GI Conditions
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      2. GI Conditions

      Irritable Bowel Syndrome

      Brief Overview: Irritable Bowel Syndrome (IBS) is a chronic condition that is quite common. It affects the GI system and the main symptoms are constipation, diarrhea, or both, and abdominal pain.

      Prevalence: According to UpToDate, “The prevalence of irritable bowel syndrome (IBS) in North America estimated from population-based studies is approximately 10 to 15 percent.”

      Etiology: The etiology is unclear.

      Risk Factors:

      • Female
      • Age < 50
      • Family history of IBS
      • Stressful early life events
      • Severe GI infection(s)
      • Food sensitivities or intolerances

      Commonly Associated Conditions:

      • Fibromyalgia
      • Chronic fatigue syndrome
      • GERD
      • Functional dyspepsia
      • Non-cardiac chest pain
      • Psychiatric disorders: depression, anxiety, somatization

      Common Medications:

      • For constipation-predominant IBS: fiber supplementation, polyethylene glycol (PEG), Linzess, Amitizia (for women)
      • For diarrhea-predominant IBS: loperamide, lomotil, Viberzi, bile acid sequestrants (like cholestyramine, colestipol, colesevelam). Rifaximin may be indicated
      • For Mixed IBS: medications for diarrhea/constipation are not recommended, as they could inadvertently worsen symptoms
      • For persistent global symptoms (abdominal pain, cramping, bloating, that persistent despite lifestyle and diet modications and subtype-specific treatment): antispasmodics (hyoscyamine, enteric-coated peppermint oil, alverine, etc.), tricyclic antidepressants, rifaximin

      Common Labs, Imaging, and Tests:

      • Diagnosis is based on the Rome IV criteria
      • CBC
      • In patients with diarrhea: fecal calprotectin or fecal lactoferrin, stool testing for giardia, serologic testing for celiac disease, CRP
      • Age-appropriate colorectal cancer screening, or if red-flag symptoms present
      • In patients with constipation: abdominal x-ray

      Common Symptoms:

      • Chronic abdominal pain
      • Changes in bowel habits – constipation, diarrhea, alternating constipation/diarrhea, or normal bowel habits alternating with diarrhea/constipation
      • Diarrhea associated with IBS is typically described as frequent loose stools of small-moderate volume, mucus discharge may be present, bowel movements are normally in the morning or after meals, and usually preceded by abdominal cramping or pain, urgency, and a sensation of incomplete evacuation
      • Constipation associated with IBS usually includes pellet-shaped stools

      Common Treatments:

      • Medications (see above)
      • Diet modifications based on any known or suspected dietary triggers. A low-FODMAP diet may be indicated
      • Exercise – as advised by your healthcare provider
      • Sleep hygiene
      • Brain-gut behavioral therapy – this could include gut-directed hypnotherapy, mindfulness, CBT, stress reduction techniques
      • Adequate hydration

      Physical Findings:

      • Abdominal tenderness may be present
      • Otherwise, physical exam is normal

      Potential Complications and Contraindications:

      • Reduced quality of life due to chronic symptoms
      • Anxiety or depression related to symptom burden
      • Unnecessary procedures or medications if not properly diagnosed
      • Red flag symptoms (weight loss, rectal bleeding, anemia, nighttime symptoms) should prompt further evaluation

      General Health and Lifestyle Guidance:

      • Track symptoms and food triggers using a diary or app
      • Follow a low FODMAP or elimination diet as directed by your healthcare provider and/or dietitian
      • Practice stress-reduction techniques
      • Regular physical activity, as directed by your healthcare provider
      • Avoid known triggers (e.g., caffeine, alcohol, fatty foods, artificial sweeteners)
      • Eat meals slowly and regularly (avoid skipping meals)
      • Stay adequately hydrated – discuss hydration needs with your healthcare provider

      Suggested Questions to Ask Patients:

      • Are your bowel habits consistent or do they alternate between diarrhea and constipation?
      • Do your symptoms improve after a bowel movement?
      • Have you identified any foods that worsen your symptoms?
      • Are your symptoms worse with stress?
      • Have you had any unintentional weight loss or blood in your stool?

      Suggested Talking Points:

      • Keep a food/symptom diary can help identify triggers and patterns
      • Your healthcare provider will create a treatment plan specifically for you based on your history, exam, and symptoms
      • Notify your healthcare provider of any new or worsening symptoms

      Sources: