Extensive Work-Up Rarely Needed to Diagnose IBS

LAKE BUENA VISTA, FLA. — An extensive work-up that includes tests such as colonoscopy should generally be avoided for patients suspected of having irritable bowel syndrome, which is a biopsychosocial disorder characterized by altered colonic motility and enhanced visceral pain perception.

Only when there are atypical or alarming symptoms such as fever, anemia, hematochezia, or a family history of colon cancer should an extensive diagnostic work-up including colonoscopy or barium enema be undertaken, according to Dr. Georgine M. Lamvu.

Irritable bowel syndrome (IBS) is the most common functional gastrointestinal disorder, affecting 3%–15% of adults worldwide. The condition is three times more common in women than in men, Dr. Lamvu said at the annual meeting of the International Pelvic Pain Society.

The Rome criteria for IBS require at least 3 months of continuous or recurrent symptoms of pain relieved with defecation, and/or changes in frequency or consistency of stool. Bloating and distension also are common features, said Dr. Lamvu of the department of obstetrics and gynecology at Florida Hospital, Orlando.

The disorder is classified as being constipation predominant, diarrhea predominant, or alternating, and it may be exacerbated by psychological distress.

The choice of diagnostic studies should be determined by findings on the history and physical examination. For most patients, the history should focus on travel; the presence of rectal bleeding or dark, tarry stools; and the chronicity of symptoms.

Patients often report generalized pain, which can be crampy, sharp, and shooting—most notably in the left lower quadrant. Rule out masses and any signs of acute abdomen, including rigidity and tympanic bowel sounds, Dr. Lamvu said.

An appropriate diagnostic work-up includes a complete blood count, which can rule out anemia, inflammation, and infection; a chemistry panel to detect electrolyte abnormalities associated with inflammatory bowel disease; and a stool culture for occult blood, white blood cells, and ova and parasites, she said.

A hydrogen breath test can rule out lactose intolerance and, if the patient has had exposure to antibiotics within 6 weeks, testing for Clostridium difficile toxin also may be useful.

If the patient's symptoms are constipation predominant, it also is necessary to differentiate IBS from functional constipation, which is characterized by straining, lumpy hard stools, a sensation of incomplete evacuation or obstruction, and fewer than three defecations per week.

“And importantly, functional constipation is not associated with pain, which is required for a diagnosis of IBS,” Dr. Lamvu said.

To treat constipation-predominant IBS, use bulking agents such as fiber to improve colonic transit and ease stool passage. Many randomized trials have confirmed improvements in bowel function with these products, but effects on pain have been mixed.

Osmotic laxatives also can be used, but patients with constipation-predominant IBS need to know that improvements will not be immediate and, even once bowel motility is achieved, it can take weeks or even months for reductions in pain levels to occur, Dr. Lamvu said.

Treatments for diarrhea-predominant IBS include dicyclomine and hyoscyamine, and if the diarrhea is accompanied by prominent pain, tricyclic antidepressants may be helpful.

Several other agents are being made available or investigated, including lubiprostone (Amitiza), GnRH (gonadotropin-releasing hormone) analogues, and alosetron (Lotronex).

Tegaserod (Zelnorm) has been removed from the market because risks of cardiovascular events were seen in pooled data from 29 short-term clinical studies. “A lot of us were a little disappointed when this drug was recalled, but so many trials are going on now that in 5 years we may have 5–10 additional therapies available,” she said.

And always remember when dealing with IBS patients that central to successful treatment are communication, patience, and the development of long-term treatment plans, she concluded.

Dr. Lamvu stated that she had no financial interest in any of the products she discussed.

LAKE BUENA VISTA, FLA. — An extensive work-up that includes tests such as colonoscopy should generally be avoided for patients suspected of having irritable bowel syndrome, which is a biopsychosocial disorder characterized by altered colonic motility and enhanced visceral pain perception.

Only when there are atypical or alarming symptoms such as fever, anemia, hematochezia, or a family history of colon cancer should an extensive diagnostic work-up including colonoscopy or barium enema be undertaken, according to Dr. Georgine M. Lamvu.

Irritable bowel syndrome (IBS) is the most common functional gastrointestinal disorder, affecting 3%–15% of adults worldwide. The condition is three times more common in women than in men, Dr. Lamvu said at the annual meeting of the International Pelvic Pain Society.

The Rome criteria for IBS require at least 3 months of continuous or recurrent symptoms of pain relieved with defecation, and/or changes in frequency or consistency of stool. Bloating and distension also are common features, said Dr. Lamvu of the department of obstetrics and gynecology at Florida Hospital, Orlando.

The disorder is classified as being constipation predominant, diarrhea predominant, or alternating, and it may be exacerbated by psychological distress.

The choice of diagnostic studies should be determined by findings on the history and physical examination. For most patients, the history should focus on travel; the presence of rectal bleeding or dark, tarry stools; and the chronicity of symptoms.

Patients often report generalized pain, which can be crampy, sharp, and shooting—most notably in the left lower quadrant. Rule out masses and any signs of acute abdomen, including rigidity and tympanic bowel sounds, Dr. Lamvu said.

An appropriate diagnostic work-up includes a complete blood count, which can rule out anemia, inflammation, and infection; a chemistry panel to detect electrolyte abnormalities associated with inflammatory bowel disease; and a stool culture for occult blood, white blood cells, and ova and parasites, she said.

A hydrogen breath test can rule out lactose intolerance and, if the patient has had exposure to antibiotics within 6 weeks, testing for Clostridium difficile toxin also may be useful.

If the patient's symptoms are constipation predominant, it also is necessary to differentiate IBS from functional constipation, which is characterized by straining, lumpy hard stools, a sensation of incomplete evacuation or obstruction, and fewer than three defecations per week.

“And importantly, functional constipation is not associated with pain, which is required for a diagnosis of IBS,” Dr. Lamvu said.

To treat constipation-predominant IBS, use bulking agents such as fiber to improve colonic transit and ease stool passage. Many randomized trials have confirmed improvements in bowel function with these products, but effects on pain have been mixed.

Osmotic laxatives also can be used, but patients with constipation-predominant IBS need to know that improvements will not be immediate and, even once bowel motility is achieved, it can take weeks or even months for reductions in pain levels to occur, Dr. Lamvu said.

Treatments for diarrhea-predominant IBS include dicyclomine and hyoscyamine, and if the diarrhea is accompanied by prominent pain, tricyclic antidepressants may be helpful.

Several other agents are being made available or investigated, including lubiprostone (Amitiza), GnRH (gonadotropin-releasing hormone) analogues, and alosetron (Lotronex).

Tegaserod (Zelnorm) has been removed from the market because risks of cardiovascular events were seen in pooled data from 29 short-term clinical studies. “A lot of us were a little disappointed when this drug was recalled, but so many trials are going on now that in 5 years we may have 5–10 additional therapies available,” she said.

And always remember when dealing with IBS patients that central to successful treatment are communication, patience, and the development of long-term treatment plans, she concluded.

Dr. Lamvu stated that she had no financial interest in any of the products she discussed.

LAKE BUENA VISTA, FLA. — An extensive work-up that includes tests such as colonoscopy should generally be avoided for patients suspected of having irritable bowel syndrome, which is a biopsychosocial disorder characterized by altered colonic motility and enhanced visceral pain perception.

Only when there are atypical or alarming symptoms such as fever, anemia, hematochezia, or a family history of colon cancer should an extensive diagnostic work-up including colonoscopy or barium enema be undertaken, according to Dr. Georgine M. Lamvu.

Irritable bowel syndrome (IBS) is the most common functional gastrointestinal disorder, affecting 3%–15% of adults worldwide. The condition is three times more common in women than in men, Dr. Lamvu said at the annual meeting of the International Pelvic Pain Society.

The Rome criteria for IBS require at least 3 months of continuous or recurrent symptoms of pain relieved with defecation, and/or changes in frequency or consistency of stool. Bloating and distension also are common features, said Dr. Lamvu of the department of obstetrics and gynecology at Florida Hospital, Orlando.

The disorder is classified as being constipation predominant, diarrhea predominant, or alternating, and it may be exacerbated by psychological distress.

The choice of diagnostic studies should be determined by findings on the history and physical examination. For most patients, the history should focus on travel; the presence of rectal bleeding or dark, tarry stools; and the chronicity of symptoms.

Patients often report generalized pain, which can be crampy, sharp, and shooting—most notably in the left lower quadrant. Rule out masses and any signs of acute abdomen, including rigidity and tympanic bowel sounds, Dr. Lamvu said.

An appropriate diagnostic work-up includes a complete blood count, which can rule out anemia, inflammation, and infection; a chemistry panel to detect electrolyte abnormalities associated with inflammatory bowel disease; and a stool culture for occult blood, white blood cells, and ova and parasites, she said.

A hydrogen breath test can rule out lactose intolerance and, if the patient has had exposure to antibiotics within 6 weeks, testing for Clostridium difficile toxin also may be useful.

If the patient's symptoms are constipation predominant, it also is necessary to differentiate IBS from functional constipation, which is characterized by straining, lumpy hard stools, a sensation of incomplete evacuation or obstruction, and fewer than three defecations per week.

“And importantly, functional constipation is not associated with pain, which is required for a diagnosis of IBS,” Dr. Lamvu said.

To treat constipation-predominant IBS, use bulking agents such as fiber to improve colonic transit and ease stool passage. Many randomized trials have confirmed improvements in bowel function with these products, but effects on pain have been mixed.

Osmotic laxatives also can be used, but patients with constipation-predominant IBS need to know that improvements will not be immediate and, even once bowel motility is achieved, it can take weeks or even months for reductions in pain levels to occur, Dr. Lamvu said.

Treatments for diarrhea-predominant IBS include dicyclomine and hyoscyamine, and if the diarrhea is accompanied by prominent pain, tricyclic antidepressants may be helpful.

Several other agents are being made available or investigated, including lubiprostone (Amitiza), GnRH (gonadotropin-releasing hormone) analogues, and alosetron (Lotronex).

Tegaserod (Zelnorm) has been removed from the market because risks of cardiovascular events were seen in pooled data from 29 short-term clinical studies. “A lot of us were a little disappointed when this drug was recalled, but so many trials are going on now that in 5 years we may have 5–10 additional therapies available,” she said.

And always remember when dealing with IBS patients that central to successful treatment are communication, patience, and the development of long-term treatment plans, she concluded.

Dr. Lamvu stated that she had no financial interest in any of the products she discussed.