American Gastroenterological AssociationAGA technical review on irritable bowel syndrome☆,☆☆
Section snippets
Definition and classification
The Rome classification system1 characterizes the IBS in terms of multiple physiological determinants contributing to a common set of symptoms rather than a single disease entity. It is defined as a “group of functional bowel disorders in which abdominal discomfort or pain is associated with defecation or a change in bowel habit, and with features of disordered defecation.”2, 3 Table 1 lists the recently revised Rome II diagnostic criteria for IBS.1
Prevalence
Table 2 gives the prevalence estimates for IBS from population surveys among American, European, and Australia/New Zealand adults.These prevalence estimates vary due to the diversity of definitional criteria and to differences in the specific questions used to elicit the information. There is also evidence that survey recall rates for reporting bowel symptoms are frequently inaccurate5 and are strongly influenced by anxiety.6
The data from Table 2 may be summarized as follows: (1) the prevalence
Pathophysiology of IBS symptoms
The physiological mechanisms responsible for abdominal pain and altered bowel habits occur in healthy control subjects and in persons with IBS. Symptoms can occur in response to a disruption of functioning of the GI tract from an infection, dietary indiscretions (e.g., increased fat or alcohol intake), lifestyle changes (e.g., traveling or vigorous physical activity), or psychologic stress. Among college students and hospital employees, 71% reported that stresses affected their bowel pattern,
Role of psychosocial factors in IBS
Research on the psychosocial aspects of patients with IBS has yielded 4 general observations.100
1. Psychologic stress exacerbates GI symptoms. Although stressful experiences produce GI symptoms in most individuals, patients with IBS are particularly susceptible.10 Studies of the effects of stressful life events on IBS patients are shown in Table 5.Subjects studied Assessment Results Study 102 IBS Unvalidated stress interview More stress in IBS than in IBD or healthy
Symptom-based criteria
A diagnosis is based on identifying positive symptoms (e.g., Rome criteria) consistent with the condition (Table 1), and excluding, in a cost-effective manner, other conditions with similar clinical presentations, which may include organic or other functional (e.g., functional diarrhea or bloating, pelvic floor disorders, or slow transit constipation with associated abdominal discomfort relieved with defecation) disorders.3, 140 Any needed tests, as suggested by “alarm features,” should be
Treatment
The treatment strategy is based on the nature and severity of the symptoms, the correlation of IBS symptoms with food intake and/or defecation, the degree of functional impairment, and the presence of psychosocial difficulties and psychiatric comorbidity affecting the course of the illness. Table 7 provides a practical framework, supported by recent empiric evidence150 for differentiating patients into subgroups of severity based primarily on patient pain reports and behaviors.22, 151, 152
Conclusions
There is sufficient evidence to conclude that IBS is an important medical disorder with significant impact on those afflicted with regard to symptom severity, disability, and impaired quality of life. Furthermore, the burden to society in terms of direct health care costs and indirect effects including work absenteeism exceeds that of most GI disorders. The authors believe that a compelling need exists for investigations that address the mechanisms for these effects through basic studies, as
Acknowledgements
The Clinical Practice Committee acknowledges the following individuals whose critiques of this review paper provided valuable guidance to the authors: James E. Allison, M.D., Lisa Gangarosa, M.D., Richard G. Locke III, M.D., George F. Longstreth, M.D., Howard R. Mertz, M.D., and Amy Foxx-Orenstein, D.O.
The authors thank Carlar Blackman and Cathy Coleman for their invaluable assistance in the preparation of this manuscript.
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This literature review and the recommendations therein were prepared for the American Gastroenterological Association Clinical Practice Committee. The paper was approved by the Committee on August 5, 2002 and by the AGA Governing Board on September 13, 2002.
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Address requests for reprints to: Chair, Clinical Practice Committee, AGA National Office, c/o Membership Department, 7910 Woodmont Avenue, 7th Floor, Bethesda, Maryland 20814. Fax: (301) 654-5920.