IRRITABLE BOWEL SYNDROME (IBS)
Characterized by altered bowel habits, abdominal pain, and absence of detectable organic pathology. Most common GI disease in clinical practice. Three types of clinical presentations: (1) spastic colon (chronic abdominal pain and constipation), (2) alternating constipation and diarrhea, or (3) chronic, painless diarrhea.
Visceral hyperalgesia to mechanoreceptor stimuli is common. Reported abnormalities include altered colonic motility at rest and in response to stress, cholinergic drugs, cholecystokinin; altered small-intestinal motility; enhanced visceral sensation (lower pain threshold in response to gut distention); and abnormal extrinsic innervation of the gut. Pts presenting with IBS to a physician have an increased frequency of psychological disturbances—depression, hysteria, obsessive-compulsive disorder. Specific food intolerances and malabsorption of bile acids by the terminal ileum may account for a few cases.
Onset often before age 30; females:males = 2:1. Abdominal pain and irregular bowel habits. Additional symptoms often include abdominal distention, relief of abdominal pain with bowel movement, increased frequency of stools with pain, loose stools with pain, mucus in stools, and sense of incomplete evacuation. Associated findings include pasty stools, ribbony or pencil-thin stools, heartburn, bloating, back pain, weakness, faintness, palpitations, urinary frequency.
IBS is a diagnosis of exclusion. Rome criteria for diagnosis are shown in Table 160-1. Consider sigmoidoscopy and barium radiographs to exclude inflammatory bowel disease or malignancy; consider excluding giardiasis, intestinal lactase deficiency, hyperthyroidism.
TABLE 160-1DIAGNOSTIC CRITERIA FOR IRRITABLE BOWEL SYNDROMEa |Favorite Table|Download (.pdf) TABLE 160-1DIAGNOSTIC CRITERIA FOR IRRITABLE BOWEL SYNDROMEa
|Recurrent abdominal pain or discomfortb at least 3 days per month in the last 3 months associated with two or more of the following: |
|1. Improvement with defecation |
|2. Onset associated with a change in frequency of stool |
|3. Onset associated with a change in form (appearance) of stool |
TREATMENT Irritable Bowel Syndrome (Table 160-2)
Reassurance and supportive physician-pt relationship, avoidance of stress or precipitating factors, dietary bulk (fiber, psyllium extract, e.g., Metamucil 1 tbsp daily or bid); for diarrhea, trials of loperamide (2-mg tabs PO q a.m. then 1 PO after each loose stool to a maximum of 8/d, then titrate), diphenoxylate (Lomotil) (up to 2-mg tabs PO qid), or cholestyramine (up to 1-g packet mixed in water PO qid); for pain, anticholinergics (e.g., dicyclomine HCl 10–40 mg PO qid) orhyoscyamine as Levsin 1–2 PO q4h prn. Amitriptyline 25–50 mg ...