs.

The following questions provide a framework for physicians to better understand the etiology and clinical presentations of IBS, to be more aware of patient perspectives, and to recognize and confidently diagnose and treat the condition. These questions outline the steps necessary for developing the continuous trusting interactions necessary for helping patients accept the diagnosis and actively engage in effective self-management (Table 12,3,11,1422 ). Figure 1 outlines the principles of the evaluation and management of IBS.7,8,14,15,2329

RecommendedLikely effectiveAvoid
Express empathy and be alert for psychosocial cuesAcknowledging that the patient's explanations and symptoms are real; ask how symptoms affect daily life (e.g., “I am sorry you are feeling this way. I can see that the pain has affected your life.”)
Be alert for empathic opportunities; many patients provide cues to emotional or social problems; acknowledge and address psychosocial concerns
Dismissing symptoms (e.g., “There is nothing wrong with you.”)
Missing or failing to engage with cues and addressing only symptoms; this may further somatization in patients
Solicit the patient's views about causes and triggers of symptomsAsking open-ended questions (e.g., “Can you tell me what you think is causing your symptoms?” or “What do you think triggers your symptoms?”)Asking closed-ended questions (e.g., “Do you think your pain is caused by eating?”)
Assess the patient's views on the connection between their symptoms and stressEmphasizing that gastrointestinal abnormalities may disproportionately affect patients who are simultaneously experiencing stressful life events may be a more effective and acceptable starting point for discussionsFocusing on individuals with certain personality types who are susceptible to IBS may be less acceptable to patients
Understand the patient's concerns about symptoms and expectations from the visitAsking open-ended questions (e.g., “Tell me a little about what you are expecting from this consultation.” or “I'm hearing that you have been experiencing pain for many years.
Could you tell me about why you want to see me today?”)
Using judgmental statements (e.g., “I am not sure I can help you. You have been to so many doctors already.”)
Help the patient understand and accept the diagnostic processAlthough abnormal findings are rare (abdominal tenderness or a palpable colon are common findings in general), the physical examination is importantNeglecting to perform a physical examination even if no abnormal findings are expected
Performing tests only for reassurance
Understand the patient's expectations from treatment(s)Acknowledging the patient's frustration with multiple treatments that have not been helpful
Ask probing, open-ended questions (e.g., “What would be a tolerable pain level that we can try to achieve?”)
Imposing a treatment plan (e.g., “My plan is to refer you to a pain specialist and a psychiatrist.”)
Assess the patient's understanding of the education you providedHaving patients reiterate what they have heard (e.g., “I provided you with a lot of information today. I hope that it was understandable and makes sense to you. Can you tell me what you have understood so far?”)Using a unilateral flow of information (e.g., “I hope you understood all the things we discussed today and that you implement the suggestions I gave you.”)
Enlist the patient as an active participant in their own IBS symptom managementSuggesting that the patient keep a diary of symptoms for three to four weeks; take time to review and discuss in detail at the return visitPrescribing treatments in which the patient is a passive recipient
Leverage the benefits of a continuous caring physician-patient relationshipScheduling a return visitAssuming that patients who do not return have responded to treatment or are now symptom free

What Is the Current Understanding of the Pathophysiology of IBS and Its Relationship to Psychological Concerns?

IBS is a heterogeneous group of conditions that is best understood in the context of the biopsychosocial model. Several different biologic and cellular abnormalities may cause similar disturbances in gut-brain modulation over time, especially in susceptible individuals, resulting in pain and abnormal stool patterns23 (eFigure A). Other functional gastrointestinal (GI) disorders and chronic pain syndromes, including fibromyalgia, fatigue, or chronic pelvic pain, often coexist with IBS.13 Many people with IBS may also have coexisting anxiety or depressed mood, a history of adverse life events, or psychosocial stressors.30 Although stress may alter colonic motility and sensation, psychological factors may be the result of, rather than the cause of, IBS symptoms.14

EVIDENCE SUMMARY

Several pathologic processes that trigger IBS in certain individuals have been identified, such as immune activation following gastroenteritis (postinfectious IBS), altered permeability of the bowel wall caused by certain foods, or alterations of gut microflora caused by medications. Over time, sensory (afferent) nerves from the gut to the brain and regulatory (efferent) nerves from the brain to the gut are activated, leading to heightened peripheral and central pain perception and altered bowel motility, transit, and function.23

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