The Treatment of Irritable Bowel Syndrome.docx
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TheTreatmentofIrritableBowelSyndrome
TheTreatmentofIrritableBowelSyndrome
BrianE.Lacy,KirstenWeiser,RyanDeLee
TherAdvGastroenterol. 2009;2(4):
221-238.
AbstractandIntroduction
Abstract
Irritablebowelsyndrome(IBS)isahighlyprevalentfunctionalboweldisorderroutinelyencounteredbyhealthcareproviders.Althoughnotlife-threatening,thischronicdisorderreducespatients'qualityoflifeandimposesasignificanteconomicburdentothehealthcaresystem.IBSisnolongerconsideredadiagnosisofexclusionthatcanonlybemadeafterperformingabatteryofexpensivediagnostictests.Rather,IBSshouldbeconfidentlydiagnosedintheclinicatthetimeofthefirstvisitusingtheRomeIIIcriteriaandacarefulhistoryandphysicalexamination.TreatmentoptionsforIBShaveincreasedinnumberinthepastdecadeandcliniciansshouldnotbelimitedtousingonlyfibersupplementsandsmoothmusclerelaxants.AlthoughallpatientswithIBShavesymptomsofabdominalpainanddisordereddefecation,treatmentneedstobeindividualizedandshouldfocusonthepredominantsymptom.ThispaperwillreviewtherapeuticoptionsforthetreatmentofIBSusingatailoredapproachbasedonthepredominantsymptom.Abdominalpain,bloating,constipationanddiarrheaarethefourmainsymptomsthatcanbeaddressedusingacombinationofdietaryinterventionsandmedications.Treatmentoptionsincludeprobiotics,antibiotics,tricyclicantidepressants,selectiveserotoninreuptakeinhibitorsandagentsthatmodulatechloridechannelsandserotonin.Eachclassofagentwillbereviewedusingthelatestdatafromtheliterature.
Introduction
Irritablebowelsyndrome(IBS)isahighlyprevalentdisorderthatreducespatients'qualityoflifeandwhichimposesasignificanteconomicburdentothehealthcaresystem[Lacy etal.2006;Frank etal.2002;Sandler etal.2002;AmericanGastroenterologicalAssociation,2001;Creed etal.2001;Gralnek etal.2000;Talley etal.1995,1991].ManyhealthcareprovidersviewIBSasastaticdisorderthatishardtodefine,difficulttodiagnoseandimpossibletotreat.ThesepopularviewsarejustseveralofthemostcommonmisconceptionsrelatedtothediagnosisandtreatmentofIBS.Thetruth,however,isthatIBSisadynamicfieldcharacterizedbysignificantchangesindiagnosticstrategiesandtherapeuticoptionsoverthelastdecade.ThispaperwillbrieflyreviewthecurrentdefinitionofIBS,andthenfocusoncurrenttherapeuticoptionsusingasymptombasedapproach.
DefiningandDiagnosingIBS
ThedefinitionofIBShasevolvedoverthepastdecadeinordertoincorporatenewinformationaboutthiscomplexdisorder.TheRomeIIIcommitteedefinesIBSasachronicdisordercharacterizedbyabdominalpainordiscomfortassociatedwithdisordereddefecation(eitherconstipation[IBS-C],diarrhea[IBS-D],ormixed/alternatingsymptomsofconstipationanddiarrhea[IBS-M])[Longstreth etal.2006].Symptomonsetshouldbeatleast6monthsbeforethepatientisfirstseenforformalevaluation.Abdominalpainordiscomfortshouldbepresentatleast3dayspermonthfor3monthsandshouldbeassociatedwithtwoormoreofthefollowing:
improvementwithdefecation,onsetassociatedwithachangeinstoolfrequencyandonsetassociatedwithachangeinstoolform(see).TheAmericanCollegeofGastroenterology(ACG)guidelinesemphasizeaclinicallyorientedapproachanddefineIBSaslowerabdominalpainordiscomfortwithdisordereddefecation[Brandt etal.2002].
Box1. Irritablebowelsyndrome(IBS)defined.
RomeIIIcriteriaforthediagnosisofIBS(modifiedfromLongstreth etal. 2006)
∙Symptomonsetatleast6monthspriortodiagnosis
∙Recurrentabdominalpainordiscomfortatleast3dayspermonthinthelast3monthsassociatedwithtwoormoreofthefollowing:
oImprovementwithdefecation
oOnsetassociatedwithachangeinstoolfrequency
oOnsetassociationwithachangeinstoolform(appearance)
∙Oneormoreofthefollowingsymptomsonatleastaquarterofoccasionsforsubgroupidentification
oAbnormalstoolfrequency(<3/week)
oAbnormalstoolform(lumpy/hard)
oAbnormalstoolpassage(straining,incompleteevacuation)
oBloatingorfeelingofabdominaldistension
oPassageofmucous
oFrequent,loosestools
TheACG(2002)definesIBSas(modifiedfromBrandt etal. 2002):
∙Abdominaldiscomfortassociatedwithalteredbowelhabits
∙Symptomsofconstipationincludeinfrequentstools,straining,feelingsofincompleteevacuation,difficultevacuation,passageofrocky,hardstools
Thecost-effectivediagnosisofIBSbeginswithtakingacarefulhistorytodifferentiatefunctionalsymptomsfromorganicdisordersandtolookforwarningsignsthatsignalthepresenceofaseriousunderlyingdisorder(see).AbdominalpainordiscomfortisthecardinalsymptomofIBSandshouldbetemporallyrelatedtodefecationinsomeway;painrelatedtourination,menstruation,orexertionsuggestsanalternativediagnosis.TheabsenceoflowerabdominalpainordiscomfortisincompatiblewiththediagnosisofIBS.ThepresenceofoverlappingdisorderscommonlyassociatedwithIBS,bothgastrointestinalandnongastrointestinalinnature,increasesthepretestprobabilitythatIBSisthecorrectdiagnosis(see).TheRomeIIIcriteriashouldbeemployedtocategorizepatientsintooneofthethreemajorIBSsubgroups(see).BloatingandabdominaldistentionaresymptomscommonlyfoundinIBSpatients.Thesecomplaintsgenerallyreflectincreasedsensitivitytonormalamountsofintestinalgas,althoughcoexistinglactoseorfructoseintoleranceandexcessamountsoffibermayalsoplayarole.
Box2. Thediagnosisofirritablebowelsyndrome:
warningsigns.
∙Unintentionalweightloss(410%ofidealbodyweight)
∙Evidenceofgastrointestinalbleeding
∙Anemia
∙Recurrentnauseaandvomiting
∙Familyhistory(first-degreerelative)ofgastrointestinalmalignancyorinflammatoryboweldisease
Box3. Commondisordersassociatedwithirritablebowelsyndrome.
(A)Overlappinggastrointestinaldisorders
∙Gastroesophagealreflux
∙Functionaldyspepsia
∙Lactoseintolerance(25%ofadults)
∙Fructoseintolerance
(B)Associatednongastrointestinaldisorders
∙Fibromyalgia
∙Chronicfatiguesyndrome
∙Migraineheadaches
∙TMJsyndrome
∙Interstitialcystitis
∙Dyspareunia
Box1. Irritablebowelsyndrome(IBS)defined.
RomeIIIcriteriaforthediagnosisofIBS(modifiedfromLongstreth etal. 2006)
∙Symptomonsetatleast6monthspriortodiagnosis
∙Recurrentabdominalpainordiscomfortatleast3dayspermonthinthelast3monthsassociatedwithtwoormoreofthefollowing:
oImprovementwithdefecation
oOnsetassociatedwithachangeinstoolfrequency
oOnsetassociationwithachangeinstoolform(appearance)
∙Oneormoreofthefollowingsymptomsonatleastaquarterofoccasionsforsubgroupidentification
oAbnormalstoolfrequency(<3/week)
oAbnormalstoolform(lumpy/hard)
oAbnormalstoolpassage(straining,incompleteevacuation)
oBloatingorfeelingofabdominaldistension
oPassageofmucous
oFrequent,loosestools
TheACG(2002)definesIBSas(modifiedfromBrandt etal. 2002):
∙Abdominaldiscomfortassociatedwithalteredbowelhabits
∙Symptomsofconstipationincludeinfrequentstools,straining,feelingsofincompleteevacuation,difficultevacuation,passageofrocky,hardstools
AllpatientswithsuspectedIBSshouldundergoacarefulphysicalexamination.OtherthanmildtendernessoverthesigmoidcolonthephysicalexaminationofIBSpatientsshouldbenormal.Abnormalfindingsonphysicalexaminationshouldalertthecliniciantoanalternativediagnosis.AlthoughIBSwasonceconsidereda'diagnosisofexclusion'mandatorylaboratoryandradiologictestingisnotnecessaryinyoungerpatientswhomeetcriteriaforIBSandwhohaveanormalphysicalexaminationwithoutanyidentifiable'redflags'uncoveredduringthepatientinterview[Cash etal.2008,2002;Saito-Loftus etal.2008].InIBSpatients,thegoalsoftestingaretoestablishthediagnosisasearlyaspossible,initiatetreatmentbasedonthepredominantsymptom,andavoidexpensiveandunnecessarytests.
Treatment
CliniciansshouldfocusonfourmajorgoalswhentreatingIBSpatients:
(1)improvetheindividualsymptomsofIBS(i.e.abdominalpainanddiscomfort,bloating,constipation,anddiarrhea);
(2)amelioratetheglobalsymptomsofIBS(3)preventcomplicationsofIBSwhichincludeunnecessarysurgery,riskydiagnosticprocedures,andadversemedicationsideeffectsfrompolypharmacy;and(4)reducetheimpactofIBSonindividualpatientsbyimprovingqualityoflife,andminimizetheglobalimpactonsocietybyreducinghealthcarecosts.Theseissuesarediscussedinthesectionbelowusingappropriateevidencefromtheliteraturewheredataisavailable.
AbdominalPainandDiscomfort
SmoothMuscleRelaxants Therapyforabdominalpainoverthepasttwodecadeshasfocusedontheuseofsmoothmusclerelaxants(commonlycalledantispasmodics).Althoughthereareampletheoreticalgroundsforprescribingthesemedications,clinicalexperiencehasbeendisappointing.Moststudiesthathavelookedatthesemedicationshavebeenpoorlydesigned,poorlycontrolled,andhavenotshownsignificantbenefitsaboveplacebo[Poynard etal.2001].Nevertheless,somepatientsimprovewithantispasmodicdrugs,particularlythosewhosesymptomsareinducedbymealsandthosewhocomplainoftenesmus.Whenusedformealinducedsymptoms,anticholinergicsshouldbeprescribed30-60minutesbeforemealssothatpeakserumlevelsofthedrugcoincidewithpeaksymptoms.
Arecentmeta-analysisof22studiesinvolving1778patientsand12differentantispasmodicagentsde
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