Irritable bowel syndrome in the United ... - Wiley Online Library

This study confirms the high prevalence of IBS in the US population and its impact on the working life, social activities and well-being of ... SkiptoArticleContent SkiptoArticleInformation AlimentaryPharmacology&TherapeuticsVolume21,Issue11p.1365-1375 FreeAccess IrritablebowelsyndromeintheUnitedStates:prevalence,symptompatternsandimpact A.P.S.Hungin, CentreforIntegratedHealthCareResearch,WolfsonResearchInstitute,UniversityofDurham,Stockton-on-Tees,UKSearchformorepapersbythisauthorL.Chang, UCLA,LosAngeles,CA,USASearchformorepapersbythisauthorG.R.Locke, MayoClinicCollegeofMedicine,Rochester,NY,USASearchformorepapersbythisauthorE.H.Dennis, NovartisPharmaceuticalsCorp.,EastHanover,NJ,USASearchformorepapersbythisauthorV.Barghout, NovartisPharmaceuticalsCorp.,EastHanover,NJ,USASearchformorepapersbythisauthor A.P.S.Hungin, CentreforIntegratedHealthCareResearch,WolfsonResearchInstitute,UniversityofDurham,Stockton-on-Tees,UKSearchformorepapersbythisauthorL.Chang, UCLA,LosAngeles,CA,USASearchformorepapersbythisauthorG.R.Locke, MayoClinicCollegeofMedicine,Rochester,NY,USASearchformorepapersbythisauthorE.H.Dennis, NovartisPharmaceuticalsCorp.,EastHanover,NJ,USASearchformorepapersbythisauthorV.Barghout, NovartisPharmaceuticalsCorp.,EastHanover,NJ,USASearchformorepapersbythisauthor Firstpublished:02June2005 https://doi.org/10.1111/j.1365-2036.2005.02463.xCitations:300 Prof.A.P.S.Hungin,CentreforIntegratedHealthCareResearch,WolfsonResearchInstitute,UniversityofDurham,Stockton-on-TeesTS17 6BH,UK. E-mail:[email protected] AboutSectionsPDF ToolsRequestpermissionExportcitationAddtofavoritesTrackcitation ShareShare GiveaccessSharefulltextaccessSharefull-textaccessPleasereviewourTermsandConditionsofUseandcheckboxbelowtosharefull-textversionofarticle.IhavereadandaccepttheWileyOnlineLibraryTermsandConditionsofUseShareableLinkUsethelinkbelowtoshareafull-textversionofthisarticlewithyourfriendsandcolleagues.Learnmore.CopyURL SharealinkShareonEmailFacebookTwitterLinkedInRedditWechat Summary Background:Theimpactofirritablebowelsyndrome,agastrointestinalmotilitydisorder,isunderestimatedandpoorlyquantified,ascliniciansmayseeonlyaminorityofsufferers. Aim:Todeterminetheprevalence,symptompatternsandimpactofirritablebowelsyndromeintheUS. Methods:Thistwo-phasecommunitysurveyusedquotasamplingandrandom-digittelephonedialling(screeninginterview)toidentifyindividualswithmedicallydiagnosedirritablebowelsyndromeorindividualsnotformallydiagnosed,butfulfillingirritablebowelsyndromediagnosticcriteria(Manning,RomeIorII).Informationonirritablebowelsyndromesymptoms,generalhealthstatus,lifestyleandimpactofsymptomsonindividuals’liveswascollectedusingin-depthfollow-upinterviews.Datawerealsocollectedforhealthycontrolsidentifiedinthescreeninginterviews. Results:Thetotalprevalenceofirritablebowelsyndromein5009screeninginterviewswas14.1%(medicallydiagnosed:3.3%;undiagnosed,butmeetingirritablebowelsyndromecriteria:10.8%).Abdominalpain/discomfortwasthemostcommonsymptompromptingconsultation.Mostsufferers(74%medicallydiagnosed;63%undiagnosed)reportedalternatingconstipationanddiarrhoea.Previouslydiagnosedgastrointestinaldisordersoccurredmoreofteninsufferersthannon-sufferers.Irritablebowelsyndromesufferershadmoredaysoffwork(6.4vs.3.0)anddaysinbed,andreducedactivitiestoagreaterextentthannon-sufferers. Conclusions:Most(76.6%)irritablebowelsyndromesufferersintheUSareundiagnosed.Irritablebowelsyndromehasasubstantialimpactonsufferers’well-beingandhealth,withconsiderablesocioeconomicconsequences. Introduction Irritablebowelsyndrome(IBS)isachronic,episodicfunctionalgastrointestinal(GI)disordercharacterizedbyabdominalpain/discomfortandalteredbowelhabit(constipation,diarrhoeaoralternatingperiodsofboth).1Patientsoftenexperienceadditionalsymptomssuchasbloating,sensationofincompleteevacuation,straining(constipation)andurgency(diarrhoea).IBSpatientscanexperiencesymptomsformanyyears,withanaveragedurationof10ormoreyears.1,2IBSisoftenunrecognizedoruntreated,withasfewas25%ofIBSsufferersseekingprofessionalhealthcare.3Thoseseekingcareareoftenfrustratedbythelackofeffectivenessoftraditionaltreatmentandmanagementstrategies.4 IBSprevalenceisestimatedtobe10–15%inWesterncountries.5-9Prevalencedataandinformationonthehealthcare-seekingbehaviourofIBSsufferershavemostlybeenderivedfromindependentstudiesusingdifferentmethodologiesanddifferentdiagnosticcriteria.AstherearenoIBS-specificbiologicalmarkerstoaiddiagnosis,doctorsgenerallyrelyonsymptom-basedcriteria.Atleastthreesetsofdiagnosticcriteriahavebeendeveloped,includingtheManning,10RomeI11andRomeIIcriteria.12TheRomeIandIIcriteriaaremorerefinedthantheManningcriteria,andincludesymptomdurationwithintheirdefinitions.Variationsinstudydesign,particularlythecriteriausedtodiagnoseIBS,affecttheabilitytocompareorsummarizedatafrommultiplestudies.13 Onechallengeofpopulation-basedIBSstudiesisensuringthatIBSisaccuratelydiagnosedusingspecific,validatedcriteria,ratherthantheclinicaljudgementofhealthcareprofessionals.7 IBSplacesasignificantfinancialburdenonsociety.Symptomscansignificantlyimpactonthequalityoflifeofsufferers,withconsiderablesocioeconomicconsequences.14-18Forexample,absenteeismfromworkismoreprevalentinindividualswithIBSthaninthosewithout,1,19andemployersintheUnitedStates(US)areestimatedtopay,onaverage,$1251moreforindividualswithIBSthanmatchedcontrolbeneficiariesovera1-yearperiod(P 3times/day),looser/morewaterystoolsthanusualandperiodsofurgency.PatientsweredefinedashavingIBSwithdiarrhoea(IBS-D)iftheyexperiencedoneormoreofthefollowing:looser/morewaterystoolsthanusual,theneedtopassstoolsmoreoftenthanusual(>3times/day),orperiodsofurgency,whichwerenotaccompaniedbytheneedtopassstoolslessoftenthanusual(<3times/week),harder/morelumpystoolsthanusualandperiodsofstraining.PatientswithotherbowelhabitpatternsweredefinedashavingalternatingIBS(IBS-A).DifferentiationintothesespecificIBSsubtypeswasbasedonlyonthesymptomssufferedbyeachrespondent,withoutreferencetoaspecifictimeframe. Inthesecondphaseofthesurvey,respondentswhowereidentifiedashavingIBSinphaseIofthesurvey,eithermedicallydiagnosedordiagnosedusingIBScriteria(Manning,RomeIorRomeII),wereinvitedtoparticipateinamoreformalinterviewregardingtheirsymptoms,generalhealthfactors,lifestyleandimpactofIBSsymptomsontheirlives.Dataoncomorbidconditions,therapy/medicationuseandconsultationpatternswerealsocollected.Thus,threegroupsofrespondentswereidentified:thosewithmedicallydiagnosedIBS;thosewhohadIBSthathadnotbeenmedicallydiagnosed,butwhofulfilledIBSdiagnosticcriteria;andahealthycomparatorgroupidentifiedfromthescreeningquestionnaireasnothavingIBS.AnyindividualswhohadexperiencedIBSsymptomswithintheprevious12-monthperiodwereidentifiedascurrentIBSsufferers. Forsymptomsofconstipationordiarrhoea,individualswerequestioned(basedontheIBSdiagnosticcriteria)about:anyperiodsneedingtopassstoolsmoreoftenthanusual(>3times/day)orlessoftenthanusual(<3times/week);anyperiodswhenstoolswerelooser/morewaterythanusualorharder/morelumpythanusual;periodsofstrainingwhengoingtopassastool;periodsofurgencywhengoingtopassastool;feelingofincompleteevacuationafterpassingastool;periodsofbloating. AsintheEuropeanstudy,21thedevelopmentofthequestionnaireusedintheUSpopulationincorporatedtheclinicalexperienceofthecliniciansinvolvedwiththisstudy.Alternativediagnoses(notIBS)wereexcludedatanearlystageofthequestionnaireandpilotresearchwasperformedtoensuretheManningandRomeI/IIcriteriawereeffectiveinthissetting.Thequestionnairewasdesignedandcarefullyvalidatedtoavoidordereffects,suchassuggestionbasedonearlierquestions. BasedontheassumptionofaconservativeIBSprevalencerateof5–10%,itwasestimatedthat5000respondentswouldneedtobecontactedtoreach250–500IBSsufferersintheUS.Specifictargetagegroupsforthepopulationwere18–34,35–54andover55 years,withequalnumberscontactedwithintheseagegroups. Subjects ThestudywascarriedoutintheUSinasampleofsubjectsaged18 yearsorover.ThosepreviouslydiagnosedwithCrohn'sdisease,ulcerativecolitis,coeliacdisease,diverticulitis,pepticulcerorcancer(includingcolonandgynaecologicalcancers)wereexcludedfromtheresultsbecauseofpossibleoverlapwithIBSsymptoms. Results Fromapproximately14 000initialtelephonecontacts,atotalof5009screeninginterviewswereconducted;allquestionsinthissectionwererelatedtogeneralhealth.Amongthese,708individualswereidentifiedashavingcurrentIBS(anydiagnosticcriteria)and,fromthisgroup,318individualsparticipatedinthesecondphaseofthequestionnaire(366individualseitherdidnotwanttotakepartinthesecondphaseofthequestionnaireordidagreebutwerenotavailablewhencontacted). Prevalence,characteristicsandsymptompatternsofIBS(medicallydiagnosedandnotmedicallydiagnosed) Overall708individuals(14.1%oftotalscreened)wereidentifiedashavingcurrentIBS[medicallydiagnosed(n = 166;3.3%)ormetanydiagnosticcriteria(notmedicallydiagnosed;n = 542;10.8%)].ResultsfromthisquestionnaireareshowninTable 1. Factor MedicallydiagnosedIBSsufferers NotmedicallydiagnosedIBSsufferers Manning RomeI RomeII TotalIBS Prevalence,n(%) 166(3.3) 542(10.8) 520(96.0) 394(72.7) 336(62.0) 708(14.1) IBStype(%)  IBS-C 4.3 15.2 15.0 15.5 16.1 12.7  IBS-D 21.3 21.3 22.1 20.7 22.6 21.3  IBS-A 74.4 63.4 63.0 63.8 61.3 66 Age(years,%)  18–24 5.1 18.5 18.5 17.6 17.5 15.4  25–34 10.3 24.1 24.3 23.6 24.0 20.9  35–44 28.5 25.3 24.6 25.2 24.7 26.1  45–54 27 18.3 18.5 18.2 19.1 20.3  55–64 15.5 7.8 7.8 8.2 7.2 9.6  65+ 13.2 6 6.3 7.2 7.5 7.8 Gender  Female(%) 81.3 58.7 59.0 57.9 57.7 64  Male(%) 18.7 41.3 41.0 42.1 42.3 36 Symptoms  Periodsofwaterystools(%) 86 56 58.0 54.3 58.0 63  Urgency(%) 79 48 49.3 47.5 49.3 55  Bloatingorswelling(%) 77 48 50.2 48.1 46.9 55  Periodsofstoolsthatareharderormorelumpythanusual(%) 63 47 47.6 48.0 50.2 51  Incompleteevacuation(%) 77 41 42.4 40.3 42.4 49  Straining(%) 63 44 45.0 44.8 47.2 48  Periodsofneedingtopassstools>3times/day(%) 69 23 23.9 24.5 26.8 34  Periodsofneedingtopassstools<3times/week(%) 39 27 26.9 30.0 30.8 30  Mucusinstool(%) 51 16 16.3 17.3 19.0 24 Ingeneral,medicallydiagnosedIBSpatientsreportedagreaterprevalenceofindividualIBSsymptoms.TheManningcriteriaidentifiedallcurrentIBSsufferers(100%);theRomeIcriteriaidentified73%andtheRomeIIcriteriaidentified62%.Thus,onlypartialoverlapoftheIBSdiagnosiswasseenacrossthesediagnosticcriteria.TheRomeIIcriteriaappearedtobethemostrestrictiveset.OfthoseindividualswhohadbeenmedicallydiagnosedwithIBS,4%weredeemedtohaveIBS-Ccomparedwith21%withIBS-D.Inthosenotmedicallydiagnosed,thesepercentageswere15%and21%,respectively.MostindividualswithIBS(74%ofthosemedicallydiagnosedand63%notmedicallydiagnosed)reportedalternatingsymptomsofconstipationanddiarrhoea(IBS-A).WhenIBSsuffererswereaskedtocategorizethemselvesaccordingtothesethreesubgroups,onlyapproximatelyone-thirdofindividualsmedicallydiagnosedandnotmedicallydiagnosedwithIBSdefinedthemselvesashavingIBS-A(33%and27%,respectively)comparedwithIBS-C(17%and30%,respectively)andIBS-D(45%and29%,respectively). Age/sexdistributionofcurrentIBSsufferers(medicallydiagnosedandnotmedicallydiagnosed) Overall,thepeakagesforcurrentIBSsymptomswerebetween25and54 years(67.3%ofIBStotal;Table 1).IBSwasmorecommoninwomenthanmen(64%vs.36%,respectively),particularlyamongthosewhohadbeenmedicallydiagnosedwithIBS(81.3%vs.18.7%,respectively).ThehighestprevalenceofIBSwasseeninworkingwomen,withaprevalenceof21%(5%medicallydiagnosed,16%notmedicallydiagnosed). Comorbidconditions CurrentIBSsufferers(bothmedicallydiagnosedandnotmedicallydiagnosed)weremorelikelytohavesufferedfromotherGIdisordersoffunction(previouslydiagnosedbyadoctor)comparedwithnon-IBSsufferers.IBSsufferersweretwiceaslikelytosufferfromgastro-oesophagealrefluxdisease(GERD;22%vs.10%,P 1 yearbeforeseeingahealthprofessional(%) 42 47 45 Medication/othertreatmentsused  Over-the-countermedications(%) 54 20 60  Canlivewithoutmedication(%) 32 56 50  Alterdiet(%) 58 43 47  Prescriptionmedications(%) 54 20 28  Antacidandacidsuppressiontherapy(%) 12 30 25  Antidiarrhoeals(%) 18 23 22  Exercise(%) 20 13 14  Laxatives(%) 7 12 11  Relaxation(%) 9 3 4  Antispasmodics(%) 6 2 3 * Onlyofallmedicallydiagnosedsufferersandallthosewhohadconsultedahealthcareprofessional. CurrentIBSsuffererscommonlyinformedtheirpartnerabouttheircondition(68%).Althoughtheyalsooftentoldotherfamilymembers(56%)andfriends(54%),theywerelesslikelytoinformcolleagues(22%)ortheiremployer(16%).Mostconfidantsweredeemedtobevery(44%)orfairly(39%)understanding.Overall,one-quarterofIBSsufferershighlightedthattheirself-confidencewasreducedasaresultofIBS;thiswasparticularlyevidentamongthemedicallydiagnosedgroup(46%vs.17%ofthosenotmedicallydiagnosed).Themajority(87%)ofrespondentsmedicallydiagnosedwithIBSbelievedtheirIBStobearealmedicalcondition,comparedwithonly43%ofindividualsnotmedicallydiagnosed(Table 2).Asanindicationofdesireforeffectivetherapy,nearlyhalfofcurrentIBSsufferers(46%)agreedthattheywouldtry‘anything’toalleviatetheirIBSsymptoms. Consultationpatternandhealthcareuse AprimarycaredoctorwasthemostcommonhealthprofessionalseenbycurrentIBSsufferers(83%);gastroenterologistswerethenextmostcommonlyconsultedgroup(40%;Table 2).Abdominalpain/discomfortwasthemostcommonreasonforconsultingahealthprofessional(28%ofconsultations),followedbysymptomfrequency(10%).CurrentIBSsufferershadseenadoctorornurseanaverageof4.2timesinthepast12 monthsifmedicallydiagnosedor1.3timesifnotmedicallydiagnosed.Morethanhalf(53%)ofrespondentsnotmedicallydiagnosedhadseenahealthprofessionalatsometimefortheircondition.InpatientsmedicallydiagnosedwithIBS,25%hadvisitedahealthprofessionalfiveormoretimesbeforetheirIBSdiagnosis. Medicationused Morethanhalf(58%)ofthecurrentIBSsuffererswhohadvisitedtheirhealthprofessionalhadbeenprescribedmedicationandasimilarnumber(57%)receiveddietaryandlifestyleadvice(Table 2).Themainmedicationstakenwereantacidandacidsuppressiontherapy(25%),antidiarrhoeals(22%)andlaxatives(11%);theserotonergicagents,tegaserodandalosetron,werenotavailableatthetimeofthestudy.Antidepressant/anti-anxietymedicationwastakenby1%ofparticipants(5%inthemedicallydiagnosedgroupand0%inthosenotmedicallydiagnosed).MostIBSsufferersregularlyusedover-the-countermedication(60%)and47%hadalteredtheirdietinanattempttoalleviatetheirIBSsymptoms.Treatmentsweredeemedineffectiveforanumberofsymptomsincludingconstipation(41%),bloating(34%)andtrappedwind(31%).Treatmentsforabdominalpain/discomfortwereconsideredtobefairlyeffectivein53%ofsufferers,although18%consideredthemtobenotatalleffective. Discussion ThisstudyconfirmsthehighprevalenceofIBSintheUSpopulationanditsimpactontheworkinglife,socialactivitiesandwell-beingofsufferers.TheoverallprevalenceofIBSinthispopulationwas14.1%,withonly3.3%beingmedicallydiagnosed.Thiscompareswithaprevalencerateof11.5%inapreviousEuropeanstudy,21andisconsistentwithotherlargeUS-basedepidemiologicalstudies,whereprevalenceestimatesclusteraround10–15%.25,26ExpectedvariationsindiagnosticratesaccordingtoManning,RomeIandRomeIIcriteriawereseen,aspreviouslynoted.21,27,28Clearly,IBSprevalencecanvarysubstantiallydependingonthediagnosticcriteriaemployed.29Thiscomprehensive,representativesurveyusedspecific,validatedIBSdiagnosticcriteriatoestimateprevalenceandsymptompatterns,andalsoassessedimpactofIBSonwork,lifestyleandhealth.Inthisstudy,prevalencerateswerehighestamongthoseaged25–54 years,andtheprevalenceofIBSamongwomenwasapproximatelytwotimeshigherthanthatrecordedformeninindividualsmedicallyornotmedicallydiagnosedwithIBS.Thesefindingscorroboratepreviouslypublishedreports,whichdemonstratedahigherIBSprevalenceinwomenthaninmen.30,31InpatientsmedicallydiagnosedwithIBS,25%hadvisitedahealthprofessionalatleastfivetimesbeforebeingformallydiagnosed,suggestingthatdiagnosticcriteriaarenotbeingproperlyutilized,IBSsymptomsarenotalwaysrecognizedoraremisdiagnosed,and/orthatthediagnosisofIBSisnotbeingcommunicatedtothepatient. ThisUSpopulationstudyadoptedasurveymethodologysimilartothatusedinarecentEuropeanstudyofIBSprevalenceandimpact.21Thatstudycomprisedapproximately5000respondentsfromeachofeightcountrieswithatotalsamplepopulationof41 984,whereasintheUS,thetotalsamplepopulationwas5000.Thus,comparisonsbetweenthetwostudiesremainlimited.TheonlyotherUSstudyusingrandom-digitdiallingtoassessIBSincluded1014adultwomenwithIBS.28,32 TheclinicalpresentationofIBSisquitevaried,33withsufferersinthepresentstudyreportingawiderangeofsymptoms.IBSsufferersalsoreportedthattheirsymptomsrarelyimproveandwerefairlyorverypainful,ashighlightedinpreviousstudies.2,34Inthisstudy,theprevalenceofindividualIBSsymptomswashigherinmedicallydiagnosedIBSpatientsthanincurrentIBSsuffererswhowerenotmedicallydiagnosed.ThisfindingmayberelatedtoIBSseverity,whichislikelytobegreaterinpatientspresentingfortreatment.MedicallydiagnosedpatientsmayalsohaveagreaterawarenessofIBSanditsassociatedsymptoms.DataconfirmedthatIBSisalong-termcondition,withone-thirdofIBSsufferershavingexperiencedIBSsymptomsforover10 years,afigurecomparablewiththatinEurope(40%).21 ItiswelldocumentedthatIBScanhaveaconsiderableimpactonsufferers’lives,16,21,26,35-37andthisiscompoundedbythecondition'schronicandepisodicnature.ThisstudyreinforcesthatIBShasasubstantialimpactonqualityoflife.Therewasalargeimpactonabsenteeismandworkproductivity,confirmingpreviousfindingsinbothUS1,2,20,34andEuropean21populations.Additionally,illhealthwasrecordedforanaverageof6.4 daysincurrentIBSsufferers,comparedwith3.0 daysinnon-IBSsufferers.OneinsixcurrentIBSsufferersintheUShadchangedtheirworkscheduleandoneinfourhadworkedfewerhours.ThesedatasupportfindingsfromDrossmanet al.,26whoreportedthatIBSpatientsmissedthreetimesmoredaysfromworkthannon-sufferers.Timemanagement,theabilitytoconcentrateandcommutingtimewerealsonegativelyaffectedinIBSsufferersinthepresentstudy.Regularsocialactivitiessuchasgoingoutforameal,longjourneysorholidayswerealsohindered.Thus,thesymptomsofIBSappeartoaffecttheabilitytoliveanormallife.ThisisfurthercompoundedbythefactthatotherfunctionalGIdisordersoftencoexistwithIBS.38Althoughthiswasnotfullyassessedinthisstudy,24%ofIBSsufferershadalsosufferedfromGERDordyspepsia. SubstantialhealthcareusebecauseofIBSwasrecordedinthisUSpopulation.SufferersusedawiderangeofmedicationsforreliefofIBSsymptoms.MedicallydiagnosedIBSpatientswithcurrentsymptomsappearedtotakefewerantisecretorymedicationsandlaxativesthanthosenotmedicallydiagnosed,presumablyduetotheavailabilityofthesemedicationsoverthecounter.ThisfindingcontradictsdatafromShihet al.,39whoreportedthat89%ofdoctorvisitsgeneratedprescriptions.Atthetimeofthepresentstudy,treatmentoptionsforabdominalpain/discomfort,bloatingandconstipationwereonlyviewedasbeingcompletelyeffectiveinasmallproportionofusers.AsIBSsymptomsareintermittent,treatmentwasoftenrestrictedtotimeswhenpatientsexperiencedsymptoms. AvaryingperceptionofIBS-Awashighlightedinthisstudy.MostIBSsufferers(74%medicallydiagnosed,63%notmedicallydiagnosed)hadalternatingsymptomsofconstipationanddiarrhoeaasdefinedbydoctorsanddiagnosticcriteria.However,whensuffererswereaskedtocategorizethemselves,onlyapproximatelyone-thirdofmedicallyandnotmedicallydiagnosedrespondentswithIBSdefinedthemselvesashavingIBS-A(33%and27%,respectively)comparedwithIBS-C(17%and30%,respectively)andIBS-D(45%and29%,respectively).Thisfindingisincontrasttootherpublisheddata,whichreportedequalprevalenceratesofIBS-C,IBS-DandIBS-A.25,34ApossibleexplanationforthisdiscrepancyistheuseofmorestrictcriteriaforIBS-AinthecurrentstudythanintheRomeIIsubclassification. Inconclusion,IBSisaprevalentdisorderthatsignificantlyimpactswork,lifestyleandsocialwell-being.DiagnosingandmanagingIBScanbechallengingduetothelackofadiagnosticmarkerandeffectivetreatmentoptions.IndividualswithIBSwhoarenotformallydiagnosedreportedasignificantprevalenceofGIsymptoms,whichimpactedontheirworkandotherdailyactivities,althoughinsomeinstancestoalesserdegreethanmedicallydiagnosedindividuals.AllIBSsufferersfacethechallengeoftheirconditiononadailybasisandthisstudyhighlightsthehugeunmettherapeuticneedinIBS. Acknowledgements ThisresearchwasfundedbyNovartisPharmaAGandThomsonACUMEDprovidededitorialsupport. Declarationofinterests APSHhasservedonadvisoryboardsforNovartis,GlaxoWelcome,AstraandSolvayandhasreceivedsupportforresearchandconferences.LCisamemberoftheZelnormSpeaker'sBureauandhasreceivedgrantsupportfromNovartis.GRLisaconsultantforGlaxoWelcomeandhasreceivedresearchsupportfromAstraZeneca,ForestLabs,GlaxoWelcome,Janssen,SmithKlineBeechamandSolvay.EHDandVBareNovartisemployees. 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