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PART 1: Background
1a: What is Irritable Bowel Syndrome?
1b: What is the prevalence of IBS?
1c: What factors contribute to the onset of IBS?
1d: How long does IBS last?
1e: What effect does IBS have on one's lifestyle?
1f: Are my symptoms just "all in my head" or psychosomatic?
1g: What factors contribute to health care utilization?
PART 2: Symptoms
2a: What are the symptoms of IBS?
2b: How severe are these symptoms?
2c: Does everybody get the same symptoms?
PART 3: Medical Facts
3a: What causes IBS?
3b: What is the role of psychological and/or social factors in IBS?
3c: Is IBS life-threatening?
3d: Will IBS lead to colon or rectal cancer?
3e: Will IBS lead to IBD (Crohn's, ulcerative colitis)?
3f: Will my IBS eventually go away, or will I have it for the rest
of my life?
PART 4: Diagnosis
4a: How do I know for sure if I have IBS?
4b: Is IBS a legitimate diagnosis? Should I seek a second opinion?
PART 5: Related Maladies
5a: How does IBS differ from Crohn's disease
or ulcerative colitis?
5b: How does IBS differ from gluten enteropathy/celiac disease?
5c: How does IBS relate to other broad-spectrum symdromes, such as
Fibromylagia, Chronic Fatigue Syndrome (CFS), Myofascial Pain
Syndrome (MPS), Multiple Chemical Sensitivity Syndrome (MCSS), and
others?
Part 1: BackGround
1a: What is Irritable Bowel Syndrome?
Irritable Bowel Syndrome (IBS) is part of a
spectrum of diseases known as Functional Gastrointestinal Disorders
which include diseases such as noncardiac chest pain, nonulcer
dyspepsia, and chronic constipation or diarrhea. These diseases are all
characterized by chronic or recurrent gastrointestinal symptoms for
which no structural or biochemical cause can be found.
1b: What is the prevalence of IBS?
IBS affects between 25 and 55 million people in
the United States and results in 2.5 to 3.5 million yearly visits to
physicians. Approximately 20 to 40 percent of all visits to
gastroenterologists are due to IBS symptoms.
IBS symptoms affects men and women of all ages and
of all races. The prevalence of IBS in the general population of Western
countries varies from 6 to 22%. IBS affects 14-24% of women and 5-19% of
men. The prevalence is similar in Caucasians and African Americans, but
appears to be lower in Hispanics. Although several studies have reported
a lower prevalence of IBS among older people, the present studies do not
allow to definitely conclude whether or not an age disparity exists in
IBS. In non-Western countries such as Japan, China, India, and Africa,
IBS also appears to be very common.
1c: What factors contribute to the onset of
IBS?
Many patients with IBS report that their symptoms
began during periods of major life stressors such as a divorce, death of
a loved one, or school exams. Many patients also report the onset of
symptoms during or shortly after recovering from a gastrointestinal
infection or abdominal surgeries. Symptoms of IBS have also been known
to appear upon the ingestion of a certain food to which the individual
is sensitive. The type of food which causes symptoms varies with the
individual. (There is no one definite universal food trigger for IBS.)
Similarly, a flare of symptoms in a patient with long-standing IBS may
be triggered by all of the symptoms listed above, or for no apparent
reason.
1d: How long does IBS last?
Almost everything about IBS is totally dependent
on the individual patient. For some, IBS may arise during times of
stress or crisis, and then subside once the stressful event has passed.
For others, IBS strikes seemingly randomly and without warning and never
completely goes away. Still others will get IBS for a while, then it
will go away for a long period of time, then come back. The duration of
IBS is different for everybody.
1e: What effect does IBS have on one's
lifestyle?
IBS can be nothing more than a mild annoyance,
completely debilitating, or anywhere in between. Again, it depends on
the person and how he or she reacts to it and treats it.
1f: Are my symptoms just "all in my head"
or psychosomatic?
Several studies have shown that psychological
disturbances are more common in IBS patients than patients with other
gastrointestinal diagnoses and healthy controls. However, people with
IBS who do not seek medical care have a similar psychological profile as
the general population. Therefore, IBS is not caused by psychological
problems, but a person's outcome and illness behavior is affected by
their psychological make-up. Different people respond differently to
their IBS and IBS symptoms, depending on a number of psychosocial
factors.
1g: What factors contribute to health care
utilization?
Although IBS is very common in the general
population, only a minority of people ever seek medical care for their
symptoms. Cultural factors may affect health care utilization. For
example, as opposed to the U.S. and Europe, in India male patients are
more likely to seek medical care than women. The presence and severity
of abdominal pain, and the number of "Manning Criteria" correlate with
health care consultation. Finally, psychological disturbance (e.g.
anxiety or depression) also appears to influence health care
utilization.
Part 2: Symptoms
2a: What are the symptoms of IBS?
The most common symptoms that IBS patients
complain of are: frequent diarrhea, abdominal pain (usually in the lower
abdomen area), gas, bloating, diarrhea alternating with constipation,
mucus in the stool, bowel urgency or incontinence, and a feeling of
incomplete evacuation after a bowel movement. Since IBS is considered
mainly to be a disorder of the lower gastrointestinal tract, the
symptoms tend to remain located below the navel. However, several
symptoms of the upper gastrointestinal tract have also been shown to be
common in those with IBS, including: difficultly swallowing, a sensation
of a lump in the throat or a closing of the throat, heartburn or acid
indigestion, nausea (with or without vomiting), and chest pain.
A number of expert investigators during a meeting
in Rome, Italy, developed a consensus definition and criteria for IBS,
known as the "Rome" criteria.
At least 3 months of continuous or recurrent
symptoms of:
1. Abdominal pain or discomfort, e.g.:
a. Relieved with defecation and/or
b. Associated with a change in frequency of stool; and/or
c. Associated with a change in consistency of stool; and
2. Two or more of the following, at least on one-fourth of occasions or
days:
a. Altered stool frequency
b. Altered stool form (e.g. watery/loose stools or hard stools)
c. Altered stool passage (e.g. sensations of incomplete evacuation
after bowel movements, straining, or urgency)
d. Passage of mucus and/or
e. Bloating or feeling of abdominal distention.
In addition, a number of other non-colonic
symptoms may be present in patients with IBS. These include: nausea,
feeling full after eating only a small meal, sensation of urinary
urgency, incomplete emptying after urinating, fatigue, and pain during
sexual intercourse.
2b: How severe are these symptoms?
As with just about everything associated with IBS,
the severity of symptoms vary greatly from person to person, ranging
from barely noticeable to completely debilitating, and can vary for the
same person over periods of time.
2c: Does everybody get the same symptoms?
No. Although the symptoms listed in 2a are the
most common, each person's experience and presentation will be slightly
different. The severity and frequency of abdominal pain or discomfort
will also vary from an intermittent abdominal discomfort during stress
life events to severe continuous abdominal pain. Likewise, bowel habits
can vary. Diarrhea, constipation, or alternating between the two may be
the predominant bowel pattern.
Part 3: Medical Facts
3a: What causes IBS?
Recent physiological and psychosocial data have
emerged to improve our understanding of IBS. A biopsychosocial model of
IBS involving physiological, emotional, cognitive, and behavioral
factors is now felt to be involved in symptom generation. Physiological
factors implicated in the etiology of IBS symptoms include: visceral
hypersensitivity to spontaneous contractions and to balloon distention
of the bowel, autonomic dysfunction including exaggerated colonic
motility response to stress and alterations in fluid and electrolyte
handling by the bowel, and an alteration in the gastrocolonic response.
However, alterations in these physiological parameters are generally
found in only a subset of patients and frequently do not correlate with
bowel symptoms. Behavioral factors such as stressful life events are
reported by up to 60% of IBS patients to be associated with the first
onset of the disease or with its exacerbation. Laboratory stressors have
also been shown to affect gastrointestinal motility and visceral
perception. Cognitive factors such as inappropriate coping styles and
illness behavior are common in IBS patients and influence healthcare
utilization and clinical outcomes. Emotional and psychiatric factors,
such as anxiety and depression, are present in 40 to 60% of IBS patients
seeking healthcare with increased prevalence in those patients
presenting to tertiary referral centers. IBS patients who have sought
medical care are more likely to have abnormal psychological profiles,
abnormal illness behaviors, and psychiatric diagnoses than patients with
other medical illnesses.
3b: What is the role of psychological
and/or social factors in IBS?
Psychiatric diagnoses are present in 42-62% of IBS
patients who have sought medical consultation. In comparison,
psychiatric diagnoses are present in around 20% of patients with other
gastrointestinal diagnoses. The majority of these psychiatric diagnoses
are cases of anxiety and depression. Other common diagnoses include
somatization disorder and hypochondriasis.
Stress can affect the functioning of the
gastrointestinal tract of all people, and particularly those with IBS.
Several studies have shown that IBS patients are more likely to report
that stress changes their stool pattern and leads to abdominal pain than
people without bowel problems. In one study 65% of IBS patients reported
a severe stressful life event prior to developing IBS. The kinds of
psychological stressors often reported by patients with IBS vary
considerably, but include: loss of a parent or spouse through death,
divorce, or separation, and sometimes is accompanied by feelings of
unresolved grief, and also significant life changes which demand many
social and personal adjustments such as moving to a new job or a new
city.
3c: Is IBS life-threatening?
No, however, IBS is serious. Patients with IBS
have a higher rate of hospitalizations, work absenteeism, feelings of
poor quality of life, and abdominal surgeries than healthy controls and
patients with other gastrointestinal illnesses. In the general
population, people with IBS symptoms missed more than 3 times as many
work days than did people without bowel symptoms.
3d: Will IBS lead to colon or rectal
cancer?
No. IBS has not been linked to any type of cancer.
In fact, those with IBS are more likely to be better aware of bowel
health and cancer prevention.
3e: Does IBS lead to IBD (Crohn's,
ulcerative colitis)?
No. IBS symptoms are often present in patients
with IBD, however, there is no evidence to suggest that IBS leads to
IBD.
3f: Will my IBS eventually go away, or will
I have it for the rest of my life?
IBS symptoms may fluctuate over time. In one
study, more than 50% of IBS patient remained symptomatic 5 years after
their initial diagnosis.
Part 4: Diagnosis
4a: How do I know for sure if I have IBS?
Since there is no diagnostic marker associated
with IBS, the diagnosis is based on symptoms and by excluding other
diseases which may have a similar presentation. The extent of the
medical evaluation which is necessary prior to making a diagnosis of IBS
will vary depending on the duration of symptoms, the patient's age and
clinical presentation. For example, recent onset of symptoms in an older
patient will require more extensive testing than a younger person with
unchanged symptoms for many years. Most patients, however, will be given
a thorough physical exam which is performed mainly to rule out other
medical illnesses. If further testing is necessary it will usually be
directed toward the predominant symptom. For example, patients with
significant diarrhea will often undergo stool tests for ova and
parasite, and malabsorption if clinically indicated. On the other hand,
patients with constipation will often undergo tests such as radiopaque
marker studies (Sitzmarker) for colonic functioning and anorectal
manometry for pelvic floor functioning. Most patients over the age of 50
years should have a flexible sigmoidoscopy. In addition, if occult blood
is found by either rectal exam or on hem-occult testing a colonoscopy
may be necessary.
Some commonly performed tests are:
It is important to note that the ONLY way to be
absolutely certain you have IBS is through a doctor's diagnosis.
Because there is no diagnostic marker associated
with IBS, the diagnosis is one of exclusion and is based on symptoms.
Manning and his colleagues were the first to report six symptoms which
differentiated IBS from other gastrointestinal diseases. The six
'Manning Criteria' are as follows: 1) relief of abdominal pain with
defecation, 2) looser stools with the onset of pain, 3) more frequent
bowel movements at onset of pain, 4) abdominal bloating or distention,
5) feelings of incomplete evacuation, and 6) passage of mucus per
rectum. In general the more 'Manning Criteria' present the more likely
it is that a patient has IBS. While the 'Manning Criteria' are helpful
in diagnosing IBS a consensus meeting in Rome, Italy recently further
refined these criteria (see 2a). In addition, since many other
gastrointestinal diseases can present with similar symptoms, a diagnosis
of IBS should only be made in the right clinical setting.
4b: Is IBS a legitimate diagnosis? Should I
seek a second opinion?
Many times a person may think that he or she is
being "slighted" by being given a diagnosis of IBS. Unfortunately, to
some doctors, IBS is not considered a "true" disease, but rather an
unimportant minor condition (when in reality it is hardly all that
"minor" to those who have to deal with it), and therefore may not be
given the medical attention it deserves. Don't despair; there ARE
competent doctors out there who are very good at dealing with IBS cases.
A good doctor won't just tell you that you have IBS and give up on you.
He or she should be willing to go over your questions and concerns, and
outline and monitor a program of treatment for your individual case of
IBS. If you suspect that you have not had a thorough enough examination
for other diseases before the doctor tells you that you have IBS, you
should seek a second opinion.
Part 5: Related Maladies
5a: How does IBS differ from Crohn's
disease or ulcerative colitis?
The symptoms of IBS differ from the symptoms of
Inflammatory Bowel Disease (IBD) in that there is NO trace of blood in
the stool, or history of fevers or chills. IBS is a functional disporder,
meaning that there is no demonstrable pathology in the colon or small
bowel.
5b: How does IBS differ from celiac
disease?
People with celiac disease experience marked
intestinal symptoms such as diarrhea and gas upon the consumption of
foods that contain gluten, such as products made from wheat, oats, rye,
and barley. Upon the elimination of gluten-containing foods, the
symptoms disappear. Some people with IBS may experience an aggravation
of symptoms with the consumption of similar wheat-related products and
eliminating these products can help alleviate symptoms.
5c: How does IBS relate to other
broad-spectrum symdromes, such as Fibromylagia, Chronic Fatigue Syndrome
(CFS), Myofascial Pain Syndrome (MPS), Multiple Chemical Sensitivity
Syndrome (MCSS), and others?
An interesting point to note here is that many IBS
patients also experience symptoms in non-gastrointestinal systems.
Research has been done on the frequent "overlap" of nonspecific
broad-spectrum syndromes in a large number of patients. Muhammad Yunus,
M.D., of the University of Illinois College of Medicine has studied a
group of syndromes as being part of a larger spectrum of conditions,
which he calls Dysregulation Spectrum Syndrome or DSS.
The following syndromes are considered to be part
of DSS, according to Dr. Yunus:
-
Fibromylagia Syndrome (FMS)
-
Chronic Fatigue Syndrome (CFS)
-
Myofascial Pain Syndrome (MPS)
-
Irritable Bowel Syndrome (IBS)
-
Temporomandibular Joint Disorder (TMJ)
-
Restless Leg Syndrome (RLS)
-
Periodic Limb Movement (PLMS)
-
Multiple Chemical Sensitivity Syndrome (MCSS)
-
Tension Headaches
-
Irritable Bladder
-
Primary Dysmenorrhea
-
Migraine Headaches
Other studies are being conducted on the
occurrence of overlapping syndromes in patients. The exact cause of such
a wide range of syndromes and symptoms in a patient is not yet clear,
but it does seem to be the case that a patient with one particular
syndrome on the above list is much more likely to have symptoms from one
or more other syndromes on the same list.
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