Diagnosis and Management of IBS in Adults - American ...

The absence of abdominal pain essentially excludes irritable bowel syndrome. Other common symptoms include diarrhea, constipation, ... Advertisement <> Sep1,2012Issue    DiagnosisandManagementofIBSinAdults THADWILKINS,MD;CHRISTAPEPITONE,MD;BIJUALEX,MD;andROBERTR.SCHADE,MD,GeorgiaHealthSciencesUniversity,Augusta,GeorgiaAmFamPhysician. 2012 Sep 1;86(5):419-426.Amorerecentarticleonirritablebowelsyndromeisavailable.  Patientinformation:Seerelatedhandoutonirritablebowelsyndrome,writtenbytheauthorsofthisarticle.  Relatedletter:AbsenceofAbdominalPainDoesNotRuleoutDiagnosisofIBS Abstract EtiologyandPathophysiologyClinicalPresentationDiagnosisTreatmentReferencesArticleSections Abstract EtiologyandPathophysiologyClinicalPresentationDiagnosisTreatmentReferencesIrritablebowelsyndromeisdefinedasabdominaldiscomfortorpainassociatedwithalteredbowelhabitsforatleastthreedayspermonthinthepreviousthreemonths,withtheabsenceoforganicdisease.InNorthAmerica,theprevalenceofirritablebowelsyndromeis5to10percentwithpeakprevalencefrom20to39yearsofage.Abdominalpainisthemostcommonsymptomandoftenisdescribedasacrampingsensation.Theabsenceofabdominalpainessentiallyexcludesirritablebowelsyndrome.Othercommonsymptomsincludediarrhea,constipation,oralternatingdiarrheaandconstipation.Thegoalsoftreatmentaresymptomreliefandimprovedqualityoflife.Exercise,antibiotics,antispasmodics,peppermintoil,andprobioticsappeartoimprovesymptoms.Over-the-counterlaxativesandantidiarrhealsmayimprovestoolfrequencybutnotpain.Treatmentwithantidepressantsandpsychologicaltherapiesarealsoeffectiveforimprovingsymptomscomparedwithusualcare.Lubiprostoneiseffectiveforthetreatmentofconstipation-predominantirritablebowelsyndrome,andalosetron(restrictionsforuseapplyintheUnitedStates)andtegaserod(availableonlyforemergencyuseintheUnitedStates)areapprovedforpatientswithseveresymptomsinwhomconventionaltherapyhasbeenineffective. Irritablebowelsyndrome(IBS)isdefinedasabdominaldiscomfortorpainassociatedwithalteredbowelhabitsforatleastthreedayspermonthinthepreviousthreemonths,withtheabsenceoforganicdisease.1Alteredbowelhabitsincludediarrhea-predominant,constipation-predominant,andmixedpresentationwithalternatingdiarrheaandconstipation.PrevalenceestimatesofIBSinNorthAmericarangefrom5to10percent,withpeakprevalencefrom20to39yearsofage.1IBSaffects1.5timesmorewomenthanmenandismorecommoninlowersocioeconomicpopulations.1  Enlarge      Print SORT:KEYRECOMMENDATIONSFORPRACTICEClinicalrecommendationEvidenceratingReferencesTheabsenceofabdominalpaincanbeusedtoruleoutIBS.C12RoutinebloodandstoolstudiesarenotrecommendedinthediagnosisofIBS.C1Routinetestingforceliacdiseaseshouldbeconsideredinpatientswithdiarrhea-predominantormixedpresentationIBS.C1ThepresenceofalarmfeaturesinpatientswithIBSsymptomsshouldpromptadditionaltestingwithcolonoscopyandbiopsytoevaluateforotherconditions.C1Exercise,probiotics,antibiotics,antispasmodics,antidepressants,psychologicaltreatments,andpeppermintoilmayimproveIBSsymptoms.B18,19,22–25,27–29IBS=irritablebowelsyndrome.A=consistent,good-qualitypatient-orientedevidence;B=inconsistentorlimited-qualitypatient-orientedevidence;C=consensus,disease-orientedevidence,usualpractice,expertopinion,orcaseseries.ForinformationabouttheSORTevidenceratingsystem,gotohttps://www.aafp.org/afpsort.xml.SORT:KEYRECOMMENDATIONSFORPRACTICEClinicalrecommendationEvidenceratingReferencesTheabsenceofabdominalpaincanbeusedtoruleoutIBS.C12RoutinebloodandstoolstudiesarenotrecommendedinthediagnosisofIBS.C1Routinetestingforceliacdiseaseshouldbeconsideredinpatientswithdiarrhea-predominantormixedpresentationIBS.C1ThepresenceofalarmfeaturesinpatientswithIBSsymptomsshouldpromptadditionaltestingwithcolonoscopyandbiopsytoevaluateforotherconditions.C1Exercise,probiotics,antibiotics,antispasmodics,antidepressants,psychologicaltreatments,andpeppermintoilmayimproveIBSsymptoms.B18,19,22–25,27–29IBS=irritablebowelsyndrome.A=consistent,good-qualitypatient-orientedevidence;B=inconsistentorlimited-qualitypatient-orientedevidence;C=consensus,disease-orientedevidence,usualpractice,expertopinion,orcaseseries.ForinformationabouttheSORTevidenceratingsystem,gotohttps://www.aafp.org/afpsort.xml.PatientswithIBShavelowerworkproductivityandhigherabsenteeism;takemoremedications;andrequiremorephysicianvisits,diagnostictests,andhospitalizationscomparedwithpatientsofthesameagewithoutIBS.2Oneprospectivestudyof112patientsdiagnosedwithIBSinthe1960swithlong-termfollow-upconcludedthatthepresenceofIBSdidnotincreasetheriskofmortalityortheriskofdevelopingothergastrointestinaldiseases,suchaschronicpancreatitis,gastrointestinalcancers,smallbowelobstruction,andgastriculcers.3ThisarticlereviewsIBSinadults,butnotspecialpopulations,suchaschildrenorpregnantwomen.Figure1isanalgorithmfortheevaluationandtreatmentofpatientswithsuspectedIBS.  Enlarge      Print EvaluationandTreatmentofSuspectedIBSFigure1.Algorithmfortheevaluationandtreatmentofpatientswithsuspectedirritablebowelsyndrome(IBS).EvaluationandTreatmentofSuspectedIBSFigure1.Algorithmfortheevaluationandtreatmentofpatientswithsuspectedirritablebowelsyndrome(IBS).EtiologyandPathophysiologyJumptosection+ Abstract EtiologyandPathophysiologyClinicalPresentationDiagnosisTreatmentReferencesOnestudyshowedathreefoldincreaseintheriskofIBSinpersonswithanimmediatefamilymemberwhohashadthecondition.4Inadditiontogenetics,otherpossibleetiologiesforIBSincludedisturbancesingastrointestinalmotility,mucosalbarrierdisruption,visceralhypersensitivity,dysfunctionofthegut-brainaxis(neurohormonalinteractionsbetweenthecentralnervoussystemandthegut),andastressresponsewithinvolvementofneurotransmitters.5Reducedplasmaserotoninlevelsmaybecorrelatedwithconstipation-predominantIBS,whereasincreasedserotoninreleasemayplayaroleindiarrhea-predominantIBS.6ThereisanassociationbetweenIBSandpsychologicaldisorders(e.g.,anxiety,depression,posttraumaticstressdisorder),withuptotwo-thirdsofpatientswithIBSintertiarycarecentershavingaconcurrentpsychologicaldisorder.7,8PriorphysicalandsexualabuseispredictiveofsevereIBSsymptoms.Inastudyof257personswithsevereIBS,12percentreportedahistoryofrape,andthesepatientsshowedimprovedqualityoflifefollowingpsychologicaltreatmentandantidepressanttherapy.9Inasystematicreviewof18prospectivestudies,infectiousgastroenteritiswasassociatedwithanincreasedriskofsubsequentlydevelopingIBS(pooledoddsratio=5.9).10ClinicalPresentationJumptosection+ Abstract EtiologyandPathophysiologyClinicalPresentationDiagnosisTreatmentReferencesPatientswithIBSmaypresentwithrecurrentandepisodicabdominalpain,alteredbowelhabits(constipation,diarrhea,ormixed),orothergastrointestinalorextraintestinalsymptoms11 (Table112).Abdominalpainisthemostcommonsymptomandoftenisdescribedasacrampingsensation,whichmaybesevere.12Emotionalstressandeatingmayworsenthepain,anddefecationmayrelieveit.11Painthatisprogressive;thatawakensthepatientfromsleep;orthatisassociatedwithanorexia,malnutrition,orweightlossisnotcharacteristicofIBS.  Enlarge      Print Table1.PooledSensitivityandSpecificityofIndividualSymptomsintheDiagnosisofIrritableBowelSyndromeSymptomSymptomfrequency(%)Sensitivity(%)Specificity(%)Positivepredictivevalue(%)Negativepredictivevalue(%)Abdominalpain739032997Painrelievedbydefecation5260661196Feelingofincompleteevacuation697445996Looserstoolsatonsetofpain4658731496Morefrequentstoolsatonsetofpain5253721295Patient-reportedvisibleabdominaldistension3239771194Passageofmucusthroughtherectum404565994Informationfromreference12.Table1.PooledSensitivityandSpecificityofIndividualSymptomsintheDiagnosisofIrritableBowelSyndromeSymptomSymptomfrequency(%)Sensitivity(%)Specificity(%)Positivepredictivevalue(%)Negativepredictivevalue(%)Abdominalpain739032997Painrelievedbydefecation5260661196Feelingofincompleteevacuation697445996Looserstoolsatonsetofpain4658731496Morefrequentstoolsatonsetofpain5253721295Patient-reportedvisibleabdominaldistension3239771194Passageofmucusthroughtherectum404565994Informationfromreference12.Diarrheaisdescribedasfrequentloosestoolsprecededbylowerabdominalcramping.Patientswithdiarrheamayhavethefeelingofurgencyandincompletereliefafterdefecation,ormayhavemucusinthestools.Largevolume,bloody,andnocturnaldiarrheaarenotcharacteristicofIBS.Ifconstipationoccurs,itcanlastfordaysorlongerandcanalternatewithnormalbowelhabitsordiarrhea.Constipationcanbedescribedashard,pellet-shapedstoolsandmaypresentwithafeelingofincompletereliefafterdefecation.TheBristolStoolScalecanbeusedtodescribestoolconsistencytodifferentiateconstipationfromdiarrheaandmonitortreatmentresponse.Thescaleisseparatedintoseventypes:(1)separate,hardlumps,likenuts;(2)sausage-likebutlumpy;(3)likeasausageorsnake,withcracksinthesurface;(4)likeasausageorsnake,smoothandsoft;(5)softblobswithclear-cutedges;(6)fluffypieceswithraggededges,amushystool;and(7)watery,nosolidpieces.Types1and2mayindicateconstipation,types3and4mayindicate“normal”stool,andtypes5through7mayindicatediarrhea.13OthergastrointestinalsymptomsofIBSincludefeelingofalumpinthethroat(globussensation),belching,acidreflux,dysphagia,earlysatiety,intermittentdyspepsia,nausea,noncardiacchestpain,abdominalbloating,andflatulence.11Extraintestinalsymptomsincludedysmenorrhea,dyspareunia,urinaryurgencyorfrequency,andfibromyalgia.14,15Theabsenceofabdominalpain,aswellasotherIBSsymptomssuchaspainrelievedbydefecation,passageofmucusbytherectum,andfeelingofincompleteevacuation,hasastrongnegativepredictivevalueandessentiallyexcludesIBS.12TheIBSSeverityScoringSystem(Figure2)isavalidatedmeasuretoassesstheseverityofIBSsymptoms,andcanhelpmonitorresponsetotreatment.16  Enlarge      Print IBSSeverityScoreFigure2.Scoringsystemtoassesstheseverityofirritablebowelsyndrome(IBS)symptoms.AdaptedwithpermissionfromFrancisCY,MorrisJ,WhorwellPJ.Theirritablebowelseverityscoringsystem:asimplemethodofmonitoringirritablebowelsyndromeanditsprogress.AlimentPharmacolTher.1997;11(2):401.IBSSeverityScoreFigure2.Scoringsystemtoassesstheseverityofirritablebowelsyndrome(IBS)symptoms.AdaptedwithpermissionfromFrancisCY,MorrisJ,WhorwellPJ.Theirritablebowelseverityscoringsystem:asimplemethodofmonitoringirritablebowelsyndromeanditsprogress.AlimentPharmacolTher.1997;11(2):401.DiagnosisJumptosection+ Abstract EtiologyandPathophysiologyClinicalPresentationDiagnosisTreatmentReferencesEvaluationforsuspectedIBSincludesacompletehistoryandphysicalexamination,althoughexaminationfindingsoftenarenormal.TheRomeIIIcriteriacommonlyareusedinresearchandlessofteninclinicalpractice.Thesecriteriaincludeimprovementinpainwithdefecation,onsetassociatedwithachangeinfrequencyofstools,andonsetassociatedwithachangeintheform(appearance)ofstools;criteriamusthavebeenmetforthepreviousthreemonths,withsymptomonsetatleastsixmonthsbeforediagnosis.1Completebloodcount,serumchemistries,thyroidfunctionstudies,stooltestingforovaandparasites,andabdominalimagingarelow-yieldteststhatarenotrecommendedintheroutinediagnosticevaluationofIBS.1Asystematicreviewincludingmorethan4,000patientsshowedthat4percentofthosewithdiarrhea-predominantormixedpresentationIBShadbiopsy-provenceliacdisease.17Physiciansshouldconsiderroutinetestingforceliacdiseaseinpatientswithdiarrhea-predominantormixedpresentationIBS.1ThereisconflictingevidenceregardingtheassociationbetweenIBSandsmallintestinalbacterialovergrowth,andthusroutinehydrogenbreathtestingisnotrecommended.1Alarmfeaturessuchasanemia;rectalbleeding;nocturnalsymptoms;weightloss;recentantibioticuse;onsetafter50yearsofage;andafamilyhistoryofcolorectalcancer,inflammatoryboweldisease,orceliacdiseaseshouldpromptinvestigationforotherdiseases(Table2).Colonoscopywithbiopsyisthediagnosticstudyofchoicewhenalarmfeaturesarepresent,althoughupperendoscopyorreferraltoagastroenterologistmayalsobeindicated.1  Enlarge      Print Table2.DifferentialDiagnosisofIrritableBowelSyndromeSymptomsCarcinoidtumorCeliacdiseaseColorectalcancerDiverticulardiseaseDruguse(opiateanalgesics,calciumchannelblockers,antidepressants)Gastrointestinalinfection(e.g.,Giardia,Amoeba,humanimmunodeficiencyvirus,bacterialovergrowth)HyperthyroidismHypothyroidismInflammatoryboweldisease(e.g.,Crohndisease,ulcerativecolitis)IschemiccolitisLactoseintoleranceTable2.DifferentialDiagnosisofIrritableBowelSyndromeSymptomsCarcinoidtumorCeliacdiseaseColorectalcancerDiverticulardiseaseDruguse(opiateanalgesics,calciumchannelblockers,antidepressants)Gastrointestinalinfection(e.g.,Giardia,Amoeba,humanimmunodeficiencyvirus,bacterialovergrowth)HyperthyroidismHypothyroidismInflammatoryboweldisease(e.g.,Crohndisease,ulcerativecolitis)IschemiccolitisLactoseintoleranceTreatmentJumptosection+ Abstract EtiologyandPathophysiologyClinicalPresentationDiagnosisTreatmentReferencesThegoalsoftreatmentaresymptomreliefandimprovedqualityoflife.TreatingIBScanbeparticularlychallengingbecausesymptomsoftenarerecurrentandresistanttotherapy.Apositivepatient-physicianinteractionisassociatedwithfewerreturnvisitsforIBSandisakeycomponentinthetreatmentofthesepatients.3 High-qualityclinicaltrialshavebeendifficulttoconductinpatientswithIBS;therefore,evidencesupportingtreatmentmodalitiesisoftenoflowquality.AsummaryofIBStherapiesispresentedinTable3.18–34  Enlarge      Print Table3.SummaryofTherapiesforIBSCategoryExamplesTypeofIBS*CommentsExercise VigorousexercisethreetofivetimesperweekAlltypes NNT=7.4topreventagreaterthan50-pointincreaseontheIBSSeverityScoreover12weeks18Fiber PsylliumhuskAlltypes Fiberisineffective19Over-the-counterlaxatives Polyethyleneglycol(Miralax)Constipation-predominant Improvesstoolfrequency,butnotabdominalpain;scantevidenceofeffectiveness20Antidiarrheals Loperamide(Imodium)Diarrhea-predominant Effectivelydecreasesstoolfrequencyandincreasesstoolconsistency21Diphenoxylate/atropine(Lomotil)hasnotbeenstudiedforIBSProbiotics Lactobacillus,Bifidobacterium,StreptococcusAlltypes NNT=4topreventworseningglobalIBSsymptoms†22,23Antibiotics Rifaximin(Xifaxan)Diarrhea-predominant,mixedpresentation NNT=11topreventworseningglobalIBSsymptomsoverfourweeks NeomycinConstipation-predominant Improvesconstipationandbloating24,25Antispasmodics Hyoscyamine(Levsin),dicyclomine(Bentyl)Alltypes NNT=7forimprovementofabdominalpain†NNT=5forimprovementofglobalassessmentNNT=3forimprovementinsymptomscore19SelectiveC-2chloridechannelactivators Lubiprostone(Amitiza)Constipation-predominant ImprovesglobalIBSsymptoms26Antidepressants SSRIs:citalopram(Celexa),fluoxetine(Prozac),paroxetine(Paxil)TCAs:amitriptyline,desipramine(Norpramin),doxepin,imipramine(Tofranil),trimipramine(Surmontil)Alltypes NNT=5forimprovementinabdominalpainNNT=4forimprovementinglobalassessmentNNT=4forimprovementinsymptomscore19Complementaryandalternativetherapies Psychologicaltreatments,hypnotherapy,acupuncture,herbaltherapies,peppermintoilAlltypes NNT=4topreventpersistentIBSsymptoms(psychologicaltreatments)†QualityofincludedtrialswasinadequatetodrawconclusionsabouthypnotherapyoracupunctureSomeherbaltherapiesmaybeeffectivefortreatingIBS,buttrialshaveinadequatemethodologyandsmallsamplesizesNNT=2.5toimproveIBSsymptoms(peppermintoil)†27–325-HT3antagonists Alosetron(Lotronex)Severediarrhea-predominant(womenonly) ImprovesglobalIBSsymptomsandabdominalpainNNT=7toimprovesymptoms†Seriousadverseeventsincludingischemiccolitis,constipation,anddeath;restricteduseintheUnitedStates335-HT4agonists Tegaserod(Zelnorm)Constipation-predominant NNT=17toimproveconstipationandstoolfrequency†Seriousadverseeventsincludingmyocardialinfarction,unstableangina,andstrokeAvailableonlyforemergencyusethroughtheU.S.FoodandDrugAdministration345-HT=5-hydroxytryptamine;IBS=irritablebowelsyndrome;NNT=numberneededtotreat;SSRI=selectiveserotoninreuptakeinhibitor;TCA=tricyclicantidepressant.*—Typesincludediarrhea-predominant,constipation-predominant,andmixedpresentationwithalternatingdiarrheaandconstipation.†—Durationnotspecified.Informationfromreferences18through34.Table3.SummaryofTherapiesforIBSCategoryExamplesTypeofIBS*CommentsExercise VigorousexercisethreetofivetimesperweekAlltypes NNT=7.4topreventagreaterthan50-pointincreaseontheIBSSeverityScoreover12weeks18Fiber PsylliumhuskAlltypes Fiberisineffective19Over-the-counterlaxatives Polyethyleneglycol(Miralax)Constipation-predominant Improvesstoolfrequency,butnotabdominalpain;scantevidenceofeffectiveness20Antidiarrheals Loperamide(Imodium)Diarrhea-predominant Effectivelydecreasesstoolfrequencyandincreasesstoolconsistency21Diphenoxylate/atropine(Lomotil)hasnotbeenstudiedforIBSProbiotics Lactobacillus,Bifidobacterium,StreptococcusAlltypes NNT=4topreventworseningglobalIBSsymptoms†22,23Antibiotics Rifaximin(Xifaxan)Diarrhea-predominant,mixedpresentation NNT=11topreventworseningglobalIBSsymptomsoverfourweeks NeomycinConstipation-predominant Improvesconstipationandbloating24,25Antispasmodics Hyoscyamine(Levsin),dicyclomine(Bentyl)Alltypes NNT=7forimprovementofabdominalpain†NNT=5forimprovementofglobalassessmentNNT=3forimprovementinsymptomscore19SelectiveC-2chloridechannelactivators Lubiprostone(Amitiza)Constipation-predominant ImprovesglobalIBSsymptoms26Antidepressants SSRIs:citalopram(Celexa),fluoxetine(Prozac),paroxetine(Paxil)TCAs:amitriptyline,desipramine(Norpramin),doxepin,imipramine(Tofranil),trimipramine(Surmontil)Alltypes NNT=5forimprovementinabdominalpainNNT=4forimprovementinglobalassessmentNNT=4forimprovementinsymptomscore19Complementaryandalternativetherapies Psychologicaltreatments,hypnotherapy,acupuncture,herbaltherapies,peppermintoilAlltypes NNT=4topreventpersistentIBSsymptoms(psychologicaltreatments)†QualityofincludedtrialswasinadequatetodrawconclusionsabouthypnotherapyoracupunctureSomeherbaltherapiesmaybeeffectivefortreatingIBS,buttrialshaveinadequatemethodologyandsmallsamplesizesNNT=2.5toimproveIBSsymptoms(peppermintoil)†27–325-HT3antagonists Alosetron(Lotronex)Severediarrhea-predominant(womenonly) ImprovesglobalIBSsymptomsandabdominalpainNNT=7toimprovesymptoms†Seriousadverseeventsincludingischemiccolitis,constipation,anddeath;restricteduseintheUnitedStates335-HT4agonists Tegaserod(Zelnorm)Constipation-predominant NNT=17toimproveconstipationandstoolfrequency†Seriousadverseeventsincludingmyocardialinfarction,unstableangina,andstrokeAvailableonlyforemergencyusethroughtheU.S.FoodandDrugAdministration345-HT=5-hydroxytryptamine;IBS=irritablebowelsyndrome;NNT=numberneededtotreat;SSRI=selectiveserotoninreuptakeinhibitor;TCA=tricyclicantidepressant.*—Typesincludediarrhea-predominant,constipation-predominant,andmixedpresentationwithalternatingdiarrheaandconstipation.†—Durationnotspecified.Informationfromreferences18through34.EXERCISEANDDIETArandomizedcontrolledtrial(RCT)involving102patientswithIBSshowedthatthosewhowererandomizedtophysicalactivityhadfewerIBSsymptomscomparedwiththecontrolgroup(8versus23percent).18ThereisnoevidencetosupporttestingforfoodallergiesorusingexclusiondietsinthetreatmentofIBS.1However,afooddiarymaybeusefultodetermineanassociationbetweencertainfoodsandIBSsymptomsinindividualpatients.FIBERACochranereviewof12RCTsinvolving621patientsshowednobeneficialeffectforsolubleorinsolublefiberoverplaceboforimprovementinabdominalpain,globalassessment,orsymptomscore.Therefore,thereisnoevidencethatfiberiseffectivefortreatingIBS.19OVER-THE-COUNTERLAXATIVESThequalityofevidencesupportingover-the-counterlaxativeuseinpersonswithIBSispoor.1Onesmallstudycomparingpolyethyleneglycol(Miralax)withplaceboin48adolescentswithconstipation-predominantIBSshowedthatthelaxativeimprovedstoolfrequencybutdidnotalleviateabdominalpain.20PolyethyleneglycolisapprovedbytheU.S.FoodandDrugAdministration(FDA)forthetreatmentofchronicconstipation,butnotforIBS.ANTIDIARRHEALSLoperamide(Imodium),asyntheticopioidthatdecreasesintestinaltransitandenhancesintestinalwaterandionabsorption,istheonlyantidiarrhealthathasbeensufficientlyevaluatedinRCTsforIBS.AsystematicreviewofthreeRCTsinvolving126patientswithIBSshowedthatloperamidewaseffectiveatdecreasingstoolfrequencyandincreasingstoolconsistency;however,itdidnotimproveabdominalpainandincreasednocturnalpain.21Diphenoxylate/atropine(Lomotil)hasnotbeenstudiedinpatientswithIBS.PROBIOTICSEvidencesupportingtheuseofprobioticsforIBSisweakbecauseoftheheterogeneityofstudiesandthevaryingprobioticsstudied.However,asystematicreviewof10RCTsinvolving918personswithIBSshowedasignificantbenefitforreducingIBSsymptomsanddecreasingpainandflatulence.22Anothersystematicreviewof14RCTsshowedamodestimprovementinoverallsymptoms,abdominalpain,andflatulenceinpatientstakingprobioticsversusplacebo.23ThereisnodifferenceamongLactobacillus,Streptococcus,Bifidobacterium,andcombinationsofprobiotics.22Themagnitudeofeffectandthemosteffectivespecies,strain,anddosageareunknown.22ANTIBIOTICSTwoRCTsinvolving1,260patientswithdiarrhea-predominantormixedpresentationIBSshowedthattwoweeksofrifaximin(Xifaxan)significantlyimprovedbloating,abdominalpain,andstoolconsistencycomparedwithplacebo.24AsmallRCTinvolving39patientswithconstipation-predominantIBSshowedthatneomycinimprovedconstipationandglobalIBSsymptomscomparedwithplacebo.25TheseresultssuggestthatalterationofgutmicrofloramayhavearoleintheetiologyofIBS.ANTISPASMODICSACochranereviewof29RCTsinvolving2,333patientsshowedthatantispasmodicswereeffectiveinimprovingabdominalpain,globalassessment,andsymptomscorecomparedwithplaceboornotreatment,althoughtherewassignificantheterogeneityamongstudies.Commonadverseeventswithantispasmodicsincludedrymouth,dizziness,andblurredvision.19CommonlyusedantispasmodicsintheUnitedStatesincludehyoscyamine(Levsin)anddicyclomine(Bentyl).SELECTIVEC-2CHLORIDECHANNELACTIVATORSLubiprostone(Amitiza)canbeusedforchronicconstipationandconstipation-predominantIBS.1TwoRCTsof1,171patientswithconstipation-predominantIBSshowedsignificantlyhigheroverallsymptomreliefinthosetreatedwithlubiprostonethaninthosetreatedwithplacebo(17.9versus10.1percent).Theratesofadverseeventsweresimilarinbothgroupsandincludeddiarrheaandnausea.26ANTIDEPRESSANTSACochranereviewof15studiesinvolving922patientsfoundabeneficialeffectwithantidepressantsoverplaceboforimprovementinabdominalpain,globalassessment,andsymptomscore.Statisticallysignificantbenefitwasshownwithselectiveserotoninreuptakeinhibitorsforimprovementofglobalassessment,andwithtricyclicantidepressantsforimprovementofabdominalpainandsymptomscore.19COMPLEMENTARYANDALTERNATIVETHERAPIESPsychologicaltreatmentsincludingcognitivebehaviortherapy,interpersonalpsychotherapy,andrelaxationandstressmanagementareeffectiveinimprovingIBSsymptomscomparedwithusualcare.28,29Areviewoffourtrialsinvolving147patientsthatcomparedhypnotherapywithpsychotherapyandplaceboconcludedthatthequalityoftheRCTswasinadequatetodeterminetheeffectivenessofhypnotherapyinIBS.30ACochranereviewofsixtrialsinvolving109patientsdidnotshowasignificantdifferencebetweenacupunctureandshamtherapy.31ACochranereviewof75RCTsinvolving7,957patientsconcludedthatherbaltherapiesmayimprovethesymptomsofIBS;however,manyofthesetrialshadinadequatemethodologyandasmallsamplesize.32AsystematicreviewoffourRCTsinvolving392patientsshowedthatpeppermintoilwasmoreeffectivethanplaceboatreducingIBSsymptoms.275-HYDROXYTRYPTAMINE3ANTAGONISTSAlosetron(Lotronex)isFDA-approvedforthetreatmentofwomenwithseverediarrhea-predominantIBSwhosesymptomshavenotimprovedwithconventionaltherapy.AsystematicreviewofeightRCTsinvolving4,987womenshowedthatalosetronwasmoreeffectivethanplaceboatreducingIBSsymptoms.33However,becausealosetronisassociatedwithuncommonbutseriousadverseevents,includingischemiccolitis,constipation,anddeath,therearerestrictionsforitsuseintheUnitedStates.5-HYDROXYTRYPTAMINE4AGONISTSACochranereviewofRCTsandquasi-RCTsreportedthattegaserod(Zelnorm)improvedspontaneousbowelmovementsperweekinpatientswithconstipation-predominantIBScomparedwithplacebo.34However,tegaserodwastakenoffoftheU.S.marketin2007becauseofanincreasedriskofmyocardialinfarction,unstableangina,andstroke.ItisavailableonlyforemergencyusethroughtheFDA.DataSources:APubMedsearchwascompletedinClinicalQueriesusingthekeysearchtermsirritablebowelsyndrome,pathogenesis,diagnosis,andtreatment.Thesearchincludedmeta-analyses,randomizedcontrolledtrials,clinicaltrials,andreviews.AdditionalsearchesincludedtheAgencyforHealthcareResearchandQualityevidencereports,ClinicalEvidence,theCochranedatabase,EssentialEvidencePlus,theNationalGuidelineClearinghouse,andDynaMed.Searchdate:February17,2011.Readthefullarticle.Getimmediateaccess,anytime,anywhere.Chooseasinglearticle,issue,orfull-accesssubscription.Earnupto6CMEcreditsperissue.Alreadyamember/subscriber? Login>> PurchaseAccess:SeeMyOptionscloseAlreadyamemberorsubscriber?Login BestValue!GetFullAccessFrom$145SubscribeIncludes:Immediate,unlimitedaccesstoallAFPcontentMorethan130CMEcreditsperyearAccessthejournalthroughtheAAFPappPrintdeliveryoption AccessThisIssue$59.95 Includes:Immediateaccesstothisissue CMEcreditsinthisissue  AccessThisArticle$25.95  Includes:ImmediateaccesstothisarticleInterestedinAAFPmembership?Learnmore     Toseethefullarticle,loginorpurchaseaccess.TheAuthorsshowallauthorinfoTHADWILKINS,MD,isaprofessorintheDepartmentofFamilyMedicineatGeorgiaHealthSciencesUniversityinAugusta....CHRISTAPEPITONE,MD,isanassistantprofessorintheDepartmentofFamilyMedicineatGeorgiaHealthSciencesUniversity.Atthetimethisarticlewaswritten,shewasathird-yearresidentattheuniversity.BIJUALEX,MD,isagastroenterologyfellowatGeorgiaHealthSciencesUniversity.ROBERTR.SCHADE,MD,isaprofessorintheDepartmentofMedicineatGeorgiaHealthSciencesUniversity.AddresscorrespondencetoThadWilkins,MD,GeorgiaHealthSciencesUniversity,112015thSt.,HB-4032,Augusta,GA30912(e-mail:[email protected]).Reprintsarenotavailablefromtheauthors.Authordisclosure:Norelevantfinancialaffiliationstodisclose.REFERENCESshowallreferences1.BrandtLJ, CheyWD, Foxx-OrensteinAE, etal.; AmericanCollegeofGastroenterologyTaskForceonIrritableBowelSyndrome. Anevidence-basedpositionstatementonthemanagementofirritablebowelsyndrome.AmJGastroenterol. 2009;104(suppl1):S1–S35....2.LockeGRIII. TheepidemiologyoffunctionalgastrointestinaldisordersinNorthAmerica.GastroenterolClinNorthAm. 1996;25(1):1–19.3.OwensDM, NelsonDK, TalleyNJ. Theirritablebowelsyndrome:long-termprognosisandthephysician-patientinteraction.AnnInternMed. 1995;122(2):107–112.4.SaitoYA, PetersenGM, LarsonJJ, etal. Familialaggregationofirritablebowelsyndrome:afamilycase-controlstudy.AmJGastroenterol. 2010;105(4):833–841.5.CamilleriM. Evolvingconceptsofthepathogenesisofirritablebowelsyndrome:totreatthebrainorthegut?JPediatrGastroenterolNutr. 2009;48(suppl2):S46–S48.6.DunlopSP, ColemanNS, BlackshawE, etal. Abnormalitiesof5-hydroxytryptaminemetabolisminirritablebowelsyndrome.ClinGastroenterolHepatol. 2005;3(4):349–357.7.WhiteDL, SavasLS, DaciK, etal. 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