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ESSENTIALS OF DIAGNOSIS

  • Chronic functional disorder characterized by abdominal pain with alterations in bowel habits.

  • Symptoms usually begin in late teens to early twenties.

  • Limited evaluation to exclude organic causes of symptoms.

GENERAL CONSIDERATIONS

The functional gastrointestinal disorders are characterized by a variable combination of chronic or recurrent gastrointestinal symptoms not explicable by the presence of structural or biochemical abnormalities. Several clinical entities are included under this broad rubric, including chest pain of unclear origin (noncardiac chest pain), functional dyspepsia, and biliary dyskinesia (sphincter of Oddi dysfunction). There is a large overlap among these entities. For example, over 50% of patients with noncardiac chest pain and over one-third with functional dyspepsia also have symptoms compatible with irritable bowel syndrome. In none of these disorders is there a definitive diagnostic study. Rather, the diagnosis is a subjective one based on the presence of a compatible profile and the exclusion of similar disorders.

Irritable bowel syndrome can be defined, therefore, as an idiopathic clinical entity characterized by chronic (more than 3 months) abdominal pain that occurs in association with altered bowel habits. These symptoms may be continuous or intermittent. The 2016 Rome IV consensus definition of irritable bowel syndrome is abdominal pain that has two of the following three features: (1) related to defecation, (2) associated with a change in frequency of stool, or (3) associated with a change in form (appearance) of stool. Symptoms of abdominal pain should be present on average at least 1 day per week. Other symptoms supporting the diagnosis include abnormal stool frequency; abnormal stool form (lumpy or hard; loose or watery); abnormal stool passage (straining, urgency, or feeling of incomplete evacuation); and abdominal bloating or a feeling of abdominal distention.

Patients may have other somatic or psychological complaints such as dyspepsia, heartburn, chest pain, headaches, fatigue, myalgias, urologic dysfunction, gynecologic symptoms, anxiety, or depression.

The disorder is a common problem presenting to both gastroenterologists and primary care physicians. Up to 10% of adults have symptoms compatible with the diagnosis, but most never seek medical attention. Approximately two-thirds of patients with irritable bowel syndrome are women.

PATHOGENESIS

A number of pathophysiologic mechanisms have been identified and may have varying importance in different individuals.

A. Abnormal Motility

A variety of abnormal myoelectrical and motor abnormalities have been identified in the colon and small intestine. In some cases, these are temporally correlated with episodes of abdominal pain or emotional stress. Differences between patients with constipation-predominant (slow intestinal transit) and diarrhea-predominant (rapid intestinal transit) syndromes are reported.

B. Visceral Hypersensitivity

Patients often have a lower visceral pain threshold, reporting abdominal pain at lower volumes of colonic gas insufflation or colonic balloon inflation than controls. Many patients complain of bloating and distention, which may be due to a number of ...

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