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D Psychosocial Abnormalities
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More than 50% of patients with irritable bowel who seek medical attention have underlying depression, anxiety, or somatization By contrast, those who do not seek medical attention are similar psychologically to normal individuals Psychological abnormalities may influence how the patient perceives or reacts to illness and minor visceral sensations Chronic stress may alter intestinal motility or modulate pathways that affect central and spinal processing of visceral afferent sensation
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A number of pathophysiologic mechanisms have been identified and may have varying importance in different individuals
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Clinical Findings
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A Symptoms and Signs
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Irritable bowel is a chronic condition Symptoms usually begin in the late teens to twenties Symptoms should be present for at least 3 months before the diagnosis can be considered The diagnosis is established in the presence of compatible symptoms and the judicious use of tests to exclude organic disease Abdominal pain usually is intermittent, crampy, and in the lower abdominal region As previously stated, the onset of pain typically is associated with a change in stool frequency or form and commonly is relieved by defecation It does not usually occur at night or interfere with sleep Patients with irritable bowel syndrome may be classified into one of three categories: those who have predominant problems with constipation, diarrhea, or alternating constipation and diarrhea It is important to clarify what the patient means by these complaints Patients with irritable bowel and constipation report infrequent bowel movements (less than three per week), hard or lumpy stools, or straining Patients with irritable bowel syndrome with diarrhea refer to loose or watery stools, frequent stools (more than three per day), urgency, or fecal incontinence Many patients report that they have a firm stool in the morning followed by progressively looser movements Mucus is commonly seen Com-
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A Abnormal Motility
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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 Whether they represent a primary motility disorder or are secondary to psychosocial stress is debated Differences between patients with constipation-predominant and diarrhea-predominant syndromes are reported
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B Visceral Hypersensitivity
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Patients often have a lower visceral pain threshold, reporting abdominal pain at lower volumes of colonic gas insufflation or colonic balloon inflation than controls Although many patients complain of bloating and distention, their absolute intestinal gas volume is normal Many patients report rectal urgency despite small rectal volumes of stool
C Enteric Infection
Symptoms compatible with irritable bowel syndrome develop within 1 year in up to 10% of patients after an
Gastrointestinal Disorders
plaints of visible distention and bloating are common, though these are not always clinically evident The patient should be asked about alarm symptoms that suggest a diagnosis other than irritable bowel syndrome and warrant further investigation The acute onset of symptoms raises the likelihood of organic disease, especially in patients aged > 40 50 years Nocturnal diarrhea, severe constipation or diarrhea, hematochezia, weight loss, and fever are incompatible with a diagnosis of irritable bowel syndrome and warrant investigation for underlying disease Patients who have a family history of cancer, inflammatory bowel disease, or celiac disease should undergo additional evaluation A physical examination should be performed to look for evidence of organic disease and to allay the patient s anxieties The physical examination usually is normal Abdominal tenderness, especially in the lower abdomen, is common but not pronounced A new onset of symptoms in a patient over age 40 years warrants further examination
CMDT 2008
Treatment
A General Measures
As with other functional disorders, the most important interventions the clinician can offer are reassurance, education, and support This includes identifying and responding to the patient s concerns, careful explanation of the pathophysiology and natural history of the disorder, setting realistic treatment goals, and involving the patient in the treatment process Because irritable bowel symptoms are chronic, the patient s reasons for seeking consultation at this time should be determined These may include major life events or recent psychosocial stressors, dietary or medication changes, concerns about serious underlying disease, or reduced quality of life and impairment of daily activities In discussing with the patient the importance of the mind-gut interaction, it may be helpful to explain that alterations in visceral motility and sensitivity may be exacerbated by environmental, social, or psychological factors such as foods, medications, hormones, and stress Symptoms such as pain, bloating, and altered bowel habits may lead to anxiety and distress, which in turn may further exacerbate bowel disturbances due to disordered communication between the gut and the central nervous system A symptom diary in which patients record the time and severity of symptoms, food intake, and life events may help uncover aggravating dietary or psychosocial factors Fears that the symptoms will progress, require surgery, or degenerate into serious illness should be allayed The patient should understand that irritable bowel syndrome is a chronic disorder characterized by periods of exacerbation and quiescence The emphasis should be shifted from finding the cause of the symptoms to finding a way to cope with them Clinicians must resist the temptation to chase chronic complaints with new or repeated diagnostic studies
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