Irritable Bowel Syndrome Treatment & Management

Irritable bowel syndrome:

(IBS) is a functional GI disorder characterized by abdominal pain as well as altered bowel habits in the absence of a specific and unique organic pathology. Although, microscopic inflammation has been documented in some patients. In fact, population-based studies estimate the prevalence of irritable bowel syndrome at 10-20% and the incidence of irritable bowel syndrome at 1-2% per year.

Irritable bowel syndrome 

Signs and symptoms:

Manifestations of IBS are as follows:

Altered bowel habits
Abdominal pain
Abdominal distention
Altered bowel habits in IBS may have the following characteristics:

Constipation variably results in complaints of hard stools of narrow caliber, painful or infrequent defecation, and intractability to laxatives
Additionally, Diarrhea usually is described as small volumes of loose stool, with evacuation preceded by urgency or frequent defecation
Also, Postprandial urgency is common, as is alternation between constipation and diarrhea
Characteristically, one feature predominates in a single patient, but significant variability exists among patients
Abdominal pain in IBS is protean, but may have the following characteristics:

Usually, pain frequently is diffused without radiation
Common sites of pain include the lower abdomen, specifically the left lower quadrant
Acute episodes of sharp pain are often superimposed on a more constant dull ache
Meals may precipitate pain
Defecation commonly improves pain but may not fully relieve it
Pain from presumed gas pockets in the splenic flexure may masquerade as anterior chest pain or left upper quadrant abdominal pain
Additional symptoms consistent with irritable bowel syndrome are as follows:

Clear or white mucorrhea of a noninflammatory etiology
Dyspepsia, heartburn
Nausea, vomiting
Sexual dysfunction (including dyspareunia and poor libido)
Urinary frequency and urgency have been noted
Worsening of symptoms in the perimenstrual period
Comorbid fibromyalgia
Stressor-related symptoms
Finally, Symptoms not consistent with irritable bowel syndrome should alert the clinician to the possibility of an organic pathology. Inconsistent symptoms include the following:

Onset in middle age or older
Acute symptoms (irritable bowel syndrome is defined by chronicity)
Progressive symptoms
Nocturnal symptoms
Anorexia or weight loss
Fever
Rectal bleeding
Painless diarrhea
Steatorrhea
Gluten intolerance

Diagnosis

The Rome III criteria for the diagnosis of irritable bowel syndrome require that patients have had recurrent abdominal pain or discomfort at least 3 days per month during the previous 3 months that is associated with 2 or more of the following:

Relieved by defecation
Onset associated with a change in stool frequency
Onset associated with a change in stool form or appearance
Supporting symptoms include the following:
Altered stool frequency, stool form, stool passage (straining and/or urgency)
Mucorrhea
Abdominal bloating or subjective distention, as well as four bowel patterns appear with irritable bowel syndrome. These patterns include the following:

1.IBS-D (diarrhea predominant)
2.IBS-C (constipation predominant)
3.IBS-M (mixed diarrhea and constipation)
4.IBS-A (alternating diarrhea and constipation)
The usefulness of these subtypes is debatable. Notably, within 1 year, 75% of patients change subtypes, and 29% switch between constipation-predominant IBS and diarrhea-predominant IBS.

A comprehensive history, a physical examination, and tailored laboratory as well as radiographic studies can establish a diagnosis of irritable bowel syndrome in most patients. Furthermore, the American College of Gastroenterologists does not recommend laboratory testing or diagnostic imaging in patients younger than 50 years with typical IBS symptoms and without the following “alarm features” :

Weight loss

Iron deficiency anemia
Family history of certain organic GI illnesses (eg, inflammatory bowel disease, celiac sprue, colorectal cancer)
Screening studies to rule out disorders other than IBS include the following:

Complete blood count with differential to screen for anemia, inflammation, and infection
A comprehensive metabolic panel to evaluate for metabolic disorders and to rule out dehydration/electrolyte abnormalities in patients with diarrhea
Further, Stool examinations for ova and parasites, enteric pathogens, leukocytes, Clostridium difficile toxin, and possibly Giardia antigen
History-specific studies include the following:

Hydrogen breath testing to exclude bacterial overgrowth in patients with diarrhea to screen for lactose and/or fructose intolerance
In addition, tissue transglutaminase antibody testing and small bowel biopsy in IBS-D to diagnose celiac disease.
Thyroid function tests
Serum calcium testing to screen for hyperparathyroidism
Erythrocyte sedimentation rate and C-reactive protein measurement are nonspecific screening tests for inflammation

In addition, management of irritable bowel syndrome consists primarily of providing psychological support and recommending dietary measures. Pharmacologic treatment directs at symptoms.

Dietary measures may include the following:

Fiber supplementation may improve symptoms of constipation and diarrhea
Polycarbophil compounds (eg, Citrucel, FiberCon) may produce less flatulence than psyllium compounds (eg, Metamucil)
Also, physicians recommend judicious water intake in patients who predominantly experience constipation
Caffeine avoidance may limit anxiety and symptom exacerbation
Furthermore, legume avoidance may decrease abdominal bloating
Additionally, Patients should limit lactose, fructose, and/or FODMAPs (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols)
Probiotics are being studied for their use in decreasing IBS symptoms
Although the evidence is mixed regarding long-term improvement in GI symptoms with successful treatment of psychiatric comorbidities, the American College of Gastroenterology has concluded the following:

Conclusively, psychological interventions, cognitive-behavioral therapy, dynamic psychotherapy, and hypnotherapy are more effective than placebo
Furthemore, relaxation therapy is no more effective than usual care

Pharmacologic agents used for management of symptoms in IBS include the following:

Anticholinergics (eg, dicyclomine, hyoscyamine)                                                                                                            Antidiarrheals (eg, diphenoxylate, loperamide)

Tricyclic antidepressants (eg, imipramine, amitriptyline)
Prokinetics
Bulk-forming laxatives
Serotonin receptor antagonists (eg, alosetron)
Chloride channel activators (eg, lubiprostone)
Guanylate cyclase C (GC-C) agonists (eg, linaclotide)
Antispasmodics (eg, peppermint oil, pinaverium, trimebutine, cimetropium/dicyclomine)
Potentially, rifaxamin (this is still investigational and not FDA approved).

Probiotics like VSL#3 and Visbiome could help or even eliminate the symptoms of IBS and other digestive disorders and diseases. This formulation had over 60 studies showing its effectiveness for patients with Irritable Bowel Syndrome.