Physicians' attitudes and practices in the evaluation and treatment of irritable bowel syndrome

Sex Differences in Visceral Pain and Comorbidities: Clinical Outcomes, Preclinical Models, and Cellular and Molecular Mechanisms

Sexual dimorphism of visceral pain has been documented in clinics and experimental animal models. Aside from hormones, emerging evidence suggests the sex-differential intrinsic neural regulation of pain generation and maintenance. According to the International Association for the Study of Pain (IASP) and the American College of Gastroenterology (ACG), up to 25% of the population have visceral pain at any one time, and in the United States 10-15 percent of adults suffer from irritable bowel syndrome (IBS). Here we examine the preclinical and clinical evidence of sex differences in visceral pain focusing on IBS, other forms of bowel dysfunction and IBS-associated comorbidities. We summarize preclinical animal models that provide a means to investigate the underlying molecular mechanisms in the sexual dimorphism of visceral pain. Neurons and nonneuronal cells (glia and immune cells) in the peripheral and central nervous systems, and the communication of gut microbiota and neural systems all contribute to sex-dependent nociception and nociplasticity in visceral painful signal processing. Emotion is another factor in pain perception and appears to have sexual dimorphism.

Treatment of functional bowel disorders in an integrative medicine clinic resulting in improved digestive tract symptoms

Background and Aim

Functional bowel disorders (FBDs), including irritable bowel syndrome (IBS) and others, are conditions without a physically identifiable etiology that, as a result, are difficult to treat. Alternatives to traditional medical interventions are needed because IBS patients require more of physician time and higher healthcare spending. The goal of this study was to determine the efficacy of alternative lifestyle interventions for patients with FBDs seen in an integrative medicine (IM) clinic at an academic medical center.

Methods

We performed a retrospective chart review to determine whether patients with FBDs had improvement in symptoms following predominantly nutrition-based IM interventions that included recommendations for dietary supplements and elimination diets. We measured symptoms before and after intervention (average time between measurements 8.75 months) using a medical symptoms questionnaire (MSQ) commonly used to quantify symptom change in IM clinics.

Results

Digestive tract symptoms, as measured by the MSQ, improved significantly in patients (n = 57) with FBDs following IM intervention. The MSQ Digestive Tract subtotal for FBD patients decreased from 10.2 (SD, 5.4) to 7.2 (SD, 5.2) (P < 0.001) after IM intervention.

Conclusions

Patients in an IM clinic had improved digestive tract symptoms scores following IM intervention. Because nutrition-based interventions were the primary intervention recommended by IM providers, primary care physicians and gastroenterologists may wish to consider referring FBD patients to registered dietitian-nutritionists (RDNs) skilled in implementing elimination diets.

Shared decision-making improving efficacy in diarrhoea-dominant irritable bowel syndrome in Chinese outpatient setting: protocol of a prospective, randomised controlled trial

INTRODUCTION

Diarrhoea-dominant irritable bowel syndrome (IBS-D) is a disorder with multiple pathogenesis; many people with IBS-D may have psychosocial issues which can make assessment and treatment more difficult. Routine treatment procedure might not always achieve the desired outcome. Therefore, patients may not be satisfied with the conventional experience and would like to be more involved in clinical decision-making. A shared decision-making (SDM) model, that requires patient participation, has been demonstrated to have a powerful effect on the diagnosis and treatment of other diseases, which improves patients' compliance, satisfaction, thus refining the clinical outcome. However, there is no corresponding evidence in IBS-D. Herein, we hope to verify the effect of SDM through clinical studies, and we anticipate that SDM can improve the therapeutic effect in patients with IBS-D.

METHODS

The study is a prospective, randomised, single-centre trial. 166 IBS-D outpatients who attend Peking Union Medical College Hospital will be allocated into routine treatment group and SDM group. The primary endpoint is the severity of bowel symptoms, measured by the IBS symptom severity scale. Secondary endpoints include impact of disease and quality of life, negative psychology and the evaluation of diagnosis and treatment process.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the research ethics committee of Peking Union Medical College Hospital (I-23PJ470). This protocol has been approved by Chinese Clinical Trial Register (ChiCTR2300073681) in July 2023. The results of this trial will be published in an open-access way and disseminated among gastrointestinal physicians.

TRIAL REGISTRATION NUMBER

Chinese Clinical Trial Register (ChiCTR2300073681).

Persistent somatic symptom related stigmatisation by healthcare professionals: A systematic review of questionnaire measurement instruments

OBJECTIVE

Patients with persistent somatic symptoms (PSS) experience stigmatising attitudes and behaviours by healthcare professionals. While previous research has focussed on individual manifestations of PSS related stigma, less is known about sound ways to measure stigmatisation by healthcare professionals towards patients with PSS. This review aims to assess the quality of questionnaire measurement instruments and make recommendations about their use.

METHODS

A systematic review using six databases (PubMed, Embase, CINAHL, PsycINFO, Open Grey and EThOS). The search strategy combined three search strings related to healthcare professionals, PSS and stigma. Additional publications were identified by searching bibliographies. Three authors independently extracted the data. Data analysis and synthesis followed COSMIN methodology for reviews of outcome measurement instruments.

RESULTS

We identified 90 publications that met the inclusion criteria using 62 questionnaire measurement instruments. Stereotypes were explored in 92% of instruments, prejudices in 52% of instruments, and discrimination in 19% of instruments. The development process of the instruments was not rated higher than doubtful. Construct validity, structural validity, internal consistency and reliability were the most commonly investigated measurement properties. Evidence around content validity was inconsistent or indeterminate.

CONCLUSION

No instrument provided acceptable evidence on all measurement properties. Many instruments were developed for use within a single publication, with little evidence of their development or establishment of content validity. This is problematic because stigma instruments should reflect the challenges that healthcare professionals face when working with patients with PSS. They should also reflect the experiences that patients with PSS have widely reported during clinical encounters.

Translational Gap between Guidelines and Clinical Medicine: The Viewpoint of Italian General Practitioners in the Management of IBS

Irritable bowel syndrome (IBS) guidelines are generally developed by experts, with the possibility of a translational gap in clinical medicine. The aim of our study was to assess an Italian group of general practitioners (GPs) for their awareness and use of criteria for the diagnosis and management of IBS. For this purpose, a survey was carried out involving 235 GPs, divided into two groups according to their years of activity: 65 “junior general practitioners” (JGPs) (≤10 years) and 170 “senior general practitioners” (SGPs) (>10 years). JGPs were more familiar with the Rome IV Criteria and Bristol Scale than SGPs. Abdominal pain, bowel movement frequency and bloating were the symptoms most frequently used to make a diagnosis. The most probable causes of IBS were reported to be abnormal gastrointestinal motility and psychological triggers. SGPs reported more frequently than JGPs that challenging management and patient’s request were motivations for a gastroenterological consultation. The practice of clinical medicine is still far from the guidelines provided by the specialists. Abdominal pain related to defecation and changes in bowel frequency are considered to be the more important symptoms for IBS diagnosis, but most GPs, both JGPs and SGPs, like to consider abdominal bloating as another useful symptom. Involving both gastroenterologists and GPs in developing shared guidelines would be highly desirable in order to improve IBS management strategies in everyday clinical practice.

Central Sensitization Symptom Severity and Patient-Provider Relationships in a Community Setting

Introduction

Central sensitization syndromes (CSS) comprise an overlapping group of clinical conditions with the core feature of “pain arising as a direct consequence of a lesion or disease affecting the somatosensory system.” Patients with CSS are known to have challenging interactions with healthcare providers contributing to psychological distress and increased healthcare utilization. CSS symptom severity has been associated with psychologic comorbidities, but little is known about how symptom severity relates to provider interactions.

Methods

We performed a cross-sectional survey among patients with CSS in our primary care practices to examine the relationship between CSS symptom severity and experiences with doctors.

Results

A total of 775 respondents completed the survey (775/5000; 15.5%) with 72% reporting high CSS symptom severity. About 44% of respondents had a prior diagnosis of fibromyalgia, 72% had migraines, and 28% had IBS. Patients with high CSS symptom severity were more likely to report that doctor(s) had often/always told them that they don’t need treatment when they feel like they do (OR = 3.6, 95% CI 1.9-7.5), that doctor(s) often/always don’t understand them (OR = 3.1, 95% CI 1.9-5.4), and that doctor(s) often/always seem annoyed with them when compared with respondents with low-moderate CSS symptom severity (OR = 4.8, 95% CI 2.2-12.5). Patients with high CSS symptom severity were at greater than 5 times odds of reporting being told that their symptoms were “all in their head” when compared to patients with low-moderate symptom severity (OR = 5.4, 95% CI 3.3-9.0).

Conclusion

Patients with CSS spectrum disorders experience frequent pain and decreased quality of life. A high degree of CSS symptom severity is associated with negative experiences with healthcare providers, which deters the establishment of a positive provider-patient relationship. Further research is needed to help understand symptom severity in CSS and harness the power of the therapeutic alliance as a treatment modality.

Knowledge and practices of primary care physicians or general practitioners treating post-infectious Irritable Bowel Syndrome

Background

Post-infectious Irritable Bowel Syndrome (PI-IBS) is a functional bowel disorder which has significant impacts to a patient’s quality of life. No IBS-specific biomarker or treatment regimen for PI-IBS currently exists, therefore understanding practice patterns and variance is of interest.

Methods

This online survey of primary care physicians and general practitioners in the USA aimed to understand the knowledge and treatment of PI-IBS within the physician’s current practice. Summary statistics are provided with a commentary on implications for practices and treatment of PI-IBS.

Results

Most physician survey respondents (n = 50) were aware of PI-IBS, but less than half discussed this condition as a possible outcome in their patients with a recent gastrointestinal infection. Most physicians indicated that they would treat the patients themselves with a focus on managing IBS through different treatment modalities based on severity. Treatment for PI-IBS followed IBS recommendations, but most physicians also prescribed a probiotic for therapy. Physicians estimated that 4 out of 10 patients who develop PI-IBS will have life-long symptoms and described significant impacts to their patient’s quality of life. Additionally, physicians estimated a significant financial burden for PI-IBS patients, ranging from $100–1000 (USD) over the course of their illness. Most physicians agreed that they would use a risk score to predict the probability of their patients developing PI-IBS, if available.

Conclusions

While this survey is limited due to sample size, physician knowledge and treatment of PI-IBS was consistent across respondents. Overall, the physicians identified significant impacts to patient’s quality of life due to PI-IBS.

Understanding symptom burden and attitudes to irritable bowel syndrome with diarrhoea: Results from patient and healthcare professional surveys

BACKGROUND

Irritable bowel syndrome with diarrhoea (IBS-D) comprises multiple troublesome symptoms and negatively impacts patients' quality of life.

OBJECTIVE

The objective of this article is to assess IBS-D patient burden and patient and healthcare professional (HCP) attitudes towards IBS.

METHODS

Patients and HCPs from Australia, Canada, France, Germany, Italy, Spain and the United Kingdom completed internet-based surveys via market research panels. Attitudes to IBS-D-related statements were scored using seven-point Likert scales.

RESULTS

The patient survey included 513 patients (70% female, mean age 40.9 years). Faecal urgency was reported as the most troublesome symptom (27%) and fatigue occurred on the most days per month (mean: 18); 61% of patients used ≥3 types of treatment daily or intermittently; 19% used antidepressants daily. Thirty-three per cent thought HCPs should listen and provide more support and 46% reported willingness to 'try anything' to help manage their IBS-D. The HCP survey included 366 primary care physicians and 313 gastroenterologists: A total of 70% and 65%, respectively, agreed it was important that IBS-D patients feel listened to and supported; 73% agreed their main aim was to improve quality of life; ∼30% expressed frustration at managing IBS-D.

CONCLUSION

IBS-D imposes a substantial burden on patients and HCPs. These findings point towards a need for improved patient-HCP communication.

Layperson's knowledge and perceptions of irritable bowel syndrome as potential barriers to care

AIMS

The aim of this study was to describe the layperson's knowledge and perceptions regarding the aetiology, pathogenesis, prevalence, medical evaluation, diagnosis and treatment of irritable bowel syndrome.

BACKGROUND

Diagnosis acceptance and adherence to treatment is influenced by the views of the patient's social networks. Little is known how these networks influence those with irritable bowel syndrome.

DESIGN

Cross-sectional study of two-hundred four laypersons, ages 18-80 years without an irritable bowel syndrome diagnosis.

METHODS

Data were collected May 2016-March 2017. Laypersons without a diagnosis of IBS self-reported their knowledge and perceptions about IBS.

RESULTS/FINDINGS

Participants were able to identify many symptoms associated with irritable bowel syndrome however held misconceptions regarding the development of irritable bowel syndrome as noted by the endorsement of genetics, environment and diet or alcohol/smoking behaviours as specific causes. Further misconceptions held included the belief that irritable bowel syndrome was associated with an increased risk for the development of colon cancer and inflammatory bowel disease. Contrary to current guidelines, many thought a gastroenterologist was the only person appropriate to diagnose irritable bowel syndrome and objective testing, such as colonoscopy, was necessary to establish a diagnosis.

CONCLUSION

Laypersons have an understanding of the symptoms associated with IBS; however, hold numerous misconceptions regarding the aetiology, role of the healthcare provider, necessary testing and risks associated with irritable bowel syndrome. These misconceptions are inconsistent with current guidelines and practices. Establishing partnerships and educating social networks in addition to patients may enhance outcomes for those with IBS.

Irritable Bowel Syndrome: Patient-Provider Interaction and Patient Education

The Patient-Provider (P-P) relationship is the foundation of medical practice. The quality of this relationship is essential, particularly for the management of chronic illness such as Irritable Bowel Syndrome (IBS), since it correlates with disease improvement. A significant aspect of fostering the P-P relationship is providing effective patient-centered education about IBS. An effective education empowers the patients to achieve the main therapeutic goals: to reduce symptoms and improve quality of life. Method: A literature search of PubMed was conducted using the terms “Irritable Bowel syndrome”, “Patient Physician Relationship”, “Patient Provider Relationship”, and “Patient Physician interaction”. Preference was given to articles with a clearly defined methodology and those with control groups if applicable/appropriate. This article provides a review of the literature on Patient-Provider interaction and patient education as it relates to IBS and provides practical recommendations on how to optimize this important relationship.

Gastroparesis: Quality of Life and Health Care Utilization

BACKGROUND AND AIMS

Gastroparesis (GP) patients suffer from recurrent symptoms of nausea, vomiting, early satiety, and abdominal pain. The impact of GP on quality of life (QoL), health care utilization and daily activities is not well understood.

MATERIALS AND METHODS

Part 1: 398 adult patients (≥18 y) with documented GP (symptoms >6 mo) were surveyed to assess QoL and pain using the Short Form 36 and McGill pain questionnaires. Part 2: 491 adult GP patients were surveyed to evaluate employment status, work and daily activities, medication use, physician visits, diagnostic testing, emergency room visits, and hospitalizations related to their GP symptoms. Both protocols received Institutional Review Board approval.

RESULTS

Part 1: 250 fully evaluable surveys were returned (63%). The mean age was 46.8 years (range, 18 to 84 y); 78% were women. Mean Short Form 36 scores for mental health (56.9) and social functioning (68.1) were analogous to scores for patients with serious chronic medical disorders and depression. Pain scores were lower in patients with idiopathic GP compared with diabetic GP. Part 2: 228 evaluable surveys were analyzed (58.3% response rate). The mean age was 49.6 (19 to 86 y); 77.2% were women. GP symptoms reduced daily activities in 67.5% and lowered annual income in 28.5%. In total, 11% were disabled due to GP symptoms.

CONCLUSIONS

GP reduces patients' QoL and places a significant financial burden on the health care system. Treatment strategies for GP patients should be broad based and incorporate pain management, psychological evaluation and management, and strategies to improve overall well-being with a return to work and daily activities.

Exploring clinicians' attitudes about using aspirin for risk reduction in people with Lynch Syndrome with no personal diagnosis of colorectal cancer

Recent research has shown that aspirin reduces the risk of cancers associated with Lynch Syndrome. However, uncertainty exists around the optimal dosage, treatment duration and whether the benefits of aspirin as a risk-reducing medication (RRM) outweigh adverse medication related side-effects. Little is known about clinicians' attitudes, current practice, and perceived barriers to recommending aspirin as a RRM. To explore the attitudes of clinicians who discuss risk management options with patients with Lynch Syndrome towards using aspirin as a RRM. Clinicians were invited through professional organisations to complete an online survey. Topics included their clinical experience with Lynch Syndrome, views and practice of recommending aspirin as a RRM, and knowledge about clinical risk management guidelines for Lynch Syndrome. Comparison of attitudes was made between three professional groups. 181 respondents were included in the analysis: 59 genetics professionals (genetic counsellors and clinical geneticists, medical oncologists with specialist training in familial cancer), 49 gastroenterologists and 73 colorectal surgeons. Most clinicians (76 %) considered aspirin to be an effective RRM and most (72 %) were confident about discussing it. In all professional categories, those who were confident about discussing aspirin with patients perceived it to be an effective RRM (OR = 2.8 [95 % CI = 1.8-4.2], p < 0.001). Eighty percent (47/59) of genetics professionals reported having discussed the use of aspirin with Lynch Syndrome patients compared to 69 % of gastroenterologists and 68 % of colorectal surgeons. Those who considered aspirin as an effective RRM or who felt confident in their knowledge of the aspirin literature were more likely (OR = 10 [95 % CI = 1.5-65], p = 0.010, OR = 6 [95 % CI = 2.2-16], p < 0.001, respectively) to discuss it with their patients than other professionals in the study. Similarly health professionals who felt confident in their knowledge of literature of aspirin/confident in discussing with the patients were more likely (OR = 6 [95 % CI = 2.2-16], p < 0.001) to discuss with their patients. Health professionals who saw more than ten patients with Lynch Syndrome per year were more likely to be confident in their knowledge of the aspirin literature and discussing it with patients (OR = 4.1 [95 % CI = 1.6-10.2], p = 0.003). Explicit recommendations to take aspirin, was reported by 65/83 (78 %) of health professionals. Eighty-seven percent of health professionals reported a need for patient educational materials about aspirin. Continuing training is needed to increase clinicians' confidence in their knowledge of the literature on the use of aspirin as a RRM. Patient education materials may be helpful in improving consistency in patient care and facilitate communication between clinicians and people living with Lynch Syndrome.

Economic burden of irritable bowel syndrome in China

AIM

To estimate annual direct and indirect costs for patients diagnosed with irritable bowel syndrome (IBS) and subtypes.

METHODS

Patients completed a standardized questionnaire concerning usage of healthcare resources, travel costs, meals, and productivity loss of patients when seeking treatment for IBS. Total annual costs per patient were calculated as the sum of direct (including medical and nonmedical) and indirect costs. Total annual costs per patient among various IBS subtypes were compared. Analysis of variance and bootstrapped independent sample t-tests were performed to determine differences between groups after controlling for IBS subtypes.

RESULTS

A total of 105 IBS patients (64.80% female), mean age of 57.12 years ± 10.31 years), mean disease duration of 4.31 years ± 5.40 years, were included. Total annual costs per patient were estimated as CNY18262.84 (USD2933.08). Inpatient and outpatient healthcare use were major cost drivers, accounting for 46.41%and 23.36% of total annual costs, respectively. Productivity loss accounted for 25.32% of total annual costs. The proportions of direct and indirect costs were similar to published studies in other countries. Nationally, the total costs of managing IBS would amount to CNY123.83 billion (USD1.99 billion). Among the IBS subtypes, total annual costs per patient of IBS-M was highest at CNY18891.18 (USD3034). Furthermore, there was significant difference in productivity loss among IBS subtypes (P = 0.031).

CONCLUSION

IBS imposes a huge economic burden on patients and healthcare systems, which could account for 3.3% of the total healthcare budget for the entire Chinese nation. More than two-thirds of total annual costs of IBS consist of inpatient and outpatient healthcare use. Among the subtypes, IBS-M patients appear to have the greatest economic burden but require further confirmation.

A systematic review with meta-analysis of the role of anxiety and depression in irritable bowel syndrome onset

BACKGROUND

It is well established that people with irritable bowel syndrome (IBS) have higher levels of anxiety and depression compared with controls. However, the role of these as risk factors is less clearly established. The aims of this systematic review were to investigate: (1) whether anxiety and/or depression predict IBS onset; (2) the size of the relative risk (RR) of anxiety versus depression in IBS onset. Subgroup analyses explored if methodological factors affected the overall findings.

METHOD

Prospective cohort or case-control studies were included if they: (1) focused on the development of IBS in population-based or gastroenteritis cohorts; (2) explored the effects of anxiety and/or depression at baseline as predictors of IBS onset at a future point. In all, 11 studies were included of which eight recruited participants with a gastrointestinal infection. Meta-analyses were conducted.

RESULTS

The risk of developing IBS was double for anxiety cases at baseline compared with those who were not [RR 2.38, 95% confidence interval (CI) 1.58-3.60]. Similar results were found for depression (RR 2.06, 95% CI 1.44-2.96). Anxiety and depression seemed to play a stronger role in IBS onset in individuals with a gastrointestinal infection although this could be attributed to other differences in methodology, such as use of diagnostic interviews rather than self-report.

CONCLUSIONS

The findings suggest that self-reported anxiety and depression provide a twofold risk for IBS onset. There is less support for the role of anxiety or depressive disorder diagnosed using clinical interview. These findings may have implications for the development of interventions focused on IBS prevention and treatment.

Age, Gender and Women's Health and the Patient

Patients with functional gastrointestinal disorders (FGIDs) often experience distress, reduced quality of life, a perceived lack of validation, and an unsatisfactory experience with health care providers. A health care provider can provide the patient with a framework in which to understand and legitimize their symptoms, remove self-doubt or blame, and identify factors that contribute to symptoms that the patient can influence or control. This framework is implemented with the consideration of important factors that impact FGIDs, such as gender, age, society, and the patient's perspective. Although the majority of FGIDs, including globus, rumination syndrome, IBS, bloating, constipation, functional abdominal pain, sphincter of Oddi dyskinesia, pelvic floor dysfunction, and extra-intestinal manifestations, are more prevalent in women than men, functional chest pain, dyspepsia, vomiting, and anorectal pain do not appear to vary by gender. Studies suggest sex differences in somatic but not visceral pain perception, motility, and central processing of visceral pain; although further research is required in autonomic nervous system dysfunction, genetics and immunologic/microbiome. Gender differences in response to psychological treatments, antidepressants, fiber, probiotics, and anticholinergics have not been adequately studied. However, a greater clinical response to 5-HT3 antagonists but not 5-HT4 agonists has been reported in women compared with men.

Calculating Total Health Service Utilisation and Costs from Routinely Collected Electronic Health Records Using the Example of Patients with Irritable Bowel Syndrome Before and After Their First Gastroenterology Appointment

INTRODUCTION

Health economic models are increasingly important in funding decisions but most are based on data, which may therefore not represent the general population. We sought to establish the potential of real-world data available within the Clinical Practice Research Datalink (CPRD) and linked Hospital Episode Statistics (HES) to determine comprehensive healthcare utilisation and costs as input variables for economic modelling.

METHODS

A cohort of patients with irritable bowel syndrome (IBS) who first saw a gastroenterologist in 2008 or 2009, and with 3 years of data before and after their appointment, was created in the CPRD. Primary care, outpatient, inpatient, prescription and colonoscopy data were extracted from the linked CPRD and HES. The appropriate cost to the NHS was attached to each event. Total and stratified annual healthcare utilisation rates and costs were calculated before and after the gastroenterology appointment with distribution parameters. Absolute differences were calculated with 95% confidence intervals.

RESULTS

Total annual healthcare costs over 3 years increase by £935 (95% CI £928-941) following a gastroenterology appointment for IBS. We derived utilisation and cost data with parameter distributions stratified by demographics and time. Women, older patients, smokers and patients with greater comorbidity utilised more healthcare resources, which generated higher costs.

CONCLUSIONS

These linked datasets provide comprehensive primary and secondary care data for large numbers of patients, which allows stratification of outcomes. It is possible to derive input parameters appropriate for economic models and their distributions directly from the population of interest.

The Science, Evidence, and Practice of Dietary Interventions in Irritable Bowel Syndrome

Irritable bowel syndrome (IBS) is a highly prevalent disorder that is characterized by symptoms of abdominal pain, bloating, constipation, and/or diarrhea. The diagnosis can be made using Rome III criteria or published guidelines after taking a thoughtful history, excluding warning signs, and performing a careful physical examination. Limited testing (ie, complete blood count and C-reactive protein level) may be useful in appropriate patients. A number of pharmacologic options are available, although many patients fail to respond to pharmacologic therapy. Although several IBS diets frequently are recommended, data supporting their use are limited. This article provides a rationale as to why specific diets might improve IBS symptoms and evaluates published trials.

The importance of a person-centered approach in diagnostic workups of patients with irritable bowel syndrome: a qualitative study

The aim of this study was to explore experiences of undergoing a diagnostic workup in patients with irritable bowel syndrome (IBS) at a unit for functional gastrointestinal disorders. Research has been sparse in addressing such experiences and the impact on well-being. Patients with IBS were invited to perform a workup of gastrointestinal tests. Of 120 patients who completed the tests, 20 were invited for an interview. Analysis of interviews was conducted through interpretative phenomenological analysis. One master theme emerged: validation of IBS experience inferred from three subthemes: the duality of suffering in IBS, coping with inflicted discomfort and pain, and capacity for resilience.Patients reported long-term suffering from symptoms including poor management within the healthcare organization. Despite inconvenience associated with the tests, patients expressed appreciation for professional attributes such as attentiveness that were perceived as a sense of being cared for and seen as a "person." During the workup, patients acquired greater knowledge of what IBS means, including knowledge about their own body functions and experienced relief that symptoms were not caused by any "dangerous" disease. Validation of IBS experience surfaced in the data implying that in such context, patients with IBS appear to find personal solutions to cope with everyday experiences and enhance autonomy.

Systematic review: the perceptions, diagnosis and management of irritable bowel syndrome in primary care--a Rome Foundation working team report

OBJECTIVE

To review studies on the perceptions, diagnosis and management of irritable bowel syndrome (IBS) in primary care.

METHODS

Systematic searches of PubMed and Embase.

RESULTS

Of 746 initial search hits, 29 studies were included. Relatively few primary care physicians were aware of (2-36%; nine studies) or used (0-21%; six studies) formal diagnostic criteria for IBS. Nevertheless, most could recognise the key IBS symptoms of abdominal pain, bloating and disturbed defaecation. A minority of primary care physicians [7-32%; one study (six European countries)] preferred to refer patients to a specialist before making an IBS diagnosis, and few patients [4-23%; three studies (two European, one US)] were referred to a gastroenterologist by their primary care physician. Most PCPs were unsure about IBS causes and treatment effectiveness, leading to varied therapeutic approaches and broad but frequent use of diagnostic tests. Diagnostic tests, including colon investigations, were more common in older patients (>45 years) than in younger patients [<45 years; five studies (four European, one US)].

CONCLUSIONS

There has been much emphasis about the desirability of an initial positive diagnosis of IBS. While it appears most primary care physicians do make a tentative IBS diagnosis from the start, they still tend to use additional testing to confirm it. Although an early, positive diagnosis has advantages in avoiding unnecessary investigations and costs, until formal diagnostic criteria are conclusively shown to sufficiently exclude organic disease, bowel investigations, such as colonoscopy, will continue to be important to primary care physicians.

A biomarker panel and psychological morbidity differentiates the irritable bowel syndrome from health and provides novel pathophysiological leads

BACKGROUNDS

The development of a reliable biomarker for irritable bowel syndrome (IBS) remains one of the major aims of research in functional gastrointestinal disorders (FGIDs) and is complicated by the absence of a perfect reference standard. Previous efforts based on genetic and immune markers have showed promise, but have not been robust.

AIM

To evaluate an extensive panel of gene expression and serology markers combined with psychological measures in differentiating IBS from health and between subtypes of IBS.

METHODS

Of subjects eligible for analysis (N = 244), 168 met criteria for IBS (60 IBS-C, 57 IBS-D and 51 mixed), while 76 were free of any FGID. A total of 34 markers were selected based on pathways implicated in pathophysiology of IBS or whole human genome screening. Psychological measures were recorded that covered anxiety, depression and somatisation. Models differentiating disease and health were based on unconditional logistic regression and performance assessed through area under the receiver-operator characteristic curve (AUC), sensitivity and specificity.

RESULTS

The performance of a combination of 34 markers was good in differentiating IBS from health (AUC = 0.81) and was improved considerably with the addition of four psychological markers (combined AUC = 0.93). Of the 34 markers considered, discrimination was derived largely from a small subset. Good discrimination was also obtained between IBS subtypes with the best being observed for IBS-C vs. IBS-D (AUC = 0.92); however, psychological variables provided almost no incremental discrimination subtypes over biological markers (combined AUC = 0.94).

CONCLUSIONS

A combination of gene expression and serological markers in combination with psychological measures shows exciting progress towards a diagnostic test for IBS compared with healthy subjects, and to discriminate IBS-C from IBS-D.

IBS patients' willingness to take risks with medications

OBJECTIVES

We explored irritable bowel syndrome (IBS) patients' impulsivity and risk-taking behavior and their willingness to take medication risks.

METHODS

A validated questionnaire assessed the illness experience of IBS patients. A standard gamble evaluated respondents' willingness to take medication risks.

RESULTS

IBS patients with severe symptoms were more willing to take significant medication risks than those with mild or moderate symptoms. Impulsivity scores were not associated with an increased likelihood of taking medication risks. Age, gender, and years of IBS symptoms were not associated with medication risk-taking behavior. IBS patients reported they would accept a median 1% risk of sudden death for a 99% chance of cure for their symptoms using a hypothetical medication.

CONCLUSIONS

IBS patients are willing to take significant medication risks to cure their symptoms. To counsel patients effectively, physicians must determine and understand IBS patients' risk aversion.

Knowledge, attitudes, and practices of primary care physicians about irritable bowel syndrome in Northern Saudi Arabia

BACKGROUND/AIM

Primary health care (PHC) physicians manage most patients with irritable bowel syndrome (IBS). In Saudi Arabia, there are limited data on their knowledge, attitudes, and practices about this disorder. This study aimed to assess knowledge, attitudes, and practices of primary care physicians about IBS.

PATIENTS AND METHODS

A cross-sectional survey of 70 practitioners aged 36 ± 10.25 years was carried out in primary care centers in AlJouf Province of Saudi Arabia. The physicians were asked to fill a valid questionnaire containing their sociodemographic data, and well-modified questions regarding their knowledge, attitudes, and practices about IBS. Data was processed and analyzed using SPSS (version 15) program, and the level of significance was set at P<0.05.

RESULTS

A response rate of 92.9% yielded 65 questionnaires for analysis. Majority of physicians surveyed (83.1%) considered IBS as a common health problem in Saudi Arabia, and (55.4%) believed it is underestimated. There was a significant association between physicians' qualifications and using diagnostic tools to facilitate IBS diagnosis (14.3% vs 35.5%; P<0.05), while utilization of "Rome or Manning criteria" was more frequent by physicians with master's degree (35.5%) compared to residents (14.3%). Also, 35.4% of physicians (15 males and 8 females) were not sure how to diagnose IBS.

CONCLUSIONS

This study suggested that PHC physicians had a suitable attitude toward IBS, but they lacked knowledge, and their practices toward this condition were inappropriate.

Perceptions of gastroenterologists and nurses regarding irritable bowel syndrome and inflammatory bowel disease

OBJECTIVE

Irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD) have similar symptoms, and both adversely affect patients' quality of life. The objective of this study was to compare the perceptions of physicians and nurses regarding IBS and IBD.

METHODS

The Illness Perception Questionnaire Revised, adapted for medical staff, was sent at random to 300 physicians and nurses of gastroenterology departments and outpatient clinics nationwide to assess perceptions of IBS or IBD. Responses were statistically analyzed by illness and professional group.

RESULTS

Fifty-five physicians and 43 nurses returned the questionnaire (response rate, 32.6%). Fifty-two questionnaires pertained to IBS and 46 to IBD. More physicians than nurses stated that the course of both illnesses does not improve over time (P<0.05). Both groups showed that medical treatment is of greater benefit for IBD than IBS (P<0.05) and that patients with IBD better understand their illness than patients with IBS (P<0.05).

CONCLUSION

Physicians and nurses hold different attitudes to and perceptions of IBD and IBS in terms of chronicity, severity of the consequences, treatment efficacy, personal control, and illness coherence. These differences may have important effects on the patient-health provider relationship and should be addressed.

Alosetron for severe diarrhea-predominant irritable bowel syndrome: improving patient outcomes

BACKGROUND

Irritable bowel syndrome (IBS) is a common gastrointestinal disorder often diagnosed and managed by primary care physicians (PCPs). Despite the high prevalence of IBS, symptom severity is often underappreciated and inadequately managed. The goal of this review is to discern IBS treatment gaps and identify opportunities for improving its management in the primary care setting, as well as describe the most current clinical experience with alosetron, a targeted treatment for severe diarrhea-predominant IBS (IBS-D) in women.

SCOPE

PubMed was searched for English language articles using combinations of the following key words: 'irritable bowel syndrome,' 'diarrhea-predominant irritable bowel syndrome,' 'diagnosis,' 'guidelines,' 'general practice,' 'primary care,' 'quality of life,' 'burden,' 'prevalence,' 'patient satisfaction,' 'patient survey,' 'severe,' 'severity,' and 'alosetron.'

FINDINGS

Establishing the diagnosis of IBS in primary care represents a clinical challenge for many healthcare professionals. While many patients seek care for IBS symptoms in the primary care setting, evidence shows that PCPs are often unaware of established diagnostic criteria for IBS. Establishing the severity of IBS is also problematic, given the lack of consensus guidelines defining severe IBS, which in turn complicates treatment decisions. Severe IBS is often inferred after inadequate response to conventional agents; the level of disease impact on quality of life and patient functioning also defines severity. The selective 5-HT(3) antagonist alosetron has been shown to provide improvement across multiple symptom domains, and the incidence of adverse events continues to be low since the implementation of the Prescribing Program for Lotronex. Alosetron is the only agent approved by the US Food and Drug Administration for treatment of severe IBS-D in women.

CONCLUSION

PCPs often are required to evaluate and treat suspected IBS. The diagnosis and management of IBS in the primary care setting could be optimized through the use of published diagnostic criteria, adequate assessment of symptom severity, and a thorough knowledge of the therapeutic agents that have provided evidence of effectiveness. In the subset of women who suffer from IBS-D, targeted serotonergic therapy with alosetron has been shown to provide symptom relief across multiple domains, including improvement of the patient's quality of life.

The role of diagnostic testing in irritable bowel syndrome

This article discusses the diagnostic criteria and processes applicable to irritable bowel syndrome (IBS). The authors describe the various diagnostic criteria with a focus on the Rome criteria for IBS and the judicious application of historical information such as alarm features and the yield of various diagnostic modalities such as blood, stool, breath, and endoscopic tests.

Irritable bowel syndrome: diagnostic approaches in clinical practice

BACKGROUND

Irritable bowel syndrome (IBS), a functional gastrointestinal disorder long considered a diagnosis of exclusion, has chronic symptoms that vary over time and overlap with those of non-IBS disorders. Traditional symptom-based criteria effectively identify IBS patients but are not easily applied in clinical practice, leaving >40% of patients to experience symptoms up to 5 years before diagnosis.

OBJECTIVE

To review the diagnostic evaluation of patients with suspected IBS, strengths and weaknesses of current methodologies, and newer diagnostic tools that can augment current symptom-based criteria.

METHODS

The peer-reviewed literature (PubMed) was searched for primary reports and reviews using the limiters of date (1999-2009) and English language and the search terms irritable bowel syndrome, diagnosis, gastrointestinal disease, symptom-based criteria, outcome, serology, and fecal markers. Abstracts from Digestive Disease Week 2008-2009 and reference lists of identified articles were reviewed.

RESULTS

A disconnect is apparent between practice guidelines and clinical practice. The American Gastroenterological Association and American College of Gastroenterology recommend diagnosing IBS in patients without alarm features of organic disease using symptom-based criteria (eg, Rome). However, physicians report confidence in a symptom-based diagnosis without further testing only up to 42% of the time; many order laboratory tests and perform sigmoidoscopies or colonoscopies despite good evidence showing no utility for this work-up in uncomplicated cases. In the absence of diagnostic criteria easily usable in a busy practice, newer diagnostic methods, such as stool-form examination, fecal inflammatory markers, and serum biomarkers, have been proposed as adjunctive tools to aid in an IBS diagnosis by increasing physicians' confidence and changing the diagnostic paradigm to one of inclusion rather than exclusion.

CONCLUSION

New adjunctive testing for IBS can augment traditional symptom-based criteria, improving the speed and safety with which a patient is diagnosed and avoiding unnecessary, sometimes invasive, testing that adds little to the diagnostic process in suspected IBS.

Importance of early diagnosis in patients with irritable bowel syndrome

Patients with irritable bowel syndrome (IBS) account for >$20 billion in direct and indirect costs annually, a large portion of which relates to making the diagnosis. The diagnosis of IBS is challenging because symptoms can vary between patients and overlap with those of other disorders. This review examines the current diagnostic approach in IBS and discusses new tools that may improve diagnostic confidence earlier in the process. The prevalence of organic disease among patients who meet symptom-based criteria for IBS (eg, Rome III) is generally low; therefore, in the absence of "alarm features," the probability for organic disease is very low. Increased public awareness of IBS symptoms and physician awareness of symptom-based criteria for IBS are needed to facilitate earlier diagnosis. Accumulating evidence suggests that fecal and/or serum biomarkers may be helpful in differentiating IBS from non-IBS disorders. These tools may help minimize unnecessary testing and diagnostic delays. As biomarkers are further studied and developed, they are likely to become an integral part of the diagnosis of IBS and reduce the potential for incorrect diagnosis and treatment delays.

Alosetron for severe diarrhea-predominant irritable bowel syndrome: safety and efficacy in perspective

Irritable bowel syndrome affects 5-10% of North Americans, with an estimated one-third having a diarrhea-predominant form. Alosetron hydrochloride (Lotronex) is a serotonin receptor type 3 antagonist approved in early 2000 for use in women with diarrhea-predominant irritable bowel syndrome (IBS-D). Initial use was widespread, but infrequent serious adverse events of ischemic colitis and severe constipation-related complications prompted alosetron's voluntary withdrawal from the US market in November 2000. Unprecedented public request prompted its reintroduction in 2002 under a Risk Management Plan, including a more restricted indication and a Prescribing Program for Lotronex. Despite these measures, the use of alosetron has been very limited since its reintroduction. Possible deterrents to its use include concerns over safety and the possible medical-legal implications raised by the Risk Management Plan. It is also possible that changes in the natural history and/or diagnosis of IBS-D have reduced the target population. Given the unique regulatory history of alosetron, these issues continue to engender controversy. This article profiles these concerns and reviews the pharmacology, clinical efficacy and safety, and post-marketing experience with alosetron. Myths and misconceptions related to alosetron use, or lack thereof, are addressed to provide the reader with the evidence needed to make informed treatment decisions for their female patients with severe IBS-D.

Mid-level providers in gastroenterology

One response to the challenges of modern day clinical practice has been to employ "mid-level providers" (MLPs), such as physician assistants and nurse practitioners. MLPs may complement physicians by supporting patient self-management and performing routine, protocol-guided management. In turn, MLPs may improve health outcomes and simultaneously lower costs. Within gastroenterology, the prevalence of MLPs remains unknown, though it appears to be significant and increasing. Additionally, professional organizations predict that in the future, MLPs will play a central role in digestive disease care. Although incorporating MLPs into gastroenterology has great potential, numerous challenges exist, and their specific roles must first be defined and evaluated.

New clinical method for distinguishing D-IBS from other gastrointestinal conditions causing diarrhea: the LA/IBS diagnostic strategy

Modern methods of diagnosing diarrhea-predominant irritable bowel syndrome (D-IBS) require a "diagnosis of exclusion" approach. In this study we aim to test the diagnostic ability of using the fluctuation of frequency and consistency of bowel patterns in IBS to discriminate it from other causes of diarrhea. Eligible subjects were asked to complete a questionnaire on the changes in form and frequency of bowel habits by time. The primary endpoint was to evaluate the diagnostic effectiveness of having irregularly irregular bowel function and form as more characteristic of IBS versus non-IBS causes. Patients were prospectively recruited from a tertiary care GI clinic. Subjects had to have diarrhea as their primary complaint. In the case of IBS, D-IBS subjects were recruited. Subjects with celiac disease, Crohn's and ulcerative colitis were recruited for comparison and were categorically called "non-IBS." Non-IBS subjects could not have a recent history of blood in stool or a history of bowel surgery, fistulae or narcotic use. Sixty-two IBS and 37 non-IBS subjects were recruited. Among the 62 IBS subjects, 49 (79%) stated that their bowel habits varied in form and frequency on a daily basis compared to 35% in non-IBS subjects (OR = 8.9, CI = 3.5-22.5, P < 0.00001). When subjects were compared by the number of different stool forms they had witnessed in the prior week, IBS subjects noted 3.58 +/- 0.19 types and non-IBS reported 2.35 +/- 0.16 (P < 0.00001). Using > or = 3 stool forms per week as a method of discriminating IBS from non-IBS, 50 out of 62 subjects with IBS (81%) reported this greater number of forms compared to 15 out of 37 (41%) non-IBS subjects (sensitivity = 0.81; specificity = 0.60). The use of this simple tool that identifies an irregularly irregular bowel form and function is successful in separating D-IBS from non-IBS subjects.

The treatment of irritable bowel syndrome

Irritable bowel syndrome (IBS) is a highly prevalent functional bowel disorder routinely encountered by healthcare providers. Although not life-threatening, this chronic disorder reduces patients' quality of life and imposes a significant economic burden to the healthcare system. IBS is no longer considered a diagnosis of exclusion that can only be made after performing a battery of expensive diagnostic tests. Rather, IBS should be confidently diagnosed in the clinic at the time of the first visit using the Rome III criteria and a careful history and physical examination. Treatment options for IBS have increased in number in the past decade and clinicians should not be limited to using only fiber supplements and smooth muscle relaxants. Although all patients with IBS have symptoms of abdominal pain and disordered defecation, treatment needs to be individualized and should focus on the predominant symptom. This paper will review therapeutic options for the treatment of IBS using a tailored approach based on the predominant symptom. Abdominal pain, bloating, constipation and diarrhea are the four main symptoms that can be addressed using a combination of dietary interventions and medications. Treatment options include probiotics, antibiotics, tricyclic antidepressants, selective serotonin reuptake inhibitors and agents that modulate chloride channels and serotonin. Each class of agent will be reviewed using the latest data from the literature.

"I know this is bad for me, but...": a qualitative investigation of women with irritable bowel syndrome and inflammatory bowel disease: part II

INTRODUCTION

Individuals with inflammatory bowel disease (IBD) and irritable bowel syndrome (IBS) experience similar symptoms; however, individuals with IBD have alterations in their digestive tract and an increased probability of developing colorectal cancer, whereas individuals with IBS do not. Although not well documented within the literature, individuals with gastrointestinal (GI) disorders may engage in adverse behaviors regarding their intake of food, regardless of the fact that the "offending agents" have been identified. Further study into these negative behaviors is warranted for healthcare professionals to be provided with a better understanding of the behaviors that individuals with GI disorders knowingly engage in, despite the negative consequences.

PURPOSE

The overall objective of this research was to explore the lived experience of women diagnosed with the GI disorders IBD and/or IBS, with an emphasis on the dietary patterns of the women before and after diagnosis. Specifically, this article examines the adverse behaviors that women engaged in with respect to the consumption of food, beverages, and medications.

METHODS

Eight women diagnosed with IBD or IBS were recruited from a university campus in southwestern Ontario, Canada. Participants completed a background questionnaire, a 14-day food diary, and a semistructured interview consisting of 8 open-ended questions.

RESULTS

Three major themes were identified: family and friend support, control, and adverse behaviors. The focus of this article, the theme of adverse behaviors, consisted of 2 major subthemes: dietary restrictions and issues with medication. All women engaged in adverse behaviors regarding their food intake and/or consumption of medications as related to food intake.

CONCLUSIONS

Semistructured interviews with women diagnosed with IBD and IBS revealed that all women felt governed by their bowels to varying degrees. In addition, all women within this sample knowingly engaged in behaviors concerning food/beverages that had the potential to be detrimental to their conditions. A myriad of reasons were given for consuming foods/beverages. Implications for nursing practitioners are discussed.

Patient knowledge and perspective on irritable bowel syndrome: development of a survey instrument

PURPOSE

A questionnaire measuring patient knowledge of, and concerns about, irritable bowel syndrome could improve patient care. The aims of this study were to operationalize the constructs used by patients to understand their symptoms and to develop a reliable, validated questionnaire.

RESULTS

A total of 153 patients with irritable bowel syndrome completed the questionnaire. 119/153 (77.8%) completed a second identical questionnaire. Questions with high reliability and validity had responses with similar metrics. Reliability was more easily established in questions where the responses had no option for uncertainty. Test-retest reliability had a mean concordance of 0.8. Alternate form reliability had a mean concordance of 0.97. Inter-item reliability had Cronbach's alpha ranging from 0.57 to 0.86.

CONCLUSION

The survey instrument was found to be reliable, valid and usable. It provides descriptive data on patient knowledge, fears, and concerns surrounding irritable bowel syndrome. This easily administered questionnaire should provide novel information to improve patient care.

Irritable bowel syndrome: patients' attitudes, concerns and level of knowledge

BACKGROUND

Irritable bowel syndrome (IBS) is a common, chronic disorder that reduces patients' quality-of-life. Although highly prevalent, little is known about patients' understanding of this disorder.

AIM

To evaluate the knowledge, fears and concerns of IBS patients.

METHODS

Seven hundred thirty-six IBS patients (Rome II criteria) were eligible for inclusion in this prospective study. Each patient received a validated questionnaire to evaluate knowledge, attitudes and fears regarding IBS.

RESULTS

A total of 261 of 664 potential respondents completed the questionnaire (39.3%). 83% of respondents were women, with a mean age of 53.7 years, and mean duration of symptoms of 14.2 years. Patients frequently believed that IBS develops because of anxiety (80.5%), dietary factors (75.1%) and depression (63.2%). Few respondents (28.7%) recognized that abdominal pain is the cardinal symptom of IBS, and 40.6% stated that colonoscopy can diagnose IBS. One in seven patients stated that IBS turns into cancer, and 29.9% noted that IBS increases the risk of inflammatory bowel disease.

CONCLUSIONS

Many IBS patients have significant misconceptions regarding the nature of their disease and its prognosis. An overwhelming majority of IBS patients believe that anxiety, dietary factors and depression cause IBS. These findings are discordant with physicians' views and practices and highlight the need for patient-oriented educational programs.