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This is from the new medscape article eric posted http://www.medscape.com/viewarticle/430643_1 Evaluation and Diagnosis of IBSAs one of a group of functional bowel disorders in which there is an absence of a structural or biochemical abnormality, the diagnosis of IBS is based on symptoms consistent with the disorder and the exclusion of organic disease. The differential diagnosis for patients with recurrent abdominal discomfort and bowel dysfunction is quite extensive, and the goal of the evaluation should be to rule out the pertinent organic causes prior to making the diagnosis of IBS. Malabsorptive conditions include a postgastrectomy state, intestinal diseases (celiac sprue), and pancreatic insufficiency. Dietary factors, such as the consumption of lactose, caffeine, alcohol, and fat-containing or gas-producing foods (eg, cruciferous vegetables), must be considered. Colitides, such as ulcerative colitis, Crohn's disease, and collagenous and lymphocytic colitis (which can be diagnosed only with colon biopsy), should be excluded. Gynecologic conditions, including endometriosis and dysmenorrhea, and infectious causes such as Campylobacter jejuni and Giardia lamblia also should be excluded [26].The first step in evaluating patients with a possible diagnosis of IBS is a careful assessment of the patient's symptoms. The Rome II criteria should be used if IBS is suspected. A complete dietary and drug-intake history should look for agents known to induce gut irritability, and a thorough physical examination should be performed. For patients with typical IBS symptoms a very directed diagnostic workup is indicated and should be based on the age of the patient. Patients aged <50 years should undergo the following laboratory tests: complete blood cell count; electrolytes; erythrocyte sedimentation rate; thyroid function tests; and stool studies, including fecal leukocytes, occult blood, ova, and parasites. A flexible sigmoidoscopy with biopsy can be considered to rule out colitis if diarrhea is present. Patients aged >50 years should undergo the same diagnostic workup with a colonic evaluation to rule out colon cancer and other colonic lesions. If patients reside in an area where Giardia lamblia is endemic, a stool culture for Giardia antigen should be taken from patients with diarrhea [26].Because IBS is a diagnosis of exclusion, it is important to look for atypical presentations of IBS during a thorough history, physical examination, and diagnostic workup. These atypical presentations include nocturnal symptoms of pain and abnormal bowel function, new onset of symptoms in patients aged >50 years, anemia, persistent diarrhea, fever, rectal bleeding, severe constipation, and weight loss. In addition, patients with a family history of GI malignancy, inflammatory bowel disease, or celiac disease may need additional diagnostic studies, such as colonoscopy, upper endoscopy, and barium studies.
 
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