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Goodoory VC, Khasawneh M, Black CJ, Ford AC. Assessing Diagnostic Performance of Modifications to the Rome IV Criteria for Irritable Bowel Syndrome. Clin Gastroenterol Hepatol 2024; 22:1942-1943. [PMID: 38423348 DOI: 10.1016/j.cgh.2024.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 02/08/2024] [Accepted: 02/09/2024] [Indexed: 03/02/2024]
Abstract
The gold standard symptom-based criteria for diagnosis of irritable bowel syndrome (IBS) are the Rome IV criteria.1 These are more restrictive than their predecessor, Rome III, because the cardinal feature required to meet criteria for IBS was changed to presence of abdominal pain alone, rather than abdominal pain or discomfort.2 This change was made because discomfort was believed to be an ambiguous term, with no equivalent in some languages. In addition, symptom frequency required for the presence of abdominal pain was increased to 1 day per week from 2 to 3 days per month. This has led to reduced sensitivity for detecting IBS and a 50% decrease in the prevalence of the disorder in the community.3,4 In a cross-sectional survey applying both Rome IV and III criteria to people living with IBS, 89% of those with Rome III-defined IBS not meeting Rome IV criteria did not meet Rome IV criteria because of this change in pain frequency.5 Previous iterations of the Rome criteria have performed only modestly in predicting a diagnosis of IBS.6-8 However, in a validation study, the Rome IV criteria outperformed Rome III,9 largely because their more restrictive nature made them more specific than Rome III. We assessed whether modifications to the Rome IV criteria led to a better trade-off between sensitivity and specificity.
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Affiliation(s)
- Vivek C Goodoory
- Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, United Kingdom; Leeds Gastroenterology Institute, Leeds Teaching Hospitals, NHS Trust, Leeds, United Kingdom
| | - Mais Khasawneh
- Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, United Kingdom; Leeds Gastroenterology Institute, Leeds Teaching Hospitals, NHS Trust, Leeds, United Kingdom
| | - Christopher J Black
- Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, United Kingdom; Leeds Gastroenterology Institute, Leeds Teaching Hospitals, NHS Trust, Leeds, United Kingdom
| | - Alexander C Ford
- Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, United Kingdom; Leeds Gastroenterology Institute, Leeds Teaching Hospitals, NHS Trust, Leeds, United Kingdom.
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2
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Brick C, Su H, Taylor K, Burgell R. Moving beyond Symptom Criteria to Diagnose and Treat Functional Disorders: Patient-Reported Symptoms of Functional Lower Gastrointestinal Disorders Correlate Poorly with Objective Assessment of Luminal Contents Seen on Intestinal Ultrasound. J Clin Med 2024; 13:4759. [PMID: 39200901 PMCID: PMC11355646 DOI: 10.3390/jcm13164759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2024] [Revised: 07/22/2024] [Accepted: 07/24/2024] [Indexed: 09/02/2024] Open
Abstract
Background/Objectives: The diagnosis of lower functional gastrointestinal disorders (FGIDs) is currently based on subjective and unreliable patient-reported symptoms, with significant clinical overlap between diagnosed phenotypes. Objective biomarkers are urgently sought. Gastrointestinal ultrasound (GIUS) can objectively and non-invasively assess luminal contents. This study aimed to assess the utility of GIUS in phenotyping patients with lower FGIDs. Methods: Patients with lower FGIDs underwent a GIUS and completed the Rome IV Diagnostic Questionnaire, SAGIS questionnaire, and 100 mm VAS score for overall symptom severity. The faecal loading score (FLS) was obtained using a modified Leech score, where an FLS of >37 was consistent with clinically significant constipation. Results: Eighty-eight patients fulfilled the study requirements. In total, 56 met the Rome IV criteria for irritable bowel syndrome (IBS) subtypes, while 23 met the criteria for functional constipation (FC), 4 for functional diarrhoea (FD), and 5 for other diagnoses. Patients reporting constipation-predominant symptoms had a significantly higher median FLS than those describing diarrhoea-predominant symptoms (FLS = 40 [IQR 20.0-53.3] vs. 13.3 [IQR 6.7-40.0], respectively). However, 27% of patients describing diarrhoea had significant faecal loading on GIUS, and of those who described constipation, 34% did not have significant faecal loading. Sensitivity and specificity for the detection of FLS-indicated constipation by the Rome IV criteria were low at 59% and 66%, respectively. Conclusions: The symptom-based diagnosis of FGID subtypes based on the Rome IV criteria is a poor predictor of faecal loading. These findings should prompt further exploration of the limitations of symptom-based assessment and a shift towards physiological assessment of patients with FGIDs such as gastrointestinal ultrasound to develop more targeted therapy. Future research is underway to determine if targeting objective physiological endpoints results in improved clinical outcomes.
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Affiliation(s)
- Claudia Brick
- Alfred Health, Melbourne, VIC 3004, Australia; (C.B.)
| | - Heidi Su
- Alfred Health, Melbourne, VIC 3004, Australia; (C.B.)
| | - Kirstin Taylor
- Alfred Health, Melbourne, VIC 3004, Australia; (C.B.)
- School of Translational Medicine, Monash University, Melbourne, VIC 3800, Australia
| | - Rebecca Burgell
- Alfred Health, Melbourne, VIC 3004, Australia; (C.B.)
- School of Translational Medicine, Monash University, Melbourne, VIC 3800, Australia
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3
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Vakili O, Adibi Sedeh P, Pourfarzam M. Metabolic biomarkers in irritable bowel syndrome diagnosis. Clin Chim Acta 2024; 560:119753. [PMID: 38821336 DOI: 10.1016/j.cca.2024.119753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2024] [Revised: 05/24/2024] [Accepted: 05/27/2024] [Indexed: 06/02/2024]
Abstract
Irritable bowel syndrome (IBS) is a chronic gastrointestinal (GI) disorder characterized by altered bowel habits and abdominal discomfort during defecation. It significantly impacts life quality and work productivity for those affected. Global data suggests a slightly higher prevalence in females than in males. Today, unambiguous diagnosis of IBS remains challenging due to the absence of a specific biochemical, histopathological, or radiological test. Current diagnosis relies heavily on thorough symptom evaluation. Efforts by the Rome committees have established standardized diagnostic criteria (Rome I-IV), improving consistency and clinical applicability. Recent studies in this framework, seem to have successfully employed metabolomics techniques to identify distinct metabolite profiles in breath and stool samples of IBS patients, differentiating them from healthy controls and those with other functional GI disorders, such as inflammatory bowel disease (IBD). Building on this success, researchers are investigating the presence of similar metabolites in easily accessible biofluids such as urine, potentially offering a less invasive diagnostic approach. Accordingly, this review focuses on key metabolites specifically detected in IBS patients' biological specimens, with a focus on urinary metabolites, using various methods, particularly mass spectrometry (MS)-based techniques, including gas chromatography-MS (GC-MS), liquid chromatography-tandem MS (LC-MS/MS), and capillary electrophoresis-MS (CE-MS) metabolomics assays. These findings may make provision for a new set of non-invasive biomarkers for IBS diagnosis and management.
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Affiliation(s)
- Omid Vakili
- Department of Clinical Biochemistry, School of Pharmacy and Pharmaceutical Sciences, Isfahan University of Medical Sciences, Isfahan, Iran.
| | - Peyman Adibi Sedeh
- Gastroenterology and Hepatology Research Center, Isfahan University of Medical Sciences, Isfahan, Iran.
| | - Morteza Pourfarzam
- Department of Clinical Biochemistry, School of Pharmacy and Pharmaceutical Sciences, Isfahan University of Medical Sciences, Isfahan, Iran.
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Khasawneh M, Craig OF, Gracie DJ, Black CJ, Ford AC. A Diagnosis of Irritable Bowel Syndrome Using Rome IV Criteria and Limited Investigations is Durable in Secondary Care. Clin Gastroenterol Hepatol 2023; 21:3397-3404.e1. [PMID: 37302448 DOI: 10.1016/j.cgh.2023.05.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 03/30/2023] [Accepted: 05/22/2023] [Indexed: 06/13/2023]
Abstract
BACKGROUND & AIMS Irritable bowel syndrome (IBS) is a positive diagnosis, made using symptom-based criteria and limited, judicious, investigation. However, this may lead to uncertainty on the part of clinicians regarding potential for a missed diagnosis of organic gastrointestinal disease. Few studies have examined durability of a diagnosis of IBS, and none have used the current gold standard to diagnose IBS, the Rome IV criteria. METHODS We collected complete symptom data from 373 well-characterized adults meeting Rome IV criteria for IBS referred to a single UK clinic between September 2016 and March 2020. All patients underwent relatively standardized work-up to exclude relevant organic disease before diagnosis. We followed these individuals up to December 2022, assessing rates of rereferral, reinvestigation, and missed organic gastrointestinal disease. RESULTS During a mean follow-up of 4.2 years per patient (total follow-up in all patients, 1565 years), 62 (16.6%) patients were rereferred. Of these, 35 (56.5%) were rereferred for IBS and 27 (43.5%) for other gastrointestinal symptoms. Among the 35 rereferred with IBS this was caused by a change in symptoms in only 5 (14.3%). Reinvestigation was undertaken in 21 (60.0%) of 35 rereferred with IBS and 22 (81.5%) of 27 rereferred with other symptoms (P = .12). Only 4 (9.3% of those reinvestigated and 1.1% of the entire cohort) new cases of relevant organic disease, which may have been responsible for IBS symptoms at baseline, were identified (1 case of chronic calcific pancreatitis among those rereferred with IBS and 1 case each of inflammatory bowel disease-unclassified, moderate bile acid diarrhea, and small bowel obstruction among those rereferred with other gastrointestinal symptoms). CONCLUSIONS Despite rereferral for gastrointestinal symptoms among 1 in 6 patients overall, with almost 10% rereferred with ongoing IBS symptoms, and substantial reinvestigation rates, missed organic gastrointestinal disease occurred in only 1%. A diagnosis of Rome IV IBS after limited investigation is safe and durable.
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Affiliation(s)
- Mais Khasawneh
- Leeds Gastroenterology Institute, St. James's University Hospital, Leeds, United Kingdom
| | - Orla F Craig
- Leeds Gastroenterology Institute, St. James's University Hospital, Leeds, United Kingdom
| | - David J Gracie
- Leeds Gastroenterology Institute, St. James's University Hospital, Leeds, United Kingdom
| | - Christopher J Black
- Leeds Gastroenterology Institute, St. James's University Hospital, Leeds, United Kingdom; Leeds Institute for Medical Research at St. James's, University of Leeds, Leeds, United Kingdom
| | - Alexander C Ford
- Leeds Gastroenterology Institute, St. James's University Hospital, Leeds, United Kingdom; Leeds Institute for Medical Research at St. James's, University of Leeds, Leeds, United Kingdom.
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5
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Terra I, Santeiro C, da Fonseca Rua J. Supplementation With Bifidobacterium and Symptomatic Control in Irritable Bowel Syndrome: An Evidence-Based Review. Cureus 2023; 15:e44447. [PMID: 37791169 PMCID: PMC10544091 DOI: 10.7759/cureus.44447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2023] [Indexed: 10/05/2023] Open
Abstract
Irritable bowel syndrome (IBS) is a functional gastrointestinal disorder, with a global prevalence of around 11%. Family doctors should be aware of the diagnosis and treatment of this pathology. The benefit of using probiotics is questionable. The purpose of this review is to establish the evidence of the association between Bifidobacterium supplementation and symptomatic control in patients with IBS. The research was conducted using the National Guideline Clearinghouse, National Electronic Library for Health of the British NHS, Canadian Medical Association Practice Guidelines InfoBase, Cochrane Library, Database of Abstracts of Reviews of Effectiveness, Bandolier, Evidence-Based Medicine Online, and PubMed. Articles published between March 2017 and March 2022 in humans and written in Portuguese, Spanish, and English using the terms IBS and Bifidobacterium were included. To stratify the level of evidence (LOE), the Strength of Recommendation Taxonomy (SORT), from the American Academy of Family Physicians, was used. Thirty-seven articles were found corresponding to the search terms, and a total of seven articles were selected. Three clinical trials and a simple review have demonstrated improvement in symptoms, although further studies are needed. The guideline and the systematic review did not demonstrate superiority in symptomatic relief when compared to other species of probiotics. The meta-analysis did not show the efficacy of the isolated use of Bifidobacterium. The evidence of an association between supplementation with Bifidobacterium and symptomatic control in patients with IBS is not clear. Some studies seem to demonstrate benefits in improving symptoms (SORT C).
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Affiliation(s)
- Inês Terra
- Family Medicine, Unidades de Saúde Familiar (USF) Casa dos Pescadores, Póvoa de Varzim, PRT
| | - Catarina Santeiro
- Family Medicine, Unidades de Saúde Familiar (USF) Lusitânia, Évora, PRT
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6
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Zheng LF, Liu S, Zhu JX. Editorial: Advances in research on the role of inflammation in gut functional disorders. Front Physiol 2023; 14:1248333. [PMID: 37485061 PMCID: PMC10361611 DOI: 10.3389/fphys.2023.1248333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 06/29/2023] [Indexed: 07/25/2023] Open
Affiliation(s)
- Li-Fei Zheng
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Capital Medical University, Beijing, China
| | - Sumei Liu
- Department of Biology, College of Science and Health, University of Wisconsin-La Crosse, La Crosse, WI, United States
| | - Jin-Xia Zhu
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Capital Medical University, Beijing, China
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7
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Ejtehadi F, Anbardar MH, Imanieh MH, Niknam R, Sivandzadeh GR. Organic colonic lesions in patients with irritable bowel syndrome: A comparative study. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2023; 88:208-213. [PMID: 35906157 DOI: 10.1016/j.rgmx.2021.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 06/15/2021] [Indexed: 11/09/2023]
Abstract
INTRODUCTION AND AIMS Any alarm symptoms in patients with irritable bowel syndrome (IBS) should be carefully evaluated. Colonoscopy is a standard diagnostic procedure for evaluating the colonic mucosa and ruling out probable diseases responsible for patient symptoms. We analyzed the colonoscopy findings in patients with and without IBS. MATERIAL AND METHODS Ninety-six patients with IBS and 101 without IBS were consecutively enrolled in the study. All the patients in the IBS group met the Rome IV criteria, and underwent colonoscopy due to the appearance of red flags. The colonoscopy findings were compared between the 2 groups of patients. RESULTS The main indications for colonoscopy in the IBS group were progressive abdominal pain (36.7%), rectal bleeding with fresh blood (17.7%), and occult blood in stool (12.5%). In the non-IBS group, the most prevalent indicators were rectal bleeding with fresh blood (37.6%), colorectal cancer surveillance (21.8%), and abdominal pain (13.9%). The most common macroscopic findings in the 2 groups were hemorrhoids, polyps, and anal fissure. There were no statistically significant differences with respect to the microscopic and macroscopic findings between groups. CONCLUSIONS We concluded that the prevalence of organic lesions in the colon of patients with IBS was the same as that in the patients without IBS. The Rome IV criteria accurately predicted IBS. Additional evaluation through colonoscopy in IBS should be based on the presence of alarm features.
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Affiliation(s)
- F Ejtehadi
- Centro de Investigación en Gastroenterohepatología, Universidad de Ciencias Médicas de Shiraz, Shiraz, Iran
| | - M H Anbardar
- Departamento de Patología, Universidad de Ciencias Médicas de Shiraz, Shiraz, Iran
| | - M H Imanieh
- Centro de Investigación en Gastroenterohepatología, Universidad de Ciencias Médicas de Shiraz, Shiraz, Iran.
| | - R Niknam
- Centro de Investigación en Gastroenterohepatología, Universidad de Ciencias Médicas de Shiraz, Shiraz, Iran
| | - G R Sivandzadeh
- Centro de Investigación en Gastroenterohepatología, Universidad de Ciencias Médicas de Shiraz, Shiraz, Iran
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8
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Ejtehadi F, Anbardar MH, Imanieh MH, Niknam R, Sivandzadeh GR. Organic colonic lesions in patients with irritable bowel syndrome: A comparative study. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2023; 88:208-213. [PMID: 35906157 DOI: 10.1016/j.rgmxen.2022.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 06/15/2021] [Indexed: 11/25/2022]
Abstract
INTRODUCTION AND AIMS Any alarm symptoms in patients with irritable bowel syndrome (IBS) should be carefully evaluated. Colonoscopy is a standard diagnostic procedure for evaluating the colonic mucosa and ruling out probable diseases responsible for patient symptoms. We analyzed the colonoscopy findings in patients with and without IBS. MATERIAL AND METHODS Ninety-six patients with IBS and 101 without IBS were consecutively enrolled in the study. All the patients in the IBS group met the Rome IV criteria, and underwent colonoscopy due to the appearance of red flags. The colonoscopy findings were compared between the 2 groups of patients. RESULTS The main indications for colonoscopy in the IBS group were progressive abdominal pain (36.7%), rectal bleeding with fresh blood (17.7%), and occult blood in stool (12.5%). In the non-IBS group, the most prevalent indicators were rectal bleeding with fresh blood (37.6%), colorectal cancer surveillance (21.8%), and abdominal pain (13.9%). The most common macroscopic findings in the 2 groups were hemorrhoids, polyps, and anal fissure. There were no statistically significant differences with respect to the microscopic and macroscopic findings between groups. CONCLUSIONS We concluded that the prevalence of organic lesions in the colon of patients with IBS was the same as that in the patients without IBS. The Rome IV criteria accurately predicted IBS. Additional evaluation through colonoscopy in IBS should be based on the presence of alarm features.
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Affiliation(s)
- F Ejtehadi
- Centro de Investigación en Gastroenterohepatología, Universidad de Ciencias Médicas de Shiraz, Shiraz, Iran
| | - M H Anbardar
- Departamento de Patología, Universidad de Ciencias Médicas de Shiraz, Shiraz, Iran
| | - M H Imanieh
- Centro de Investigación en Gastroenterohepatología, Universidad de Ciencias Médicas de Shiraz, Shiraz, Iran.
| | - R Niknam
- Centro de Investigación en Gastroenterohepatología, Universidad de Ciencias Médicas de Shiraz, Shiraz, Iran
| | - G R Sivandzadeh
- Centro de Investigación en Gastroenterohepatología, Universidad de Ciencias Médicas de Shiraz, Shiraz, Iran
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Barbara G, Cremon C, Bellini M, Corsetti M, Di Nardo G, Falangone F, Fuccio L, Galeazzi F, Iovino P, Sarnelli G, Savarino EV, Stanghellini V, Staiano A, Stasi C, Tosetti C, Turco R, Ubaldi E, Zagari RM, Zenzeri L, Marasco G. Italian guidelines for the management of irritable bowel syndrome: Joint Consensus from the Italian Societies of: Gastroenterology and Endoscopy (SIGE), Neurogastroenterology and Motility (SINGEM), Hospital Gastroenterologists and Endoscopists (AIGO), Digestive Endoscopy (SIED), General Medicine (SIMG), Gastroenterology, Hepatology and Pediatric Nutrition (SIGENP) and Pediatrics (SIP). Dig Liver Dis 2023; 55:187-207. [PMID: 36517261 DOI: 10.1016/j.dld.2022.11.015] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 11/21/2022] [Accepted: 11/24/2022] [Indexed: 01/29/2023]
Abstract
The irritable bowel syndrome (IBS) is a chronic disorder of gut-brain interaction. IBS is still associated with areas of uncertainties, especially regarding the optimal diagnostic work-up and the more appropriate management. Experts from 7 Italian Societies conducted a Delphi consensus with literature summary and voting process on 27 statements. Recommendations and quality of evidence were evaluated using the grading of recommendations, assessment, development, and evaluation (GRADE) criteria. Consensus was defined as >80% agreement and reached for all statements. In terms of diagnosis, the consensus supports a positive diagnostic strategy with a symptom-based approach, including the psychological comorbidities assessment and the exclusion of alarm symptoms, together with the digital rectal examination, full blood count, C-reactive protein, serology for coeliac disease, and fecal calprotectin assessment. Colonoscopy should be recommended in patients with alarm features. Regarding treatment, the consensus strongly supports a dietary approach for patients with IBS, the use of soluble fiber, secretagogues, tricyclic antidepressants, psychologically directed therapies and, only in specific IBS subtypes, rifaximin. A conditional recommendation was achieved for probiotics, polyethylene glycol, antispasmodics, selective serotonin reuptake inhibitors and, only in specific IBS subtypes, 5-HT3 antagonists, 5-HT4 agonists, bile acid sequestrants.
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Affiliation(s)
- Giovanni Barbara
- IRCCS Azienda Ospedaliero Universitaria di Bologna, 40126 Bologna, Italy; Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy.
| | - Cesare Cremon
- IRCCS Azienda Ospedaliero Universitaria di Bologna, 40126 Bologna, Italy; Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy
| | - Massimo Bellini
- Gastrointestinal Unit, Department of Translational Sciences and New Technologies in Medicine and Surgery, University of Pisa, 56010 Pisa, Italy
| | - Maura Corsetti
- NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, Nottingham Digestive Diseases Biomedical Research Centre, Nottingham, United Kingdom
| | - Giovanni Di Nardo
- NESMOS Department, Faculty of Medicine and Psychology, Sapienza University of Rome, Sant'Andrea University Hospital, Rome, Italy
| | - Francesca Falangone
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, University Sapienza, Rome, Italy
| | - Lorenzo Fuccio
- Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy; Gastroenterology Unit, IRCCS Azienda Ospedaliero Universitaria di Bologna, 40126 Bologna, Italy
| | - Francesca Galeazzi
- Gastroenterology Unit, Azienda Ospedale Università di Padova, 35128 Padua, Italy
| | - Paola Iovino
- Gastrointestinal Unit Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, 84081 Baronissi, Italy
| | - Giovanni Sarnelli
- Department of Clinical Medicine and Surgery, University of Naples "Federico II", 80131 Naples, Italy
| | | | - Vincenzo Stanghellini
- IRCCS Azienda Ospedaliero Universitaria di Bologna, 40126 Bologna, Italy; Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy
| | - Annamaria Staiano
- Department of Translational Medical Sciences-Section of Pediatric, University Federico II, 80100 Naples, Italy
| | - Cristina Stasi
- Internal Medicine and Liver Unit, Department of Experimental and Clinical Medicine, Careggi University Hospital, Florence, Italy
| | | | - Rossella Turco
- Department of Translational Medical Sciences-Section of Pediatric, University Federico II, 80100 Naples, Italy
| | - Enzo Ubaldi
- Primary Care, Health Care Agency of Ascoli Piceno, Ascoli Piceno, Italy
| | - Rocco Maurizio Zagari
- Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy; Gastroenterology Unit, IRCCS Azienda Ospedaliero Universitaria di Bologna, 40126 Bologna, Italy
| | - Letizia Zenzeri
- NESMOS Department, Faculty of Medicine and Psychology, Sapienza University of Rome, Sant'Andrea University Hospital, Rome, Italy
| | - Giovanni Marasco
- IRCCS Azienda Ospedaliero Universitaria di Bologna, 40126 Bologna, Italy; Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy
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10
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Wu J, Wang C, Lv L. Diagnostic yield of colonoscopy for organic disease in irritable bowel syndrome and its risk factors: A meta-analysis. Neurogastroenterol Motil 2023; 35:e14481. [PMID: 36168183 DOI: 10.1111/nmo.14481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 07/27/2022] [Accepted: 09/16/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Colonoscopy is commonly performed in patients with irritable bowel syndrome (IBS) to rule out organic disease. We performed a meta-analysis to assess the prevalence of organic disease detected at colonoscopy in IBS and its potential risk factors. METHODS Medline, Embase, and Web of Science were searched through January 2022. Observational studies that reported diagnostic yield of colonoscopy for organic disease including colorectal cancer (CRC), inflammatory bowel disease (IBD), or microscopic colitis (MC) in adult IBS patients were eligible. Pooled prevalence and risk difference (RD) with 95% confidence intervals (CIs) were calculated. RESULTS Of 2490 citations identified, 12 studies were eligible containing 28,630 patients with IBS undergoing colonoscopy. Pooled prevalence of CRC, IBD, and MC in IBS was 0.78%, 4.48%, and 2.35%, respectively. No difference in the yield for CRC, IBD, and MC was seen between IBS and non-IBS patients. CRC was rare in IBS patients without alarm symptoms or younger than 40 years (<0.1%). Pooled Prevalence of CRC (2.47% vs. 0.11%; RD 2.57%, 95% CI 0.37%-4.78%) and IBD (8.86% vs. 4.25%; RD 10.75%, 95% CI 4.81%-16.68%) was significantly higher in IBS patients with alarm symptoms compared with those without. IBD and MC were more likely to be detected at colonoscopy in IBS-D compared with IBS-C. The prevalence of CRC and MC was higher in IBS patients with older age than younger age. CONCLUSION We provide the first pooled estimate of yield of colonoscopy in IBS and its risk factors, which may be used to inform clinical decision and support guidelines.
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Affiliation(s)
- Jie Wu
- Department of Gastroenterology, Xiangya Hospital of Central South University, Changsha, China
| | - Chunlian Wang
- Department of Gastroenterology, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Liang Lv
- Department of Gastroenterology, The Second Xiangya Hospital of Central South University, Changsha, China
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11
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Fan W, Fang X, Hu C, Fei G, Xiao Q, Li Y, Li X, Wood JD, Zhang X. Multiple rather than specific autoantibodies were identified in irritable bowel syndrome with HuProt™ proteome microarray. Front Physiol 2022; 13:1010069. [PMID: 36262261 PMCID: PMC9573966 DOI: 10.3389/fphys.2022.1010069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 09/15/2022] [Indexed: 12/05/2022] Open
Abstract
Immune activation and several autoantibodies might be involved in the pathophysiology of irritable bowel syndrome (IBS). We aimed to identify serum biomarkers for IBS by HuProt™ microarray. IBS patients met Rome III criteria were enrolled. Control groups included healthy controls (HCs) and disease controls (DCs). In stage I, we profiled sera from IBS and control groups with HuProt™ microarrays. Based on significant different proteins in stage I, IBS focused microarrays were constructed and validated in a larger cohort in stage II, then decision tree models were generated to establish a combination of biomarkers. In stage III, 4 purified proteins were verified by ELISA. Finally, we analyzed the correlation of autoantibodies with symptoms. In stage I, we identified 47 significant different proteins including 8 autoantibodies of IgG, 2 of IgA between IBS and HCs; 13 autoantibodies of IgG, 13 of IgA between IBS and DCs. In stage II, we found the positive rates of 14 IgG and IgA autoantibodies in IBS were significantly higher than HCs. Five autoantibodies of IgG and 7 IgA were comprehensively involved in differentiating IBS and HCs with the sensitivity and specificity to diagnose IBS as 40%–46.7% and 79.4%–86.3%. The median optical density value of ELAVL4 (IgG) and PIGP (IgA) were significantly higher in IBS than HCs. Parts of autoantibodies above were related to IBS symptoms. We found a combination of autoantibodies to differentiate IBS with HCs, but no specific autoantibodies could serve as serum biomarkers for IBS.
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Affiliation(s)
- Wenjuan Fan
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Department of Gastroenterology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Xiucai Fang
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- *Correspondence: Xiucai Fang,
| | - Chaojun Hu
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Guijun Fei
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qiyun Xiao
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yongzhe Li
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Department of Rheumatology and Department of Clinical Laboratory, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaoqing Li
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jackie D. Wood
- Department of Physiology and Cell Biology, Wexner Medical Center, The Ohio State University, Columbus, OH, United States
| | - Xuan Zhang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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12
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Black CJ, Ford AC. Assessing the Impact of Changes to the Rome IV Criteria for Clinical Practice in Irritable Bowel Syndrome. Gastroenterology 2022; 162:1752-1754.e1. [PMID: 35077757 DOI: 10.1053/j.gastro.2022.01.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/11/2022] [Accepted: 01/12/2022] [Indexed: 12/02/2022]
Affiliation(s)
- Christopher J Black
- Leeds Institute of Medical Research, Leeds Gastroenterology Institute, St James' University Hospital, Leeds, United Kingdom
| | - Alexander C Ford
- Leeds Institute of Medical Research, Leeds Gastroenterology Institute, St James' University Hospital, Leeds, United Kingdom.
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13
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Brandler J, Chey WD. Fishing for Irritable Bowel Syndrome: Which Alarm Features Weave the Best Net? Clin Gastroenterol Hepatol 2022; 20:276-278. [PMID: 33220527 DOI: 10.1016/j.cgh.2020.11.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 11/08/2020] [Accepted: 11/14/2020] [Indexed: 02/07/2023]
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14
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Black CJ. Review article: Diagnosis and investigation of irritable bowel syndrome. Aliment Pharmacol Ther 2021; 54 Suppl 1:S33-S43. [PMID: 34927756 DOI: 10.1111/apt.16597] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 08/22/2021] [Accepted: 08/24/2021] [Indexed: 12/17/2022]
Abstract
Irritable bowel syndrome (IBS) is a common disorder of gut-brain interaction. It is defined by the Rome criteria as the presence of abdominal pain, related to defaecation, associated with a change in stool form and/or frequency. The approach to diagnosis and investigation of suspected IBS varies between clinicians and, due in part to the uncertainty that can surround the diagnosis, many still consider it to be a diagnosis of exclusion. However, exhaustive investigation is both unnecessary and costly, and may also be counterproductive. Instead, physicians should aim to make a positive diagnosis, based on their clinical assessment of symptoms, and limit their use of investigations. The yield of routine blood tests in suspected IBS is low overall, but normal inflammatory markers may be reassuring. All patients should have serological testing for coeliac disease, irrespective of their predominant stool form. Routine testing of stool microbiology or faecal elastase is unnecessary; however, all patients with diarrhoea aged <45 should have a faecal calprotectin or a similar marker measured which, if positive, should lead to colonoscopy to exclude possible inflammatory bowel disease. Colonoscopy should also be undertaken in any patient reporting alarm symptoms suggestive of colorectal cancer, and in those whose presentation raises suspicion for microscopic colitis. Testing for bile acid diarrhoea should be considered for patients with IBS with diarrhoea where available. Hydrogen breath tests for lactose malabsorption or small intestinal bacterial overgrowth have no role in the routine assessment of suspected IBS. Adopting a standardised approach to the diagnosis and investigation of IBS will help to promote high-quality and high-value care for patients overall.
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Affiliation(s)
- Christopher J Black
- Leeds Gastroenterology Institute, St. James's University Hospital, Leeds, UK.,Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, UK
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15
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Abstract
Irritable bowel syndrome (IBS) is among the most common diagnoses made by medical providers and its symptoms are common causes for health care consultation. IBS is characterized by abdominal pain associated with abnormal stool consistency and/or frequency and is widely considered a diagnosis of exclusion, despite abundant evidence contradicting such an approach. A positive diagnosis is achieved through application of symptom-based clinical criteria, careful history and physical examination, evaluation for alarm sign/symptoms, and judicious use of diagnostic testing. This article reviews the symptom-based criteria for IBS and utility of diagnostic tests commonly included in the evaluation of IBS symptoms.
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Affiliation(s)
- Ryan S Goldstein
- Gastroenterology, Hepatology and Nutrition, UT Health Science Center at Houston, 6431 Fannin Street, MSB 4.234, Houston, TX 77030, USA
| | - Brooks D Cash
- Gastroenterology, Hepatology and Nutrition, UT Health Science Center at Houston, 6431 Fannin Street, MSB 4.234, Houston, TX 77030, USA.
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16
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Black CJ, Craig O, Gracie DJ, Ford AC. Comparison of the Rome IV criteria with the Rome III criteria for the diagnosis of irritable bowel syndrome in secondary care. Gut 2021; 70:1110-1116. [PMID: 32973070 DOI: 10.1136/gutjnl-2020-322519] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 08/25/2020] [Accepted: 09/02/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Despite being proposed 4 years ago, there has been no independent validation study of the Rome IV criteria for IBS. We assessed their performance for the diagnosis of IBS in secondary care and compared them with the previous iteration, the Rome III criteria. DESIGN We collected complete symptom data from consecutive adult patients with suspected IBS referred to a single UK clinic. All subjects underwent relatively standardised workup, with assessors blinded to symptom status. The reference standard used to confirm IBS was the presence of lower abdominal pain or discomfort in association with altered stool form or frequency, in a patient with no evidence of organic gastrointestinal disease after investigation. Sensitivity, specificity and positive and negative likelihood ratios (LRs), with 95% CIs, were calculated for each of the diagnostic criteria. RESULTS The level of agreement between the Rome IV and Rome III criteria was good (kappa=0.65). Compared with the reference standard, sensitivity and specificity of the Rome IV criteria in 572 patients (431 (75.3%) women, mean age 36.5 years) were 82.4% and 82.9%, respectively. Positive and negative LRs for the Rome IV criteria were 4.82 (95% CI 3.30 to 7.28) and 0.21 (95% CI 0.17 to 0.26), respectively. The Rome IV criteria performed best in those with IBS with constipation or mixed bowel habits. In 471 patients (350 (74.3%) women, mean age 36.7 years), compared with the reference standard, the sensitivity and specificity of the Rome III criteria were 85.8% and 65.0%; positive and negative LRs were 2.45 (95% CI 1.90 to 3.27) and 0.22 (0.16 to 0.29), respectively. Incorporating mood and extraintestinal symptom reporting into diagnostic criteria did not improve their performance significantly. CONCLUSIONS The Rome IV criteria performed significantly better than the Rome III criteria in diagnosing IBS in this single centre secondary care study, although the clinical relevance of this is uncertain.
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Affiliation(s)
- Christopher J Black
- Leeds Gastroenterology Institute, Leeds Teaching Hospitals NHS Trust, Leeds, UK.,Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, UK
| | - Orla Craig
- Leeds Gastroenterology Institute, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - David J Gracie
- Leeds Gastroenterology Institute, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Alexander C Ford
- Leeds Gastroenterology Institute, Leeds Teaching Hospitals NHS Trust, Leeds, UK .,Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, UK
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Tsukanov VV, Vasyutin AV, Tonkikh JL. Modern aspects of the management of patients with irritable bowel syndrome. MEDITSINSKIY SOVET = MEDICAL COUNCIL 2021:22-28. [DOI: 10.21518/2079-701x-2021-5-22-28] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/12/2024]
Abstract
A review of modern data from the study of functional disorders of the digestive tract is performed. In the United States, 4 million people with functional bowel disorders seek medical care annually, and the annual cost of managing these patients is $ 358 million. Due to the urgency of the problem, new developments appear, among which it is necessary to highlight the American College of Gastroenterology (ACG) guidelines for the management of patients with IBS. To examine patients with suspected IBS, the authors of the ACG guideline proposed a positive diagnostic strategy, which is based on a careful study of the anamnesis, focusing on the key symptoms of the relationship between abdominal pain and bowel function during a long course of the disease (more than 6 months) and the absence of alarming symptoms with minimal use of instrumental diagnostic tests. For the diagnosis of IBS, the authors recommended serological testing for celiac disease, determination of fecal calprotectin and C-reactive protein to exclude inflammatory bowel diseases, but they did not consider it necessary to routinely analyze stool for intestinal pathogens. From our point of view, the absence of routine stool analysis for intestinal pathogens is completely inapplicable for Russia, since in our country the frequency of detection of diphyllobothriasis, giardiasis and opisthorchiasis is very high. The ACG consensus drew attention to the need to expand the evidence base for the use of some standard drugs for the treatment of IBS, proposed a number of new drugs (lebiprostone, linaclotide), recommended the use of rifaximin (for the treatment of IBS with a predominance of diarrhea) and tricyclic antidepressants (for the treatment of IBS). Analysis of modern international recommendations suggests that the clinical guidelines of the Russian Gastroenterological Association and the Association of Coloproctologists of Russia for the diagnosis and treatment of IBS are currently the main document governing the management of these patients in our country.
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Affiliation(s)
- V. V. Tsukanov
- Krasnoyarsk Science Centre of the Siberian Branch of Russian Academy of Science, Scientific Research Institute of Medical Problems of the North
| | - A. V. Vasyutin
- Krasnoyarsk Science Centre of the Siberian Branch of Russian Academy of Science, Scientific Research Institute of Medical Problems of the North
| | - J. L. Tonkikh
- Krasnoyarsk Science Centre of the Siberian Branch of Russian Academy of Science, Scientific Research Institute of Medical Problems of the North
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18
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Abstract
IMPORTANCE The prevalence of irritable bowel syndrome (IBS) in the United States is between 7% and 16%, most common in women and young people, with annual direct costs estimated at more than $1 billion dollars in the United States. Traditionally, the diagnosis of IBS has been based on the positive identification of symptoms that correlate with several different syndromes associated with disorders such as IBS diarrhea, IBS constipation, functional diarrhea, functional constipation, chronic functional abdominal pain, or bloating. Several peripheral and central mechanisms initiate gastrointestinal motor and sensory dysfunctions leading to IBS symptoms. Those dysfunctions may require evaluation in patients whose symptoms do not respond to first-line treatments. OBSERVATIONS Validation studies of consensus symptom-based criteria have identified deficiencies that favor a simpler identification of the predominant symptoms of abdominal pain, bowel dysfunction, and bloating and exclusion of alarm symptoms such as unintentional weight loss, rectal bleeding, or recent change in bowel function. Symptom-based diagnosis of IBS is enhanced with additional history for symptoms of somatoform and psychological disorders and alarm symptoms, physical examination including digital rectal examination, and screening tests to exclude organic disease (by measuring hemoglobin and C-reactive protein concentrations). The initial treatment plan should include patient education, reassurance, and first-line treatments such as fiber and osmotic laxatives for constipation, opioids for diarrhea, antispasmodics for pain and for management of associated psychological disorders. For patients who do not respond to those IBS treatments, testing for specific functional disorders may be required in a minority of patients with IBS. These disorders include rectal evacuation disorder, abnormal colonic transit, and bile acid diarrhea. Their identification is followed by individualized treatment, such as pelvic floor retraining for rectal evacuation disorders, sequestrants for bile acid diarrhea, and secretory agents for constipation, although there is only limited evidence that this individualized management approach is effective. CONCLUSIONS AND RELEVANCE Advances in the identification of specific dysfunctions as causes of individual symptoms in the "IBS spectrum" leads to the potential to enhance the diagnosis and management of symptoms for the majority of patients for whom first-line therapies of IBS and management of comorbid psychological disorders are insufficient.
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Affiliation(s)
- Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
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19
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The overlap between irritable bowel syndrome and organic gastrointestinal diseases. Lancet Gastroenterol Hepatol 2021; 6:139-148. [DOI: 10.1016/s2468-1253(20)30212-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 06/15/2020] [Accepted: 06/22/2020] [Indexed: 12/13/2022]
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Abstract
PURPOSE OF REVIEW Irritable bowel syndrome (IBS) is a very common disorder whose clinical presentation varies considerably between patients as well as within the same individual over time. Many of its symptoms, such as pain, diarrhea, constipation and bloating, may be manifestations of a host of other gastrointestinal diseases; some accompanied by increased mortality. This presents the clinician with a real dilemma: how to sensibly investigate the patient in which one suspects IBS but there is a nagging doubt that 'it could be something else'? Could one miss 'something serious'? This short review attempts to provide both an evidence-based response to these vexing questions and a practical guide to detecting alternative diagnoses in the subject with IBS-type symptoms. RECENT FINDINGS Clinical features, patient demographics and the clinical context can help to significantly narrow the differential diagnosis of the individual with IBS-type symptoms and may permit a positive diagnosis of IBS. The advent of noninvasive serological and stool tests has greatly facilitated differentiation from celiac disease and inflammatory bowel disease, respectively. In the older, female diarrhea sufferer microscopic colitis should be considered. The role of bile acid diarrhea in the individual with diarrhea-predominant IBS is emphasized; the status of small intestinal bacterial overgrowth in IBS remain uncertain. SUMMARY Attention to detail in the clinical evaluation of the individual with IBS-like symptoms will facilitate a selective and targeted approach to investigation. Wherever indicated, widely available serological and fecal tests will serve to bolster the diagnosis by excluding other options. Proceeding to more invasive testing should be dictated by clinical presentation and scenario with the threshold for intervention being generally lower among those with prominent diarrhea.
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21
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ACG Clinical Guideline: Management of Irritable Bowel Syndrome. Am J Gastroenterol 2021; 116:17-44. [PMID: 33315591 DOI: 10.14309/ajg.0000000000001036] [Citation(s) in RCA: 350] [Impact Index Per Article: 116.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 10/08/2020] [Indexed: 02/07/2023]
Abstract
Irritable bowel syndrome (IBS) is a highly prevalent, chronic disorder that significantly reduces patients' quality of life. Advances in diagnostic testing and in therapeutic options for patients with IBS led to the development of this first-ever American College of Gastroenterology clinical guideline for the management of IBS using Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. Twenty-five clinically important questions were assessed after a comprehensive literature search; 9 questions focused on diagnostic testing; 16 questions focused on therapeutic options. Consensus was obtained using a modified Delphi approach, and based on GRADE methodology, we endorse the following: We suggest that a positive diagnostic strategy as compared to a diagnostic strategy of exclusion be used to improve time to initiating appropriate therapy. We suggest that serologic testing be performed to rule out celiac disease in patients with IBS and diarrhea symptoms. We suggest that fecal calprotectin be checked in patients with suspected IBS and diarrhea symptoms to rule out inflammatory bowel disease. We recommend a limited trial of a low fermentable oligosaccharides, disacchardies, monosaccharides, polyols (FODMAP) diet in patients with IBS to improve global symptoms. We recommend the use of chloride channel activators and guanylate cyclase activators to treat global IBS with constipation symptoms. We recommend the use of rifaximin to treat global IBS with diarrhea symptoms. We suggest that gut-directed psychotherapy be used to treat global IBS symptoms. Additional statements and information regarding diagnostic strategies, specific drugs, doses, and duration of therapy can be found in the guideline.
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22
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Ford AC, Sperber AD, Corsetti M, Camilleri M. Irritable bowel syndrome. Lancet 2020; 396:1675-1688. [PMID: 33049223 DOI: 10.1016/s0140-6736(20)31548-8] [Citation(s) in RCA: 347] [Impact Index Per Article: 86.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 06/26/2020] [Accepted: 07/03/2020] [Indexed: 12/11/2022]
Abstract
Irritable bowel syndrome is a functional gastrointestinal disorder with symptoms including abdominal pain associated with a change in stool form or frequency. The condition affects between 5% and 10% of otherwise healthy individuals at any one point in time and, in most people, runs a relapsing and remitting course. The best described risk factor is acute enteric infection, but irritable bowel syndrome is also more common in people with psychological comorbidity and in young adult women than in the rest of the general population. The pathophysiology of irritable bowel syndrome is incompletely understood, but it is well established that there is disordered communication between the gut and the brain, leading to motility disturbances, visceral hypersensitivity, and altered CNS processing. Other less reproducible mechanisms might include genetic associations, alterations in gastrointestinal microbiota, and disturbances in mucosal and immune function. In most people, diagnosis can be made on the basis of clinical history with limited and judicious use of investigations, unless alarm symptoms such as weight loss or rectal bleeding are present, or there is a family history of inflammatory bowel disease or coeliac disease. Once the diagnosis is made, an empathetic approach is key and can improve quality of life and symptoms, and reduce health-care expenditure. The mainstays of treatment include patient education about the condition, dietary changes, soluble fibre, and antispasmodic drugs. Other treatments tend to be reserved for people with severe symptoms and include central neuromodulators, intestinal secretagogues, drugs acting on opioid or 5-HT receptors, or minimally absorbed antibiotics (all of which are selected according to predominant bowel habit), as well as psychological therapies. Increased understanding of the pathophysiology of irritable bowel syndrome in the past 10 years has led to a healthy pipeline of novel drugs in development.
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Affiliation(s)
- Alexander C Ford
- Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK; Leeds Gastroenterology Institute, St James's University Hospital, Leeds, UK.
| | - Ami D Sperber
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Maura Corsetti
- National Institute for Health Research, Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK; Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research, Mayo Clinic, Rochester, MN, USA
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23
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Camilleri M. Irritable Bowel Syndrome: Straightening the road from the Rome criteria. Neurogastroenterol Motil 2020; 32:e13957. [PMID: 32808411 PMCID: PMC7640950 DOI: 10.1111/nmo.13957] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 06/10/2020] [Accepted: 07/12/2020] [Indexed: 12/20/2022]
Abstract
A sequence of consensus-based Rome criteria for irritable bowel syndrome (IBS) has been published since 1989. The fundamental definition based on abdominal pain in association with bowel dysfunction has been consistent. However, two major changes occurred in the Rome II and IV criteria. The former change involved "splitting off" of symptoms that were not consistently associated with pain, such as functional, constipation, diarrhea, and bloating. In Rome IV, the main changes were the exclusion of discomfort (in contrast to pain) and the more stringent frequency criteria for the pain to be eligible for diagnosis of IBS (specifically, on average, at least 1 day per week in the last 3 months). Validation studies of the consensus, symptom-based criteria have identified multiple deficiencies that question the rationale for "splitting" the different syndromes, and favor a simpler identification of the classical symptoms of abdominal pain, bowel dysfunction, and bloating, and exclusion of alarm symptoms. Advances in the identification of actionable biomarkers related to the symptoms suggestive of functional gastrointestinal disorders have the potential to usher a change in practice from positive diagnosis of symptom complexes followed by empirical treatment to identification of the mechanisms causing the symptoms and targeted therapy.
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Affiliation(s)
- Michael Camilleri
- Division of Gastroenterology and Hepatology, Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Mayo Clinic, Rochester, MN, USA
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24
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Black CJ, Ford AC. Rational investigations in irritable bowel syndrome. Frontline Gastroenterol 2020; 11:140-147. [PMID: 32133113 PMCID: PMC7043084 DOI: 10.1136/flgastro-2019-101211] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 05/08/2019] [Accepted: 05/18/2019] [Indexed: 02/06/2023] Open
Abstract
Irritable bowel syndrome (IBS) is a common functional gastrointestinal disorder which accounts for a substantial proportion of a gastroenterologist's time in the outpatient clinic. However, there is variability in approaches to diagnosis and investigation between physicians, dependent on expertise. Many patients express disappointment over the lack of a patient-centred approach. Consequently, there have been calls for the care of patients with IBS to be standardised, a process which aims to promote high-quality and high-value care. Making an early diagnosis, based on a clinical assessment of symptoms, while limiting use of investigations, are key tenets of this process. Exhaustive investigation to exclude all organic pathology is unnecessary, and may be counterproductive. Routine blood tests in suspected IBS have low yield, but are an acceptable part of routine practice. All patients should have coeliac serology tested, regardless of their predominant stool form. Patients with diarrhoea should have a faecal calprotectin measured, and should proceed to colonoscopy to exclude inflammatory bowel disease (IBD) if this is positive. Beyond this, the need for investigations should be made on a case-by-case basis, contingent on the reporting of known risk factors for organic pathology. Colonoscopy should be considered in any patient with alarm features for colorectal cancer, and in those whose clinical features are suggestive of microscopic colitis. A 23-seleno-25-homotaurocholic acid (SeHCAT) scan should be considered in patients with IBS-D, a third of whom may actually have bile acid diarrhoea. There is no role for routine hydrogen breath tests for lactose malabsorption or small intestinal bacterial overgrowth.
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Affiliation(s)
- Christopher J Black
- Leeds Gastroenterology Institute, St. James's University Hospital, Leeds, UK
| | - Alexander C Ford
- Leeds Gastroenterology Institute, St. James's University Hospital, Leeds, UK
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25
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Morales W, Rezaie A, Barlow G, Pimentel M. Second-Generation Biomarker Testing for Irritable Bowel Syndrome Using Plasma Anti-CdtB and Anti-Vinculin Levels. Dig Dis Sci 2019; 64:3115-3121. [PMID: 31152332 DOI: 10.1007/s10620-019-05684-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 05/24/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND ELISA testing for anti-CdtB and anti-vinculin can discriminate patients with irritable bowel syndrome with diarrhea (IBS-D) from those with inflammatory bowel disease (IBD). However, recent findings suggest the antigens can suffer from epitope instability. AIM This study aimed to assess effects of incorporating epitope stabilization on test characteristics for distinguishing IBS-D from IBD subjects. METHODS Plasma samples from IBS-D subjects from a large-scale clinical trial and subjects with endoscopically active IBD without concurrent immunomodulator therapy were used. After epitope stabilization, CdtB and vinculin were used in ELISA testing. Optical density readings were compared between IBS-D and IBD subjects. RESULTS Samples from 100 IBS-D and 31 IBD (22 UC and 9 CD) subjects were tested. IBS-D subjects had higher anti-CdtB titers (P = 0.0001) and higher anti-vinculin titers (P = 0.004) than IBD subjects. The specificities of anti-CdtB and anti-vinculin to differentiate IBS-D from IBD were 93.5% and 90.9%, respectively, with sensitivities of 43.0% and 52.2%, respectively. The positive likelihood ratios of identifying IBS-D with anti-CdtB and anti-vinculin were 6.7 and 5.7, respectively. Assuming a pretest probability of 57% for diagnosis of IBS-D in patients with abdominal pain and change in bowel habits, testing positive for both antibodies resulted in a posttest probability of > 98%. CONCLUSIONS Performing epitope stabilization for CdtB and vinculin enhances the test characteristics of ELISAs for anti-CdtB and anti-vinculin in discriminating IBS-D from IBD. Measurement of anti-CdtB and anti-vinculin with this second-generation methodology may further advance our understanding of the role of immunity in functional bowel diseases.
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Affiliation(s)
- Walter Morales
- Medically Associated Science and Technology (MAST) Program, Cedars-Sinai Medical Center, 8730 Alden Drive, Suite 240E, Los Angeles, CA, 90048, USA
| | - Ali Rezaie
- Medically Associated Science and Technology (MAST) Program, Cedars-Sinai Medical Center, 8730 Alden Drive, Suite 240E, Los Angeles, CA, 90048, USA
| | - Gillian Barlow
- Medically Associated Science and Technology (MAST) Program, Cedars-Sinai Medical Center, 8730 Alden Drive, Suite 240E, Los Angeles, CA, 90048, USA
| | - Mark Pimentel
- Medically Associated Science and Technology (MAST) Program, Cedars-Sinai Medical Center, 8730 Alden Drive, Suite 240E, Los Angeles, CA, 90048, USA.
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Harris BR, Chinta SS, Colvin R, Schnadower D, Tarr PI, Sayuk GS. Undifferentiated Abdominal Pain in Children Presenting to the Pediatric Emergency Department. Clin Pediatr (Phila) 2019; 58:1212-1223. [PMID: 31387380 DOI: 10.1177/0009922819867459] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Although common, little is known about the characteristics and management of undifferentiated abdominal pain (UAP) in the pediatric emergency department (ED). This study was a 12-month retrospective study for "abdominal pain" ED visits. Patients without an identifiable diagnosis were categorized as "UAP," while others with identified disease processes were categorized as "structural gastrointestinal diagnosis (SGID)." We included 2383 (72%) visits with 869 (36.5%) UAP visits and 1514 (63.5%) SGID visits. SGID patients had more laboratory tests (811 [53.6%] vs 422 [48.6%], P = .0186), and often had multiple tests performed (565 [69.7%] vs 264 [62.6%], P = .0116). Computed tomography and ultrasound scans were more common in SGID (computed tomography: 108 [7.1%] vs 27 [3.1%], P = .0004; ultrasound: 377 [24.9%] vs 172 [19.9%], P = .0044), and laboratory results (white blood cell count, hemoglobin, albumin, C-reactive protein) were abnormal at significantly higher rates. Analyses revealed the duration of pain as primary covariate in variance of pain etiology. Clinical features, such as duration of pain, may be augmented by laboratory tests to facilitate recognition of UAP in the ED.
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Affiliation(s)
| | - Sri S Chinta
- Medical College of Wisconsin, Milwaukee, WI, USA
| | - Ryan Colvin
- Washington University in St Louis, St Louis, MO, USA
| | - David Schnadower
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,University of Cincinnati, Cincinnati, OH, USA
| | | | - Gregory S Sayuk
- Washington University in St Louis, St Louis, MO, USA.,St Louis Veterans Affairs Medical Center, St Louis, MO, USA
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27
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El-Salhy M, Gilja OH, Hatlebakk JG. Overlapping of irritable bowel syndrome with erosive esophagitis and the performance of Rome criteria in diagnosing IBS in a clinical setting. Mol Med Rep 2019; 20:787-794. [PMID: 31180516 PMCID: PMC6580027 DOI: 10.3892/mmr.2019.10284] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Accepted: 05/15/2019] [Indexed: 02/06/2023] Open
Abstract
Irritable bowel syndrome (IBS) and gastroesophageal reflux disease (GERD) overlap. It is not clear whether GERD is caused by non-erosive esophagitis, or erosive esophagitis. The Rome criteria are not widely used for the diagnosis of IBS in the clinic. In total, 1,489 IBS patients without red flags were included in the present retrospective study. They comprised of 1,331 females and 158 males with a mean age of 51 years. The diagnosis of IBS was verified by endoscopic and histopathological examinations. Whereas erosive esophagitis occurred in 97% of patients, only 66% had GERD symptoms. Endoscopy and histopathological examinations revealed that 1.4% of the IBS patients with diarrhea as the predominant symptom had other organic gastrointestinal diseases: 0.3% with celiac disease, 0.2% with Crohn's disease, 0.07% with ulcerative colitis, 0.6% with microscopic colitis, and 0.2% with colon cancer. Applying the Rome III criteria produced a sensitivity of 100% [95% confidence intervals (CI)=99.8–100.0%] a specificity of 98.7% (95% CI=98.0–99.2%), a positive likelihood ratio of 76.9%, and a negative likelihood ratio of 0%. IBS is associated with erosive esophagitis. Applying Rome III criteria without red flags and history, was effective in diagnosing IBS. Celiac disease and microscopic colitis should be considered as alternative diagnoses.
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Affiliation(s)
- Magdy El-Salhy
- Section for Gastroenterology, Department of Medicine, Stord Hospital, 5416 Stord, Norway
| | - Odd Helge Gilja
- Department of Clinical Medicine, University of Bergen, 5007 Bergen, Norway
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28
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Moayyedi P, Andrews CN, MacQueen G, Korownyk C, Marsiglio M, Graff L, Kvern B, Lazarescu A, Liu L, Paterson WG, Sidani S, Vanner S. Canadian Association of Gastroenterology Clinical Practice Guideline for the Management of Irritable Bowel Syndrome (IBS). J Can Assoc Gastroenterol 2019; 2:6-29. [PMID: 31294724 PMCID: PMC6507291 DOI: 10.1093/jcag/gwy071] [Citation(s) in RCA: 93] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 11/04/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND & AIMS Irritable bowel syndrome (IBS) is one of the most common gastrointestinal (GI) disorders, affecting about 10% of the general population globally. The aim of this consensus was to develop guidelines for the management of IBS. METHODS A systematic literature search identified studies on the management of IBS. The quality of evidence and strength of recommendations were rated according to the Grading of Recommendation Assessment, Development and Evaluation (GRADE) approach. Statements were developed through an iterative online platform and then finalized and voted on by a multidisciplinary group of clinicians and a patient. RESULTS Consensus was reached on 28 of 31 statements. Irritable bowel syndrome is diagnosed based on symptoms; serological testing is suggested to exclude celiac disease, but routine testing for C-reactive protein (CRP), fecal calprotectin or food allergies is not recommended. A trial of a low fermentable oligosaccharides, disaccharides, monosaccharides, polyols (FODMAP) diet is suggested, while a gluten-free diet is not. Psyllium, but not wheat bran, supplementation may help reduce symptoms. Alternative therapies such as peppermint oil and probiotics are suggested, while herbal therapies and acupuncture are not. Cognitive behavioural therapy and hypnotherapy are suggested psychological therapies. Among the suggested or recommended pharmacological therapies are antispasmodics, certain antidepressants, eluxadoline, lubiprostone, and linaclotide. Loperamide, cholestyramine and osmotic laxatives are not recommended for overall IBS symptoms. The nature of the IBS symptoms (diarrhea-predominant or constipation-predominant) should be considered in the choice of pharmacological treatments. CONCLUSIONS Patients with IBS may benefit from a multipronged, individualized approach to treatment, including dietary modifications, psychological and pharmacological therapies.
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Affiliation(s)
- Paul Moayyedi
- Division of Gastroenterology, McMaster University, Hamilton, Ontario, Canada
| | | | - Glenda MacQueen
- Department of Psychiatry, University of Calgary, Calgary, Alberta, Canada
| | - Christina Korownyk
- Department of Family Medicine, University of Alberta, Edmonton, Alberta, Canada
| | | | - Lesley Graff
- Department of Clinical Health Psychology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Brent Kvern
- Department of Family Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Adriana Lazarescu
- Division of Gastroenterology, University of Alberta, Edmonton, Alberta, Canada
| | - Louis Liu
- Division of Gastroenterology, University of Toronto, Toronto, Ontario, Canada
| | - William G Paterson
- Division of Gastroenterology, Queen’s University, Kingston, Ontario, Canada
| | - Sacha Sidani
- Division of Gastroenterology, McMaster University, Hamilton, Ontario, Canada
| | - Stephen Vanner
- Division of Gastroenterology, Queen’s University, Kingston, Ontario, Canada
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29
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Making a positive diagnosis of irritable bowel syndrome. Br J Gen Pract 2019; 67:580-581. [PMID: 29192120 DOI: 10.3399/bjgp17x693857] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2017] [Accepted: 06/02/2017] [Indexed: 12/13/2022] Open
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30
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Holtmann GJ, Talley NJ. Inconsistent symptom clusters for functional gastrointestinal disorders in Asia: is Rome burning? Gut 2018; 67:1911-1915. [PMID: 29921653 DOI: 10.1136/gutjnl-2017-314775] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 04/06/2018] [Accepted: 05/12/2018] [Indexed: 12/11/2022]
Affiliation(s)
- Gerald J Holtmann
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Faculties of Medicine and Health and Behavioural Sciences, University of Queensland and Translational Research Institute (TRI), Brisbane, Queensland, Australia
| | - Nicholas J Talley
- Faculty of Health and Medicine, University of Newcastle, Newcastle, New South Wales, Australia
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31
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Chang JY, Almazar AE, Richard Locke G, Larson JJ, Atkinson EJ, Talley NJ, Saito YA. Quantifying Rome symptoms for diagnosis of the irritable bowel syndrome. Neurogastroenterol Motil 2018; 30:e13356. [PMID: 29701271 DOI: 10.1111/nmo.13356] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 03/21/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Irritable bowel syndrome (IBS) is a common functional gastrointestinal disorder, diagnosed on symptom-based criteria. Many have reported discrepancies between formal Rome criteria and diagnoses made in clinical practice. The aim of the study was to explore whether a quantitative version of the Rome criteria would better represent a clinical diagnosis of IBS than the current dichotomous criteria for symptom measure. METHODS As part of a large, case-control study, participants completed a validated bowel disease questionnaire. Rome criteria were analyzed based on 15 individual symptoms. Penalized logistic regression model with stepwise selection was used to identify significant symptoms of IBS which were independently associated with case-control status. KEY RESULTS In cases with a clinical diagnosis of IBS, 347 (70%) met Rome criteria for IBS. Increasing number of Rome symptoms were found related to the odds of being diagnosed with IBS. Nearly half of the Rome-negative case group experienced infrequent symptoms suggesting milder disease. Five of 15 Rome symptoms were associated with predicting case-control status in the final model, with 96% correctly classified among Rome-positive cases, 76% for Rome-negative cases, and 91% for controls. CONCLUSIONS AND INFERENCES Irritable bowel syndrome appears to be a spectrum disorder. Quantifying individual symptoms of Rome criteria has greater utility than the current application in representing the degree of IBS affectedness and appears to better reflect a clinical diagnosis of IBS applied by physicians. The use of a quantitative diagnostic Rome "score" may be helpful in clinical practice and research studies to better reflect the degree an individual is affected with IBS.
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Affiliation(s)
- J Y Chang
- Enteric NeuroScience Program, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - A E Almazar
- Enteric NeuroScience Program, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - G Richard Locke
- Enteric NeuroScience Program, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - J J Larson
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - E J Atkinson
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - N J Talley
- Enteric NeuroScience Program, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA.,Pro Vice-Chancellor, Global Research, University of Newcastle, New Lambton, NSW, Australia
| | - Y A Saito
- Enteric NeuroScience Program, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
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32
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Arasaradnam RP, Brown S, Forbes A, Fox MR, Hungin P, Kelman L, Major G, O'Connor M, Sanders DS, Sinha R, Smith SC, Thomas P, Walters JRF. Guidelines for the investigation of chronic diarrhoea in adults: British Society of Gastroenterology, 3rd edition. Gut 2018; 67:1380-1399. [PMID: 29653941 PMCID: PMC6204957 DOI: 10.1136/gutjnl-2017-315909] [Citation(s) in RCA: 172] [Impact Index Per Article: 28.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 02/28/2018] [Accepted: 03/11/2018] [Indexed: 02/07/2023]
Abstract
Chronic diarrhoea is a common problem, hence clear guidance on investigations is required. This is an updated guideline from 2003 for the investigations of chronic diarrhoea commissioned by the Clinical Services and Standards Committee of the British Society of Gastroenterology (BSG). This document has undergone significant revision in content through input by 13 members of the Guideline Development Group (GDG) representing various institutions. The GRADE system was used to appraise the quality of evidence and grading of recommendations.
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Affiliation(s)
- Ramesh P Arasaradnam
- University Hospital Coventry, Coventry, UK
- Department of Applied Biological Sciences, University of Coventry, Coventry, UK
- Clinical Sciences Research Institute, University of Warwick, Warwick, UK
| | | | - Alastair Forbes
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Mark R Fox
- University of Zürich, Zürich, Switzerland
- Abdominal Centre, St Claraspital, Basel, Switzerland
| | - Pali Hungin
- School of Medicine, Pharmacy & Health, University of Durham, Durham, UK
| | | | - Giles Major
- NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
| | | | | | - Rakesh Sinha
- Department of Radiology, South Warwickshire Hospitals, Warwick, UK
| | - Stephen Charles Smith
- Department of Clinical Biochemistry, Midlands and NW Bowel Cancer Screening Hub, Rugby, UK
| | - Paul Thomas
- Department of Gastroenterology, Musgrave Park Hospital, Taunton, UK
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33
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Lacy BE, Ford AC, Talley NJ. Quality of Care and the Irritable Bowel Syndrome: Is Now the Time to Set Standards? Am J Gastroenterol 2018; 113:167-169. [PMID: 29206817 DOI: 10.1038/ajg.2017.442] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Brian E Lacy
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Alexander C Ford
- Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK.,Leeds Gastroenterology Institute, St James's University Hospital, Leeds, UK
| | - Nicholas J Talley
- Faculty of Health and Medicine, University of Newcastle, Newcastle, New South Wales, Australia.,Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA.,Karolinska Institute, Stockholm, Sweden
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34
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Sagar RC, Sood R, Gracie DJ, Gold MJ, To N, Law GR, Ford AC. Cyclic vomiting syndrome is a prevalent and under-recognized condition in the gastroenterology outpatient clinic. Neurogastroenterol Motil 2018; 30. [PMID: 28745840 DOI: 10.1111/nmo.13174] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 06/30/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND Cyclic vomiting syndrome (CVS) is a functional gastrointestinal disorder (FGID) characterized by intermittent episodes of nausea and vomiting. Our aim was to report its prevalence and associated features. METHODS Data concerning demographics, symptoms, and psychiatric comorbidity were collected. Symptoms compatible with CVS were classified as per Rome III criteria. We recorded whether a diagnosis of CVS was considered in patients after negative investigation. We compared demographics and association with other FGIDs in patients with and without CVS. KEY RESULTS 920 of 1002 patients provided data. Of the 920 patients, 112 (12.2%) had symptoms compatible with CVS. Thirteen (11.6%) of these had an organic cause for their symptoms, but 99 patients (88.4%) were deemed to have CVS (prevalence=10.8%). Organic causes for symptoms compatible with CVS included gastroparesis, large hiatus hernia, achalasia, and small bowel obstruction. Only 39.4% of patients with CVS were asked about vomiting symptoms at their initial consultation, and a diagnosis of CVS was considered in only four (4.0%) of the 99 patients. CVS was associated with younger age, tobacco smoking, never having married, psychiatric comorbidity, and presence of symptoms compatible with other FGIDs (P≤.01). CONCLUSIONS AND INFERENCES Prevalence of CVS in this outpatient gastroenterology adult population was 10.8%. Identified associations included younger age, tobacco smoking, psychiatric comorbidity, and symptoms compatible with other FGIDs. The condition was considered as a possible diagnosis in <5% of patients who met the diagnostic criteria.
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Affiliation(s)
- R C Sagar
- Leeds Gastroenterology Institute, St James's University Hospital, Leeds, UK.,Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK
| | - R Sood
- Leeds Gastroenterology Institute, St James's University Hospital, Leeds, UK.,Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK
| | - D J Gracie
- Leeds Gastroenterology Institute, St James's University Hospital, Leeds, UK.,Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK
| | - M J Gold
- School of Medicine, University of Leeds, Leeds, UK
| | - N To
- Leeds Gastroenterology Institute, St James's University Hospital, Leeds, UK.,Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK
| | - G R Law
- School of Health and Social Care, University of Lincoln, Lincoln, UK
| | - A C Ford
- Leeds Gastroenterology Institute, St James's University Hospital, Leeds, UK.,Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK
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35
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Moayyedi P, Mearin F, Azpiroz F, Andresen V, Barbara G, Corsetti M, Emmanuel A, Hungin APS, Layer P, Stanghellini V, Whorwell P, Zerbib F, Tack J. Irritable bowel syndrome diagnosis and management: A simplified algorithm for clinical practice. United European Gastroenterol J 2017; 5:773-788. [PMID: 29026591 PMCID: PMC5625880 DOI: 10.1177/2050640617731968] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Accepted: 08/16/2017] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Effective management of irritable bowel syndrome (IBS), a common functional gastrointestinal disorder, can be challenging for physicians because of the lack of simple diagnostic tests and the wide variety of treatment approaches available. OBJECTIVE The objective of this article is to outline a simple algorithm for day-to-day clinical practice to help physicians navigate key stages to reaching a positive IBS diagnosis and guidance on how to prioritise the use of specific management strategies. METHODS This algorithm was based on the opinion of an expert panel evaluating current evidence. RESULTS The key principles forming the foundation of this evidence-supported algorithm are: confidently naming and explaining an IBS diagnosis for the patient, followed by assessment of key patient characteristics likely to influence the choice of therapy, such as predominant symptoms, and exploring the patient agenda and preferences. Consultation should always include education and reassurance with an explanatory model of IBS tailored to the patient. Individualised lifestyle changes, dietary modifications, pharmacological therapies, psychological strategies or a combination of interventions may be used to optimise treatment for each patient. CONCLUSION The simple visual tools developed here navigate the key stages to reaching a positive diagnosis of IBS, and provide a stepwise approach to patient-centred management targeted towards the most bothersome symptoms. Establishing a strong patient-physician relationship is central to all stages of the patient journey from diagnosis to effective management.
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Affiliation(s)
- Paul Moayyedi
- Department of Medicine, Division of Gastroenterology, McMaster University, Hamilton, ON, Canada
| | - Fermín Mearin
- Institute of Functional and Motor Digestive Disorders, Centro Médico Teknon, Barcelona, Spain
| | - Fernando Azpiroz
- Digestive System Research Unit, University Hospital Vall d’Hebron, CIBERehd, Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Viola Andresen
- Israelitic Hospital, University of Hamburg, Hamburg, Germany
| | - Giovanni Barbara
- Department of Medical and Surgical Sciences, Centre for Applied Biomedical Research, University of Bologna, Bologna, Italy
| | - Maura Corsetti
- Nottingham Digestive Diseases Biomedical Research Centre, National Institute for Health Research, Nottingham University Hospitals NHS Trust, University of Nottingham, Nottingham, UK
| | - Anton Emmanuel
- National Hospital for Neurology and Neurosurgery, University College London, London, UK
| | - A Pali S Hungin
- School of Medicine and Health, Durham University, Centre for Integrated Health Research, Wolfson Research Institute, Stockton on Tees, UK
| | - Peter Layer
- Israelitic Hospital, University of Hamburg, Hamburg, Germany
| | - Vincenzo Stanghellini
- Department of Medical and Surgical Sciences, Centre for Applied Biomedical Research, University of Bologna, Bologna, Italy
| | - Peter Whorwell
- Centre for Gastrointestinal Sciences, University of Manchester, Manchester, UK
| | - Frank Zerbib
- Department of Gastroenterology, Bordeaux University Hospital and Université de Bordeaux, Bordeaux, France
| | - Jan Tack
- Translational Research Center for Gastrointestinal Disorders (TARGID), University of Leuven, Leuven, Belgium
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36
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Corsetti M, Whorwell P. The global impact of IBS: time to think about IBS-specific models of care? Therap Adv Gastroenterol 2017; 10:727-736. [PMID: 28932273 PMCID: PMC5598808 DOI: 10.1177/1756283x17718677] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2017] [Accepted: 06/12/2017] [Indexed: 02/04/2023] Open
Abstract
Irritable bowel syndrome (IBS) is a prevalent functional gastrointestinal (GI) disorder that can significantly erode the quality of life (QoL) of sufferers and places a major cost burden on healthcare services. This paper reviews the literature on the impact of IBS on healthcare services and society, including a recent report on the subject, in order to formulate a plan for the future. A completely different model of care for these patients is recommended based on this review and the experience of the two authors who have been treating patients with functional GI disorders for 20 and 35 years, respectively.
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Affiliation(s)
- Maura Corsetti
- Nottingham Digestive Diseases Biomedical Research Centre, National Institute for Health Research, Nottingham University Hospitals NHS Trust, University of Nottingham, UK
| | - Peter Whorwell
- Centre for Gastrointestinal Sciences, University of Manchester, Manchester, UK
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37
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Sood R, Gracie DJ, Gold MJ, To N, Pinto-Sanchez MI, Bercik P, Moayyedi P, Ford AC, Law GR. Editorial: latent class analysis to improve confidence in the diagnosis of IBS - authors' reply. Aliment Pharmacol Ther 2017; 45:1268-1269. [PMID: 28370047 DOI: 10.1111/apt.14012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
Affiliation(s)
- R Sood
- Leeds Gastroenterology Institute, St. James's University Hospital, Leeds, UK.,Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK
| | - D J Gracie
- Leeds Gastroenterology Institute, St. James's University Hospital, Leeds, UK.,Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK
| | - M J Gold
- School of Medicine, University of Leeds, Leeds, UK
| | - N To
- Leeds Gastroenterology Institute, St. James's University Hospital, Leeds, UK.,Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK
| | - M I Pinto-Sanchez
- Gastroenterology Division, Health Sciences Center, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - P Bercik
- Gastroenterology Division, Health Sciences Center, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - P Moayyedi
- Gastroenterology Division, Health Sciences Center, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - A C Ford
- Leeds Gastroenterology Institute, St. James's University Hospital, Leeds, UK.,Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK
| | - G R Law
- Division of Epidemiology & Biostatistics, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
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38
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Sood R, Gracie DJ, Gold MJ, To N, Pinto-Sanchez MI, Bercik P, Moayyedi P, Ford AC, Law GR. Derivation and validation of a diagnostic test for irritable bowel syndrome using latent class analysis. Aliment Pharmacol Ther 2017; 45:824-832. [PMID: 28105700 DOI: 10.1111/apt.13949] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Revised: 12/06/2016] [Accepted: 12/28/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND The accuracy of symptom-based diagnostic criteria for irritable bowel syndrome (IBS) is modest. AIMS To derive and validate a new test that utilises latent class analysis. METHODS Symptom, colonoscopy, and histology data were collected from 1981 patients and 360 patients in two cohorts referred to secondary care for investigation of their gastrointestinal symptoms in Canada and the UK, respectively. Latent class analysis was used to identify naturally occurring clusters in patient-reported symptoms in the Canadian dataset, and the latent class model derived from this was then applied to the UK dataset in order to validate it. Sensitivity, specificity, and positive and negative likelihood ratios (LRs) were calculated for the latent class models. RESULTS In the Canadian cohort, the model had a sensitivity of 44.7% (95% CI 40.0-50.0) and a specificity of 85.3% (95% CI 83.4-87.0). Positive and negative LRs were 3.03 (95% CI 2.57-3.56) and 0.65 (95% CI 0.59-0.71) respectively. A maximum positive LR of 3.93 was achieved following construction of a receiver operating characteristic curve. The performance in the UK cohort was similar, with a sensitivity and specificity of 52.5% (95% CI 42.2-62.7) and 84.3% (95% CI 79.3-88.6), respectively. Positive and negative LRs were 3.35 (95% CI 2.38-4.70) and 0.56 (95% CI 0.45-0.68), respectively, with a maximum positive LR of 4.15. CONCLUSIONS A diagnostic test for IBS, utilising patient-reported symptoms incorporated into a latent class model, performs as accurately as symptom-based criteria. It has potential for improvement via addition of clinical markers, such as coeliac serology and faecal calprotectin.
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Affiliation(s)
- R Sood
- Leeds Gastroenterology Institute, St. James's University Hospital, Leeds, UK.,Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK
| | - D J Gracie
- Leeds Gastroenterology Institute, St. James's University Hospital, Leeds, UK.,Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK
| | - M J Gold
- School of Medicine, University of Leeds, Leeds, UK
| | - N To
- Leeds Gastroenterology Institute, St. James's University Hospital, Leeds, UK.,Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK
| | - M I Pinto-Sanchez
- Farncombe Family Digestive Health Research Institute, Gastroenterology Division, McMaster University, Health Sciences Center, Hamilton, ON, Canada
| | - P Bercik
- Farncombe Family Digestive Health Research Institute, Gastroenterology Division, McMaster University, Health Sciences Center, Hamilton, ON, Canada
| | - P Moayyedi
- Farncombe Family Digestive Health Research Institute, Gastroenterology Division, McMaster University, Health Sciences Center, Hamilton, ON, Canada
| | - A C Ford
- Leeds Gastroenterology Institute, St. James's University Hospital, Leeds, UK.,Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK
| | - G R Law
- Division of Epidemiology & Biostatistics, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
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39
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Sood R, Ford AC. Editorial: volatile organic compounds in irritable bowel syndrome - technology for an accurate and reliable point-of-care test? Aliment Pharmacol Ther 2017; 45:563-564. [PMID: 28074509 DOI: 10.1111/apt.13896] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- R Sood
- Leeds Gastroenterology Institute, St. James's University Hospital, Leeds, UK.,Leeds institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK
| | - A C Ford
- Leeds Gastroenterology Institute, St. James's University Hospital, Leeds, UK.,Leeds institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK
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