FYI:With permission from Dr DrossmanToward a Positive and ComprehensiveDiagnosis of Irritable Bowel SyndromeYehuda Ringel, MD, and Douglas A. Drossman, MD,University of North Carolina, Chapel HillDr. Ringel is an internist and gastroenterologist from Tel AvivMedical Center, Israel, and a visiting scientist at University ofNorth Carolina, and Dr. Drossman is Professor of Medicineand Psychiatry, The University of North Carolina Center forFunctional Gastrointestinal and Motility Disorders, Universityof North Carolina, Chapel Hill. IntroductionBackgroundIrritable bowel syndrome (IBS) is one of the most frequentlydiagnosed disorders in general population and medical settings.It accounts for an estimated 28% of patients seen ingastroenterology practice and up to 12% of patients seen inprimary care practice. IBS affects about 10% to 20% ofadolescents and adults (14% to 24% female, 5% to 19% male)in Western countries. The disorder can substantially impair thepatient's quality of life and increase annual healthcare costs; itposes a considerable socioeconomic burden on the healthcaresystem overall.[1-3] The high prevalence and significantsequelae of IBS have led to increased interest in this disorderamong clinicians, clinical investigators, basic scientists,physiologists, and mental health professionals. Indeed, over the last 2 decades there has been a 10-foldincrease in citations on IBS.[4] The National Institute ofDiabetes and Digestive and Kidney Diseases (NIDDK) andvarious gastroenterologic societies have increased theexposure of IBS through educational and research programs.Most recently, the pharmaceutical industry has beguninternational marketing campaigns related to new entericreceptor agents. Nevertheless, the etiology and pathogenesis ofIBS still are not completely characterized, and no uniquemorphologic, physiologic, or pathologic pattern that can serveas a marker for the disorder has been identified. Suchcircumstances where an illness exists without a defined diseasecreate certain diagnostic dilemmas for the clinician: (1) Is IBSa genuine disorder, with clearly definable determinants? (2)How can the diagnosis be made in the absence of a biologicalmarker? (3) How confident can the clinician be in making thediagnosis? A Change in ThinkingDuring the last 20 years, significant changes have occurred inhow we conceptualize IBS. This has enabled the clinician tobetter address these dilemmas and has led to the acceptance ofIBS as a discrete clinical entity that can be diagnosed andtreated in a positive and empiric manner. Two important processes have led to this change.[4] First, therehas been a movement toward understanding chronic medicaldisorders such as IBS as integrated, multidetermined conditionswith varying clinical features, based on biopsychosocialmodels of illness and disease.[5-7] Second, recent expansionand refinement of investigative methods have enabled us tostudy the various determinants (physiologic, psychological, andsocial) that underlie this disorder, its clinical expression, andoutcome. Some examples include the use of standardpsychological measures/instruments, the electronic barostat,and functional brain imaging by positron-emission tomography(PET) and functional magnetic resonance imaging (fMRI). These processes have allowed us to sort out the mechanisms bywhich physiologic, psychological, behavioral, andenvironmental factors interact simultaneously as well as atmultiple levels to characterize IBS. The relative contributionsof these factors vary between patients or in individual patientsover time and determine the severity of the symptoms and theoverall clinical presentation. This understanding helps toexplain the existence of severe symptoms in the absence of (orlack of correlation with) any significant physical or physiologicfindings or even the presence of major physiologicdisturbances in the absence of symptoms. The development of symptom-based criteria permits a focus onthe patient and his/her illness experience, which is derivedfrom the biopsychosocial determinants. These criteria also helpto standardize diagnostic and treatment approaches andselection of patients for clinical trials. (A more detailedpresentation of the relation of psychosocial factors with thepathogenesis and clinical expression of IBS and thebiopsychosocial model can be found elsewhere.[6,8])This article presents a patient-centered, comprehensiveapproach to the diagnosis of IBS using symptom-baseddiagnostic criteria. It also addresses ways to integratephysiologic and psychosocial factors into the diagnostic plan tohelp the clinician achieve a confident diagnosis in acost-effective manner. cont.. ------------------Moderator of the Cognitive Behavioral Therapy, Anxiety and Hypnotherapy forumI work with Mike and the IBS Audio Program. www.ibshealth.com www.ibsaudioprogram.com
Important Reading Toward a Positive and Comprehensive Diagnosis of IBS
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The Clinical Presentation of IBSThe diagnosis of IBS is determined by certain symptom clustersthat "breed true" as a distinct clinical entity. The evidence forand features of these specific symptoms are discussed below. Presentation of SymptomsThe most frequently reported symptom in IBS is pain ordiscomfort in the abdomen.[9,10] This pain often is poorlylocalized and may be migratory or variable in nature, and isusually relieved with defecation, thus supporting a primarycolonic origin for this symptom. It is also associated with achange in the consistency or frequency of stools and withaltered bowel habits (ie, diarrhea, constipation, or combinationof both at varying times).[3,11,12] Other symptoms -- includingbloating, urgency, or the feeling of incomplete evacuation -- arepresent frequently, again suggesting colonic dysfunction.Although IBS symptoms often occur in clusters[13]; some of thesymptoms may occur sequentially and may vary in kind,location, and severity over time.[9] The frequency of IBSepisodes also varies greatly among patients. While somepatients may have daily episodes or continuous symptoms,others experience long symptom-free periods.[9] These patternsraise the question as to when someone has IBS as opposed tooccasional bowel complaints that may be considered a part ofthe normal response of the bowel to stress.[14] For the most part,the characterization of IBS as a "disorder" is determined bycertain frequency guidelines developed from epidemiologicand clinical studies.[4]A subgroup of patients with IBS also complain about other (ie,noncolonic) gastrointestinal (GI) symptoms, such as heartburn,nausea, and early satiety. Furthermore, significant overlap hasbeen reported between IBS and other functional GI disorders(eg, functional dyspepsia, functional heartburn, proctalgiafugax),[15-18] with, as mentioned earlier, an individual's primarysymptoms shifting over time.[17] Patients with IBS have other(ie, non-GI) symptoms and therefore visit their primary carephysician quite often for both GI and non-GI complaints.[2,19]The non-GI symptoms include fibromyalgia[20-23] and othermusculoskeletal symptoms,[20] headache, genitourinarysymptoms,[24] sexual dysfunction,[25] sleep disturbances,[26,27] andchronic fatigue.[3] These findings are consistent with IBS involving dysfunction ofboth the central and peripheral nervous system (ie, a "brain-gutdisorder"). There may be a peripheral (ie, visceral) basis forsome GI symptoms due to dysfunction of the enteric nervoussystem in the upper as well as the lower gut. In addition, andparticularly for patients with higher levels of psychosocialdistress or psychological comorbidity, there may be centralupregulation of peripheral (both somatic or visceral) signalsbased on central nervous system (CNS) hypervigilance orhypersensitivity. Furthermore, not only can IBS symptoms be varied andmultiple, but they may also coexist with or be initiated by otherorganic disorders (ie, ulcerative colitis or Crohn's disease).[28]Sometimes, therefore, it is difficult to determine whether thepatient's symptoms are due to an organic (eg, inflammatorybowel disease [IBD]) or functional (eg, IBS) condition. From abiopsychosocial perspective, deciding whether a symptom is"functional" or "organic" is not as important as determiningwhich factors need further attention. Finally, it should be noted that while the symptoms describedabove help characterize the diagnosis of IBS, other types ofsymptoms or demographic and temporal features may help toexclude yet other disorders and direct the extent and nature oftreatment. For example, symptoms that awaken the patient fromsleep, present first at an older age, or manifest as GI bleeding,weight loss, or fever are regarded as alarm signs (also called"red flags"), and their presence should lead to furtherinvestigation.[3,11,12] Psychosocial Influences on Symptom Presentation andOutcomeIn keeping with the above concepts, patients with IBS have anincreased prevalence of comorbid psychosocialdisturbances.[3,8] The presence of psychosocial factors isassociated with higher symptom severity and pooreroutcome.[19,29-34] In a recent study, we compared physiologic, psychosocial, andhealth status measures between patients with moderate andsevere IBS[31] and found that pain reports relate more topsychosocial factors (eg, depression, coping style, and illnessbehaviors) than to physiologic factors (ie, rectal sensitivity).Moreover, healthcare utilization (as determined by number ofphysician visits, phone calls, and days in bed), and quality oflife were also highly influenced by psychosocial factors.[33] These findings indicate that for patients with IBS, psychosocialfactors prominently influence symptom frequency, severity,overall health status, healthcare utilization, and clinicaloutcome. This can explain the higher frequency of more severepsychosocial difficulties, including major loss[35,36] and abusehistory,[37] in IBS patients seen at referral centers and amongpatients who seek medical care/attention often.[3,38] By contrast, the psychosocial features of individuals with IBSwho do not seek healthcare are not different from those of thegeneral population.[38-40] By influencing symptom experienceand illness behavior, psychosocial factors affect the clinicalexpression and outcome of patients with IBS. However,because IBS is defined by symptoms and because psychosocialfactors vary in their features across populations with the samesymptoms, psychological factors are neither included in thediagnostic criteria for IBS nor support its diagnosis. Cont.
The Clinical Presentation of IBSThe diagnosis of IBS is determined by certain symptom clustersthat "breed true" as a distinct clinical entity. The evidence forand features of these specific symptoms are discussed below. Presentation of SymptomsThe most frequently reported symptom in IBS is pain ordiscomfort in the abdomen.[9,10] This pain often is poorlylocalized and may be migratory or variable in nature, and isusually relieved with defecation, thus supporting a primarycolonic origin for this symptom. It is also associated with achange in the consistency or frequency of stools and withaltered bowel habits (ie, diarrhea, constipation, or combinationof both at varying times).[3,11,12] Other symptoms -- includingbloating, urgency, or the feeling of incomplete evacuation -- arepresent frequently, again suggesting colonic dysfunction.Although IBS symptoms often occur in clusters[13]; some of thesymptoms may occur sequentially and may vary in kind,location, and severity over time.[9] The frequency of IBSepisodes also varies greatly among patients. While somepatients may have daily episodes or continuous symptoms,others experience long symptom-free periods.[9] These patternsraise the question as to when someone has IBS as opposed tooccasional bowel complaints that may be considered a part ofthe normal response of the bowel to stress.[14] For the most part,the characterization of IBS as a "disorder" is determined bycertain frequency guidelines developed from epidemiologicand clinical studies.[4]A subgroup of patients with IBS also complain about other (ie,noncolonic) gastrointestinal (GI) symptoms, such as heartburn,nausea, and early satiety. Furthermore, significant overlap hasbeen reported between IBS and other functional GI disorders(eg, functional dyspepsia, functional heartburn, proctalgiafugax),[15-18] with, as mentioned earlier, an individual's primarysymptoms shifting over time.[17] Patients with IBS have other(ie, non-GI) symptoms and therefore visit their primary carephysician quite often for both GI and non-GI complaints.[2,19]The non-GI symptoms include fibromyalgia[20-23] and othermusculoskeletal symptoms,[20] headache, genitourinarysymptoms,[24] sexual dysfunction,[25] sleep disturbances,[26,27] andchronic fatigue.[3] These findings are consistent with IBS involving dysfunction ofboth the central and peripheral nervous system (ie, a "brain-gutdisorder"). There may be a peripheral (ie, visceral) basis forsome GI symptoms due to dysfunction of the enteric nervoussystem in the upper as well as the lower gut. In addition, andparticularly for patients with higher levels of psychosocialdistress or psychological comorbidity, there may be centralupregulation of peripheral (both somatic or visceral) signalsbased on central nervous system (CNS) hypervigilance orhypersensitivity. Furthermore, not only can IBS symptoms be varied andmultiple, but they may also coexist with or be initiated by otherorganic disorders (ie, ulcerative colitis or Crohn's disease).[28]Sometimes, therefore, it is difficult to determine whether thepatient's symptoms are due to an organic (eg, inflammatorybowel disease [IBD]) or functional (eg, IBS) condition. From abiopsychosocial perspective, deciding whether a symptom is"functional" or "organic" is not as important as determiningwhich factors need further attention. Finally, it should be noted that while the symptoms describedabove help characterize the diagnosis of IBS, other types ofsymptoms or demographic and temporal features may help toexclude yet other disorders and direct the extent and nature oftreatment. For example, symptoms that awaken the patient fromsleep, present first at an older age, or manifest as GI bleeding,weight loss, or fever are regarded as alarm signs (also called"red flags"), and their presence should lead to furtherinvestigation.[3,11,12] Psychosocial Influences on Symptom Presentation andOutcomeIn keeping with the above concepts, patients with IBS have anincreased prevalence of comorbid psychosocialdisturbances.[3,8] The presence of psychosocial factors isassociated with higher symptom severity and pooreroutcome.[19,29-34] In a recent study, we compared physiologic, psychosocial, andhealth status measures between patients with moderate andsevere IBS[31] and found that pain reports relate more topsychosocial factors (eg, depression, coping style, and illnessbehaviors) than to physiologic factors (ie, rectal sensitivity).Moreover, healthcare utilization (as determined by number ofphysician visits, phone calls, and days in bed), and quality oflife were also highly influenced by psychosocial factors.[33] These findings indicate that for patients with IBS, psychosocialfactors prominently influence symptom frequency, severity,overall health status, healthcare utilization, and clinicaloutcome. This can explain the higher frequency of more severepsychosocial difficulties, including major loss[35,36] and abusehistory,[37] in IBS patients seen at referral centers and amongpatients who seek medical care/attention often.[3,38] By contrast, the psychosocial features of individuals with IBSwho do not seek healthcare are not different from those of thegeneral population.[38-40] By influencing symptom experienceand illness behavior, psychosocial factors affect the clinicalexpression and outcome of patients with IBS. However,because IBS is defined by symptoms and because psychosocialfactors vary in their features across populations with the samesymptoms, psychological factors are neither included in thediagnostic criteria for IBS nor support its diagnosis. Cont.
The DiagnosisSymptom-Based CriteriaThe use of symptom-based criteria allows the physician tomake a "positive diagnosis" of IBS, thereby reducing the needfor excess diagnostic tests/studies to exclude other conditions.These criteria also serve to legitimize the disorder to patientsand physicians. However, developing diagnostic criteria ischallenging because of the absence of specific physical orbiochemical findings, the variability of the symptoms (withregard to pattern, location, and severity) among patients -- andeven in the same patient over time, and the inconsistency of theclinical course. Several symptom-based diagnostic approachesfor IBS have been proposed over the last 2 decades in anattempt to standardize the diagnosis and increase its specificity.These criteria were selected through use of clusters ofsymptoms thought to be consistent with the disorder.[11,12] In a study done 20 years ago, 6 symptoms were identified thatdifferentiate between patients with irritable bowel from thosewith organic intestinal diseases.[41] These symptoms, laterknown as the "Manning criteria," for the first time suggested thefeasibility of a positive diagnostic approach to IBS based onsymptom criteria. Although widely used in epidemiologic andclinical studies, these criteria have been of limited clinicalvalue in differentiating IBS from organic, lower GI tractdiseases.[42] Nevertheless, they have provided the basis for themore recent "Rome criteria," first published for IBS in 1989[43]and for all of the functional GI disorders in 1990.[10] The Rome criteria. The Rome criteria were first developed byinternational consensus ("Delphi" approach). Thesemultinational working teams also critically reviewed theliterature on the epidemiology, pathophysiology, diagnosticapproach, and treatment for IBS and other functional GIdisorders. The original criteria (ie, "Rome I")[44] have recentlybeen revised ("Rome II") and published as a book[3] and journalsupplement.[45] The Rome II criteria for IBS are shown in theTable below. Over the 20 years since publication of theManning criteria, the use of symptom-based criteria for thediagnosis of IBS has become accepted as the diagnosticstandard for research and clinical care. According to these criteria, the presence of abdominalpain/discomfort is required for the diagnosis of IBS. The painor discomfort must be associated with at least 2 of the 3criteria that link the pain to change in bowel habit (see Table).Therefore, pain/discomfort alone, or with only 1 of the 3criteria, or the existence of altered stool habit (ie, frequency orstool form) without pain/discomfort is not sufficient for thediagnosis of IBS. Patients may have other functional bowelsymptoms that do not fulfill the criteria for IBS. Thesesymptoms may represent different functional bowel diagnoses,such as functional abdominal pain, functional constipation,functional diarrhea, functional abdominal bloating, orunspecified functional bowel disorder.[3]The Rome criteria also require certain temporal features for thediagnosis. Symptoms must be present "at least 12 weeks ormore, which need not be consecutive, in the preceding 12months," and this can apply to any 12 weeks in a year. Thus,symptoms need not be consecutive, and the chronicity criterioncan be fulfilled even if the symptoms are present for only 1 dayin a week. For epidemiologic surveys, symptoms may bepresent for 3 weeks over a 3-month period (25% of the time).The Rome II criteria for IBS have been modified from theRome I criteria in several ways[3]: (1) They have beensimplified by defining the specific symptoms regarding bowelhabit (eg, > 3 bowel movements per week, straining at stool,hard stool) as only supportive rather than diagnostic of IBS; (2)Two of the 3 major criteria (rather than 1 of 3 for Rome Icriteria) are now required for the diagnosis; and (3) Symptomsmust be present for a longer time frame (12 weeks/year, ratherthan 3 weeks/3 months). These symptom item changes werebased on new empiric evidence that helps to validate thecriteria (primarily, factor analytic studies).Subclassification of IBSIBS can be stratified by subgroup based on predominantsymptom or severity. These subclassifications can help theclinician to determine diagnostic (to exclude other diseases)and treatment approaches, and to stratify study populations forclinical trials.Predominant symptom subclassification. IBS is oftensubclassified as diarrhea-predominant,constipation-predominant, or alternating (combination of both)at varying times. The Rome multinational working teamproposed guidelines for predominant symptomsubclassification based on stool frequency, stool form, andstool passage.[3] However, because IBS is characterized bydysregulation of bowel function, patients may often alternatebetween these subgroups, and thus their predominant symptommay change over time.[18,46] Moreover, a long-term study on thenatural history of IBS and dyspepsia has shown that thepredominant functional symptom can change over time not onlywithin the specific diagnosis/disorder (eg, IBS), but alsobetween different functional disorders (eg, IBS anddyspepsia).[17,18] Symptom severity subclassification. Another strategy ofsubclassifying IBS patients is by the severity of the symptoms.Most subjects who have IBS symptoms do not see physiciansfor their symptoms (ie, IBS nonpatients). The majority (about70%) of the subjects who do see physicians (ie, IBS patients)have mild and infrequent symptoms associated with littledisability.[47] Twenty-five percent of IBS patients havemoderate symptoms, which may occasionally interfere withdaily activities (such as missing school, work, or socialfunctions), and only a small proportion (about 5%) have severesymptoms that considerably affect daily activities and qualityof life.The severity of IBS symptoms is determined by their intensity,constancy, the degree of psychosocial difficulties, and thefrequency of healthcare utilization.[11,31,47] Subclassifying IBSpatients according to the severity of their symptoms can behelpful in guiding proper management. For example, patientswith mild and infrequent symptoms can be managed by primarycare physicians and usually require only reassurance,education, and dietary or lifestyle changes. Patients withmoderate symptoms may require, in addition, pharmacologicand/or behavioral treatments. Patients who have severe, morefrequent, or constant symptoms often requirepsychopharmacologic (eg, antidepressants) and/orpsychological (eg, cognitive-behavioral) interventions and mayneed to be referred to tertiary centers.[11,12,47]Diagnostic TestingOnce the diagnostic criteria have been met, it is necessary toexclude other medical disorders having similar clinicalpresentations. This is done by looking for alarm signs (seeabove) and by performing limited diagnostic screening tests.The diagnostic strategy should be planned in a cost-effectivemanner with consideration of the duration of the symptoms, ageof onset of symptoms, family history of colon cancer, severityof the symptoms, previous diagnostic evaluations, psychosocialstatus, and change of symptoms over time.[3] Detailed recommendations for diagnostic tests that can be usedin this setting are found elsewhere.[3,11,12] In brief, the initialscreening evaluation should include at least blood tests (eg,blood count, erythrocyte sedimentation rate, serumchemistries), stool tests (eg, for ova and parasites and blood),and sigmoidoscopy. Other studies such as colonoscopy, bariumenema, ultrasound, or CT scan will depend on the presence of"alarm" signs as well as factors such as the patient's age andfamily history. More specific studies (eg, lactose breathhydrogen test, thyroid-stimulating hormone determination,celiac sprue serology) should be considered if indicated byfeatures in the patient history or results of screening studies thatpoint to other diagnoses.If the initial screening evaluation is normal, further diagnosticstudies should be withheld and treatment may be started with afollow-up visit within 4-6 weeks.[11] The patient should bereevaluated over time and additional diagnostic tests obtaineddepending on changes in clinical status and response totreatment. Nevertheless, it should be emphasized that the merepersistence of symptoms does not justify further diagnostictesting. Because IBS is a chronic disorder with frequentrelapses, repeating diagnostic studies to "convince" the patient,or to rule out other disease entities, is not only unjustified butmay be harmful in that it undermines the patient's confidence inboth the diagnosis and the physician.[3]Factors such as the severity of the symptoms, the patient'sillness behavior (eg, recurrent complaints, recurrent physicianvisits and phone calls, requests for further testing), and even anincomplete response to symptomatic treatment must beconsidered in the management approach. However, thesefactors do not justify additional diagnostic testing in theabsence of other "alarm" signs (eg, blood in the stool, abnormalphysical examination, or laboratory studies). Rather, they mayreflect the degree of psychosocial difficulties. As discussedearlier, psychosocial assessment is an essential part of thepatient's evaluation and diagnostic planning. Clinicians shouldlook for psychosocial factors that may exacerbate the clinicalexpression of the symptoms as well as the patient's illnessbehavior. Identifying or excluding these factors is helpful inestablishing an appropriate diagnostic plan and in minimizingunneeded investigative studies. Validity of the DiagnosisHow confident can a physician (and the patient) be with thediagnosis? In addition to the symptoms included in the majorcriteria, the Rome committee also listed symptoms that are notessential for the diagnosis but that are commonly present inpatients with IBS (see Table). The presence of these symptomscan add to the physician's confidence regarding the origin of thesymptoms (ie, GI) and the diagnosis (ie, IBS).[41] Nevertheless,development of symptom-based criteria in the absence of adiagnostic ("gold") standard has obvious limitations. Theconsensus achieved by expert clinicians and investigators canonly provide face validity, and additional validation studiesare needed to support the utility of the published criteria.Unfortunately, available data on the validity of the Romecriteria are still limited. In a recent study, Vanner and colleagues[48] examined thepredictive value of the Rome I criteria using thegastroenterologist's final diagnosis as the gold standard. Thestudy authors found that the combination of the Rome criteriaand the absence of "red flags" (weight loss, nocturnalsymptoms, blood in stools, recent antibiotic use, family historyof colon cancer, and abnormal physical examination) yielded63% sensitivity and 100% specificity, with a positivepredictive value (PPV) of 98% to 100% and negativepredictive value of 76%. Additional studies on the validationof the Rome criteria, particularly the new (Rome II) criteria,are currently under way.Additional support for a positive diagnosis of IBS also comesfrom studies that have looked at long-term outcomes. Inlong-term follow-up studies (up to 9 years from the diagnosis),no other explanation for the symptoms was found in 95% to100% of patients.[49-51] This suggests that a positive diagnosisusing symptom-based criteria, the absence of "red flags," andlimited investigations rarely requires revision.
The DiagnosisSymptom-Based CriteriaThe use of symptom-based criteria allows the physician tomake a "positive diagnosis" of IBS, thereby reducing the needfor excess diagnostic tests/studies to exclude other conditions.These criteria also serve to legitimize the disorder to patientsand physicians. However, developing diagnostic criteria ischallenging because of the absence of specific physical orbiochemical findings, the variability of the symptoms (withregard to pattern, location, and severity) among patients -- andeven in the same patient over time, and the inconsistency of theclinical course. Several symptom-based diagnostic approachesfor IBS have been proposed over the last 2 decades in anattempt to standardize the diagnosis and increase its specificity.These criteria were selected through use of clusters ofsymptoms thought to be consistent with the disorder.[11,12] In a study done 20 years ago, 6 symptoms were identified thatdifferentiate between patients with irritable bowel from thosewith organic intestinal diseases.[41] These symptoms, laterknown as the "Manning criteria," for the first time suggested thefeasibility of a positive diagnostic approach to IBS based onsymptom criteria. Although widely used in epidemiologic andclinical studies, these criteria have been of limited clinicalvalue in differentiating IBS from organic, lower GI tractdiseases.[42] Nevertheless, they have provided the basis for themore recent "Rome criteria," first published for IBS in 1989[43]and for all of the functional GI disorders in 1990.[10] The Rome criteria. The Rome criteria were first developed byinternational consensus ("Delphi" approach). Thesemultinational working teams also critically reviewed theliterature on the epidemiology, pathophysiology, diagnosticapproach, and treatment for IBS and other functional GIdisorders. The original criteria (ie, "Rome I")[44] have recentlybeen revised ("Rome II") and published as a book[3] and journalsupplement.[45] The Rome II criteria for IBS are shown in theTable below. Over the 20 years since publication of theManning criteria, the use of symptom-based criteria for thediagnosis of IBS has become accepted as the diagnosticstandard for research and clinical care. According to these criteria, the presence of abdominalpain/discomfort is required for the diagnosis of IBS. The painor discomfort must be associated with at least 2 of the 3criteria that link the pain to change in bowel habit (see Table).Therefore, pain/discomfort alone, or with only 1 of the 3criteria, or the existence of altered stool habit (ie, frequency orstool form) without pain/discomfort is not sufficient for thediagnosis of IBS. Patients may have other functional bowelsymptoms that do not fulfill the criteria for IBS. Thesesymptoms may represent different functional bowel diagnoses,such as functional abdominal pain, functional constipation,functional diarrhea, functional abdominal bloating, orunspecified functional bowel disorder.[3]The Rome criteria also require certain temporal features for thediagnosis. Symptoms must be present "at least 12 weeks ormore, which need not be consecutive, in the preceding 12months," and this can apply to any 12 weeks in a year. Thus,symptoms need not be consecutive, and the chronicity criterioncan be fulfilled even if the symptoms are present for only 1 dayin a week. For epidemiologic surveys, symptoms may bepresent for 3 weeks over a 3-month period (25% of the time).The Rome II criteria for IBS have been modified from theRome I criteria in several ways[3]: (1) They have beensimplified by defining the specific symptoms regarding bowelhabit (eg, > 3 bowel movements per week, straining at stool,hard stool) as only supportive rather than diagnostic of IBS; (2)Two of the 3 major criteria (rather than 1 of 3 for Rome Icriteria) are now required for the diagnosis; and (3) Symptomsmust be present for a longer time frame (12 weeks/year, ratherthan 3 weeks/3 months). These symptom item changes werebased on new empiric evidence that helps to validate thecriteria (primarily, factor analytic studies).Subclassification of IBSIBS can be stratified by subgroup based on predominantsymptom or severity. These subclassifications can help theclinician to determine diagnostic (to exclude other diseases)and treatment approaches, and to stratify study populations forclinical trials.Predominant symptom subclassification. IBS is oftensubclassified as diarrhea-predominant,constipation-predominant, or alternating (combination of both)at varying times. The Rome multinational working teamproposed guidelines for predominant symptomsubclassification based on stool frequency, stool form, andstool passage.[3] However, because IBS is characterized bydysregulation of bowel function, patients may often alternatebetween these subgroups, and thus their predominant symptommay change over time.[18,46] Moreover, a long-term study on thenatural history of IBS and dyspepsia has shown that thepredominant functional symptom can change over time not onlywithin the specific diagnosis/disorder (eg, IBS), but alsobetween different functional disorders (eg, IBS anddyspepsia).[17,18] Symptom severity subclassification. Another strategy ofsubclassifying IBS patients is by the severity of the symptoms.Most subjects who have IBS symptoms do not see physiciansfor their symptoms (ie, IBS nonpatients). The majority (about70%) of the subjects who do see physicians (ie, IBS patients)have mild and infrequent symptoms associated with littledisability.[47] Twenty-five percent of IBS patients havemoderate symptoms, which may occasionally interfere withdaily activities (such as missing school, work, or socialfunctions), and only a small proportion (about 5%) have severesymptoms that considerably affect daily activities and qualityof life.The severity of IBS symptoms is determined by their intensity,constancy, the degree of psychosocial difficulties, and thefrequency of healthcare utilization.[11,31,47] Subclassifying IBSpatients according to the severity of their symptoms can behelpful in guiding proper management. For example, patientswith mild and infrequent symptoms can be managed by primarycare physicians and usually require only reassurance,education, and dietary or lifestyle changes. Patients withmoderate symptoms may require, in addition, pharmacologicand/or behavioral treatments. Patients who have severe, morefrequent, or constant symptoms often requirepsychopharmacologic (eg, antidepressants) and/orpsychological (eg, cognitive-behavioral) interventions and mayneed to be referred to tertiary centers.[11,12,47]Diagnostic TestingOnce the diagnostic criteria have been met, it is necessary toexclude other medical disorders having similar clinicalpresentations. This is done by looking for alarm signs (seeabove) and by performing limited diagnostic screening tests.The diagnostic strategy should be planned in a cost-effectivemanner with consideration of the duration of the symptoms, ageof onset of symptoms, family history of colon cancer, severityof the symptoms, previous diagnostic evaluations, psychosocialstatus, and change of symptoms over time.[3] Detailed recommendations for diagnostic tests that can be usedin this setting are found elsewhere.[3,11,12] In brief, the initialscreening evaluation should include at least blood tests (eg,blood count, erythrocyte sedimentation rate, serumchemistries), stool tests (eg, for ova and parasites and blood),and sigmoidoscopy. Other studies such as colonoscopy, bariumenema, ultrasound, or CT scan will depend on the presence of"alarm" signs as well as factors such as the patient's age andfamily history. More specific studies (eg, lactose breathhydrogen test, thyroid-stimulating hormone determination,celiac sprue serology) should be considered if indicated byfeatures in the patient history or results of screening studies thatpoint to other diagnoses.If the initial screening evaluation is normal, further diagnosticstudies should be withheld and treatment may be started with afollow-up visit within 4-6 weeks.[11] The patient should bereevaluated over time and additional diagnostic tests obtaineddepending on changes in clinical status and response totreatment. Nevertheless, it should be emphasized that the merepersistence of symptoms does not justify further diagnostictesting. Because IBS is a chronic disorder with frequentrelapses, repeating diagnostic studies to "convince" the patient,or to rule out other disease entities, is not only unjustified butmay be harmful in that it undermines the patient's confidence inboth the diagnosis and the physician.[3]Factors such as the severity of the symptoms, the patient'sillness behavior (eg, recurrent complaints, recurrent physicianvisits and phone calls, requests for further testing), and even anincomplete response to symptomatic treatment must beconsidered in the management approach. However, thesefactors do not justify additional diagnostic testing in theabsence of other "alarm" signs (eg, blood in the stool, abnormalphysical examination, or laboratory studies). Rather, they mayreflect the degree of psychosocial difficulties. As discussedearlier, psychosocial assessment is an essential part of thepatient's evaluation and diagnostic planning. Clinicians shouldlook for psychosocial factors that may exacerbate the clinicalexpression of the symptoms as well as the patient's illnessbehavior. Identifying or excluding these factors is helpful inestablishing an appropriate diagnostic plan and in minimizingunneeded investigative studies. Validity of the DiagnosisHow confident can a physician (and the patient) be with thediagnosis? In addition to the symptoms included in the majorcriteria, the Rome committee also listed symptoms that are notessential for the diagnosis but that are commonly present inpatients with IBS (see Table). The presence of these symptomscan add to the physician's confidence regarding the origin of thesymptoms (ie, GI) and the diagnosis (ie, IBS).[41] Nevertheless,development of symptom-based criteria in the absence of adiagnostic ("gold") standard has obvious limitations. Theconsensus achieved by expert clinicians and investigators canonly provide face validity, and additional validation studiesare needed to support the utility of the published criteria.Unfortunately, available data on the validity of the Romecriteria are still limited. In a recent study, Vanner and colleagues[48] examined thepredictive value of the Rome I criteria using thegastroenterologist's final diagnosis as the gold standard. Thestudy authors found that the combination of the Rome criteriaand the absence of "red flags" (weight loss, nocturnalsymptoms, blood in stools, recent antibiotic use, family historyof colon cancer, and abnormal physical examination) yielded63% sensitivity and 100% specificity, with a positivepredictive value (PPV) of 98% to 100% and negativepredictive value of 76%. Additional studies on the validationof the Rome criteria, particularly the new (Rome II) criteria,are currently under way.Additional support for a positive diagnosis of IBS also comesfrom studies that have looked at long-term outcomes. Inlong-term follow-up studies (up to 9 years from the diagnosis),no other explanation for the symptoms was found in 95% to100% of patients.[49-51] This suggests that a positive diagnosisusing symptom-based criteria, the absence of "red flags," andlimited investigations rarely requires revision.
ConclusionA positive and comprehensive diagnosis of IBS mustincorporate both the recently developed symptom-baseddiagnostic criteria and the biopsychosocial approach. Byidentifying symptoms that are consistent with the disorder andthat fulfill the Rome criteria, by excluding clinical alarm signs,and by performing limited diagnostic testing, the physician canachieve a positive diagnosis of IBS with a great deal ofconfidence. The biopsychosocial approach offers a framework forincorporating the physiologic and psychosocial contributors toillness into the diagnostic plan. The patient's complaints,symptoms, and behaviors should be appraised in the context ofthe physiologic findings, the results of objective studies, thepsychosocial factors surrounding the illness, and the patient'sperception of his/her illness. This can lead to a morecomprehensive understanding of the patient's illness and shouldimprove management.
ConclusionA positive and comprehensive diagnosis of IBS mustincorporate both the recently developed symptom-baseddiagnostic criteria and the biopsychosocial approach. Byidentifying symptoms that are consistent with the disorder andthat fulfill the Rome criteria, by excluding clinical alarm signs,and by performing limited diagnostic testing, the physician canachieve a positive diagnosis of IBS with a great deal ofconfidence. The biopsychosocial approach offers a framework forincorporating the physiologic and psychosocial contributors toillness into the diagnostic plan. The patient's complaints,symptoms, and behaviors should be appraised in the context ofthe physiologic findings, the results of objective studies, thepsychosocial factors surrounding the illness, and the patient'sperception of his/her illness. This can lead to a morecomprehensive understanding of the patient's illness and shouldimprove management.
References1.Talley NJ, Zinsmeister AR, Van **** C, et al. Epidemiology of colonic symptoms and the irritable bowel syndrome. Gastroenterology. 1991;101:927-934. 2.Drossman DA, Li Z, Andruzzi E, et al. US householder survey of functional GI disorders: prevalence, sociodemography and health impact. Dig Dis Sci. 1993;38:1569-1580. 3.Thompson WG, Longstreth G, Drossman DA, et al. Functional bowel disorder and functional abdominal pain. In: Drossman DA, Corazziari E, Tally NJ, et al. Rome II. The Functional Gastrointestinal Disorders. Diagnosis, Pathophysiology and Treatment: A Multinational Consensus, 2nd ed. McLean, Va: Degnon Associates; 2000: 351-432. 4.Drossman DA. The Rome process: diagnosis and legitimization of irritable bowel syndrome. Am J Gastroenterol. 1999;94:2803-2807. 5.Engel GL. The need for a new medical model: a challenge for biomedicine. Science. 1977;196:129-136. 6.Drossman DA. Presidential Address: Gastrointestinal Illness and Biopsychosocial Model. Psychosom Med. 1998;60:258-267. 7.Drossman DA. Gastrointestinal illness and the biopsychosocial model. J Clin Gastroenterol. 1996;22:252-254. 8.Drossman DA, Creed FH, Olden KW, et al. Psychosocial aspects of functional gastrointestinal disorders. In: Drossman DA, Corazziari E, Tally NJ, et al. Rome II. The Functional Gastrointestinal Disorders. Diagnosis, Pathophysiology and Treatment: A Multinational Consensus, 2nd ed. McLean, Va: Degnon Associates; 2000: 157-245. 9.Hahn B, Watson M, Yan S, Gunput D, Heuijerjans J. Irritable bowel syndrome symptom patterns: frequency, duration, and severity. Dig Dis Sci. 1998;43:2715-2718. 10.Drossman DA, Thompson WG, Talley NJ, et al. Identification of subgroups of functional bowel disorders. Gastroenterology International. 1990;3:159-172. 11.Drossman DA, Whitehead WE, Camilleri M. Irritable bowel syndrome: a technical review for practice guideline development. Gastroenterology. 1997;112:2120-2137. 12.Drossman DA. Review article: an integrated approach to the irritable bowel syndrome. Aliment Pharmacol Ther. 1999;13(suppl 2):3-14. 13.Stevens JA, Wan CK, Blanchard EB. The short term natural history of irritable bowel syndrome: a time-series analysis. Behav Res Ther. 1997;35:319-326. 14.Drossman DA, Sandler RS, McKee DC, et al. Bowel patterns among subjects not seeking health care. Gastroenterology. 1982;83:529-534. 15.Agreus L, Talley NJ, Svardsudd K, et al. Identifying dyspepsia and irritable bowel syndrome: the value of pain or discomfort, and bowel habit descriptors. Scand J Gastroenterol. 2000;35:142-151. 16.Lembo T, Munakata J, Mertz H, et al. Evidence for hypersensitivity of lumbar splanchnic afferents in irritable bowel syndrome. Gastroenterology. 1994;107:1686-1696. 17.Agreus L, Talley NJ, Svardsudd K, et al. Natural history of functional abdominal disorders in the general population: overlap and lack of stability over time. Gastroenterology. 1995;109:671-680. 18.Agreus L, Talley NJ, Nyren O, et al. Natural history of reflux, dyspepsia and irritable bowel syndrome over 7 years in general population. Gastroenterology. 1998;114(suppl):A-917. 19.Drossman DA, Mc Kee DC, Sandler RS, et al. Psychosocial factors in the irritable bowel syndrome. A multivariate study of patients and nonpatients with irritable bowel syndrome. Gastroenterology. 1988;95:701-770. 20.Veale D, Kavanagh G, Fielding JF, et al. Primary fibromyalgia and the irritable bowel syndrome: different expressions of a common pathogenic process. Br J Rheumatol. 1991;30:220-222. 21.Barton A, Whorwell PJ, Marshall D. Increased prevalence of Sicca complex and fibromyalgia in patients with irritable bowel syndrome. Am J Gastroenterol. 1999;94:1898-1901. 22.Sivri A, Cindas A, Dincer F, et al. Bowel dysfunction and irritable bowel syndrome in fibromyalgia patients. Clin Rheumatol. 1996;15:283-286. 23.Sperber AD, Atzmon Y, Neumann L, et al. Fibromyalgia in the irritable bowel syndrome: studies of prevalence and clinical implications. Am J Gastroenterol. 1999;94:3541-3546. 24.Francis CY. High prevalence of irritable bowel syndrome in patients attending a urological clinic. Dig Dis Sci. 1997;42:404-407. 25.Fass R, Fullerton S, Naliboff B, et al. Sexual dysfunction in patients with irritable bowel syndrome and non-ulcer dyspepsia. Digestion. 1998;59:79-85. 26.Elsenbruch S, Harnish MJ, Orr WC. Subjective and objective sleep quality in irritable bowel syndrome. Gastroenterology. 1998;114:A749. 27.Fass R, Fullerton S, Higa L, et al. Sleep disturbances in clinic patients with functional bowel disorders. Am J Gastroenterol. 2000;95:1195-1200. 28.Isgar B, Harman M, Kaye MD, et al. Symptoms of irritable bowel syndrome in ulcerative colitis in remission. Gut. 1983;24:190-192. 29.Drossman DA. Do psychological factors define symptom severity and patient status? Am J Med. 1999;107:41S-50S. 30.Whitehead WE, Bosmajian L, Zonderman A, et al. Symptoms of psychologic distress associated with irritable bowel syndrome. Comparison of community and medical clinic samples. Gastroenterology. 1988;95:709-714. 31.Drossman DA, Whitehead WE, Toner BB, et al. What determines severity among patients with painful functional bowel disorders? Am J Gastroenterol. 2000;95:974-980. 32.Drossman DA, Hu Y, Jia H, et al. The influence of psychosocial factors on health status in patients with functional bowel disorders. Gastroenterology. 2000;118:A398. 33.Drossman DA, Hu Y, Jia H, et al. The influence of psychosocial factors on health care utilization in patients with functional bowel disorders (FBD). Gastroenterology. 2000;118:A842. 34.Satio YA, Locke GR, William DE, et al. The role of psychological distress on symptoms and health care utilization in patients with irritable bowel syndrome. Gastroenterology. 2000;118:A399. 35.Creed FH, Craig T, Farmer RG. Functional abdominal pain, psychiatric illness and life events. Gut. 1988;29:235-242. 36.Whitehead WE, Crowell MD, Robinson JC, et al. Effects of stressful life events on bowel symptoms: subjects with irritable bowel syndrome compared to subjects without bowel dysfunction. Gut. 1992;33:825-830. 37.Drossman DA, Talley NJ, Olden KW, et al. Sexual and physical abuse and gastrointestinal illness: review and recommendations. Ann Intern Med. 1995;123:782-794. 38.Gaynes B, Drossman DA. The role of psychosocial factors in irritable bowel syndrome. Baillieres Clin Gastroenterol. 1999;13:437-452. 39.Drossman DA, Mc Kee DC, Sandler RS, et al. Psychosocial factors in the irritable bowel syndrome. A multivariate study of patients and nonpatients with irritable bowel syndrome. Gastroenterology. 1988;95:701-708. 40.Whitehead WE, Bosmajian L, Zonderman A, et al. Symptoms of psychologic distress associated with irritable bowel syndrome. Comparison of community and medical clinic samples. Gastroenterology. 1988;95:709-714. 41.Manning AP, Thompson WG, Heaton KW, et al. Towards positive diagnosis of irritable bowel syndrome. Br Med J. 1978;2:653-654. 42.Hammer J, Tally NJ. Diagnostic criteria for the irritable bowel syndrome. Am J Med. 1999;107:5S-11S. 43.Thompson WG, Dotevall G, Drossman DA, et al. Irritable bowel syndrome: guidelines for the diagnosis. Gastroenterology International. 1989;2:92-95. 44.Thompson WG and the Working Team for Functional Bowel Disorders. Functional bowel disorders and functional abdominal pain. In: Drossman DA, Richter JE, Talley NJ, et al. The Functional Gastrointestinal Disorders. Diagnosis, Pathophysiology and Treatment. McLean, Va: Degnon Associates; 1994: 115-173. 45.Drossman DA, Corazziari E, Talley NJ, et al. Rome II: a multinational consensus document on functional gastrointestinal disorders. Gut. 1999;45:II1-II81. 46.Talley NJ, Weaver AL, Zinmeister AR, et al. Onset and disappearance of gastrointestinal symptoms and functional gastrointestinal disorder. Am J Epidemiol. 1992;136:165-177. 47.Drossman DA, Thompson WG. The irritable bowel syndrome: review and graduated, multicomponent treatment approach. Ann Intern Med. 1992;116:1009-1016. 48.Vaner SJ, Depew WT, Paterson WG, et al. Predictive value of the Rome criteria for diagnosing the irritable bowel syndrome. Am J Gastroenterol. 1999;94:2912-2917. 49.Owens MD, Nelson DK, Talley NJ. The irritable bowel syndrome: long term prognosis and the physician-patient interaction. Ann Intern Med. 1995;122:107-112. 50.Harvey RF, Mauad EC, Brown AM. Prognosis in the irritable bowel syndrome: a five-year prospective study. Lancet. 1987;1:963-965. 51.Svendsen JH, Munck LK, Anderson JR. Irritable bowel syndrome: prognosis and diagnostic safety. A 5-year follow up study. Scand J Gastroenterol. 1985;20:415-418. ------------------Moderator of the Cognitive Behavioral Therapy, Anxiety and Hypnotherapy forumI work with Mike and the IBS Audio Program. www.ibshealth.com www.ibsaudioprogram.com
References1.Talley NJ, Zinsmeister AR, Van **** C, et al. Epidemiology of colonic symptoms and the irritable bowel syndrome. Gastroenterology. 1991;101:927-934. 2.Drossman DA, Li Z, Andruzzi E, et al. US householder survey of functional GI disorders: prevalence, sociodemography and health impact. Dig Dis Sci. 1993;38:1569-1580. 3.Thompson WG, Longstreth G, Drossman DA, et al. Functional bowel disorder and functional abdominal pain. In: Drossman DA, Corazziari E, Tally NJ, et al. Rome II. The Functional Gastrointestinal Disorders. Diagnosis, Pathophysiology and Treatment: A Multinational Consensus, 2nd ed. McLean, Va: Degnon Associates; 2000: 351-432. 4.Drossman DA. The Rome process: diagnosis and legitimization of irritable bowel syndrome. Am J Gastroenterol. 1999;94:2803-2807. 5.Engel GL. The need for a new medical model: a challenge for biomedicine. Science. 1977;196:129-136. 6.Drossman DA. Presidential Address: Gastrointestinal Illness and Biopsychosocial Model. Psychosom Med. 1998;60:258-267. 7.Drossman DA. Gastrointestinal illness and the biopsychosocial model. J Clin Gastroenterol. 1996;22:252-254. 8.Drossman DA, Creed FH, Olden KW, et al. Psychosocial aspects of functional gastrointestinal disorders. In: Drossman DA, Corazziari E, Tally NJ, et al. Rome II. The Functional Gastrointestinal Disorders. Diagnosis, Pathophysiology and Treatment: A Multinational Consensus, 2nd ed. McLean, Va: Degnon Associates; 2000: 157-245. 9.Hahn B, Watson M, Yan S, Gunput D, Heuijerjans J. Irritable bowel syndrome symptom patterns: frequency, duration, and severity. Dig Dis Sci. 1998;43:2715-2718. 10.Drossman DA, Thompson WG, Talley NJ, et al. Identification of subgroups of functional bowel disorders. Gastroenterology International. 1990;3:159-172. 11.Drossman DA, Whitehead WE, Camilleri M. Irritable bowel syndrome: a technical review for practice guideline development. Gastroenterology. 1997;112:2120-2137. 12.Drossman DA. Review article: an integrated approach to the irritable bowel syndrome. Aliment Pharmacol Ther. 1999;13(suppl 2):3-14. 13.Stevens JA, Wan CK, Blanchard EB. The short term natural history of irritable bowel syndrome: a time-series analysis. Behav Res Ther. 1997;35:319-326. 14.Drossman DA, Sandler RS, McKee DC, et al. Bowel patterns among subjects not seeking health care. Gastroenterology. 1982;83:529-534. 15.Agreus L, Talley NJ, Svardsudd K, et al. Identifying dyspepsia and irritable bowel syndrome: the value of pain or discomfort, and bowel habit descriptors. Scand J Gastroenterol. 2000;35:142-151. 16.Lembo T, Munakata J, Mertz H, et al. Evidence for hypersensitivity of lumbar splanchnic afferents in irritable bowel syndrome. Gastroenterology. 1994;107:1686-1696. 17.Agreus L, Talley NJ, Svardsudd K, et al. Natural history of functional abdominal disorders in the general population: overlap and lack of stability over time. Gastroenterology. 1995;109:671-680. 18.Agreus L, Talley NJ, Nyren O, et al. Natural history of reflux, dyspepsia and irritable bowel syndrome over 7 years in general population. Gastroenterology. 1998;114(suppl):A-917. 19.Drossman DA, Mc Kee DC, Sandler RS, et al. Psychosocial factors in the irritable bowel syndrome. A multivariate study of patients and nonpatients with irritable bowel syndrome. Gastroenterology. 1988;95:701-770. 20.Veale D, Kavanagh G, Fielding JF, et al. Primary fibromyalgia and the irritable bowel syndrome: different expressions of a common pathogenic process. Br J Rheumatol. 1991;30:220-222. 21.Barton A, Whorwell PJ, Marshall D. Increased prevalence of Sicca complex and fibromyalgia in patients with irritable bowel syndrome. Am J Gastroenterol. 1999;94:1898-1901. 22.Sivri A, Cindas A, Dincer F, et al. Bowel dysfunction and irritable bowel syndrome in fibromyalgia patients. Clin Rheumatol. 1996;15:283-286. 23.Sperber AD, Atzmon Y, Neumann L, et al. Fibromyalgia in the irritable bowel syndrome: studies of prevalence and clinical implications. Am J Gastroenterol. 1999;94:3541-3546. 24.Francis CY. High prevalence of irritable bowel syndrome in patients attending a urological clinic. Dig Dis Sci. 1997;42:404-407. 25.Fass R, Fullerton S, Naliboff B, et al. Sexual dysfunction in patients with irritable bowel syndrome and non-ulcer dyspepsia. Digestion. 1998;59:79-85. 26.Elsenbruch S, Harnish MJ, Orr WC. Subjective and objective sleep quality in irritable bowel syndrome. Gastroenterology. 1998;114:A749. 27.Fass R, Fullerton S, Higa L, et al. Sleep disturbances in clinic patients with functional bowel disorders. Am J Gastroenterol. 2000;95:1195-1200. 28.Isgar B, Harman M, Kaye MD, et al. Symptoms of irritable bowel syndrome in ulcerative colitis in remission. Gut. 1983;24:190-192. 29.Drossman DA. Do psychological factors define symptom severity and patient status? Am J Med. 1999;107:41S-50S. 30.Whitehead WE, Bosmajian L, Zonderman A, et al. Symptoms of psychologic distress associated with irritable bowel syndrome. Comparison of community and medical clinic samples. Gastroenterology. 1988;95:709-714. 31.Drossman DA, Whitehead WE, Toner BB, et al. What determines severity among patients with painful functional bowel disorders? Am J Gastroenterol. 2000;95:974-980. 32.Drossman DA, Hu Y, Jia H, et al. The influence of psychosocial factors on health status in patients with functional bowel disorders. Gastroenterology. 2000;118:A398. 33.Drossman DA, Hu Y, Jia H, et al. The influence of psychosocial factors on health care utilization in patients with functional bowel disorders (FBD). Gastroenterology. 2000;118:A842. 34.Satio YA, Locke GR, William DE, et al. The role of psychological distress on symptoms and health care utilization in patients with irritable bowel syndrome. Gastroenterology. 2000;118:A399. 35.Creed FH, Craig T, Farmer RG. Functional abdominal pain, psychiatric illness and life events. Gut. 1988;29:235-242. 36.Whitehead WE, Crowell MD, Robinson JC, et al. Effects of stressful life events on bowel symptoms: subjects with irritable bowel syndrome compared to subjects without bowel dysfunction. Gut. 1992;33:825-830. 37.Drossman DA, Talley NJ, Olden KW, et al. Sexual and physical abuse and gastrointestinal illness: review and recommendations. Ann Intern Med. 1995;123:782-794. 38.Gaynes B, Drossman DA. The role of psychosocial factors in irritable bowel syndrome. Baillieres Clin Gastroenterol. 1999;13:437-452. 39.Drossman DA, Mc Kee DC, Sandler RS, et al. Psychosocial factors in the irritable bowel syndrome. A multivariate study of patients and nonpatients with irritable bowel syndrome. Gastroenterology. 1988;95:701-708. 40.Whitehead WE, Bosmajian L, Zonderman A, et al. Symptoms of psychologic distress associated with irritable bowel syndrome. Comparison of community and medical clinic samples. Gastroenterology. 1988;95:709-714. 41.Manning AP, Thompson WG, Heaton KW, et al. Towards positive diagnosis of irritable bowel syndrome. Br Med J. 1978;2:653-654. 42.Hammer J, Tally NJ. Diagnostic criteria for the irritable bowel syndrome. Am J Med. 1999;107:5S-11S. 43.Thompson WG, Dotevall G, Drossman DA, et al. Irritable bowel syndrome: guidelines for the diagnosis. Gastroenterology International. 1989;2:92-95. 44.Thompson WG and the Working Team for Functional Bowel Disorders. Functional bowel disorders and functional abdominal pain. In: Drossman DA, Richter JE, Talley NJ, et al. The Functional Gastrointestinal Disorders. Diagnosis, Pathophysiology and Treatment. McLean, Va: Degnon Associates; 1994: 115-173. 45.Drossman DA, Corazziari E, Talley NJ, et al. Rome II: a multinational consensus document on functional gastrointestinal disorders. Gut. 1999;45:II1-II81. 46.Talley NJ, Weaver AL, Zinmeister AR, et al. Onset and disappearance of gastrointestinal symptoms and functional gastrointestinal disorder. Am J Epidemiol. 1992;136:165-177. 47.Drossman DA, Thompson WG. The irritable bowel syndrome: review and graduated, multicomponent treatment approach. Ann Intern Med. 1992;116:1009-1016. 48.Vaner SJ, Depew WT, Paterson WG, et al. Predictive value of the Rome criteria for diagnosing the irritable bowel syndrome. Am J Gastroenterol. 1999;94:2912-2917. 49.Owens MD, Nelson DK, Talley NJ. The irritable bowel syndrome: long term prognosis and the physician-patient interaction. Ann Intern Med. 1995;122:107-112. 50.Harvey RF, Mauad EC, Brown AM. Prognosis in the irritable bowel syndrome: a five-year prospective study. Lancet. 1987;1:963-965. 51.Svendsen JH, Munck LK, Anderson JR. Irritable bowel syndrome: prognosis and diagnostic safety. A 5-year follow up study. Scand J Gastroenterol. 1985;20:415-418. ------------------Moderator of the Cognitive Behavioral Therapy, Anxiety and Hypnotherapy forumI work with Mike and the IBS Audio Program. www.ibshealth.com www.ibsaudioprogram.com
Eric: Was this published? Do you have a full reference for it, please?echris
Eric: Was this published? Do you have a full reference for it, please?echris
echris, this is published, but the abstrat is from Medscape and it is also in the IFFGD newsletter. I had to get permisson to post it here, but I felt it was worth reading for everyone. This is the whole article.The UNC is the top IBS center. Dr DRossman is one if not the top Dr on IBS.You can find more articles here, but you have to register. Its free though and a valuable resource. http://www.medscape.com/server-java/Search...l?QueryText=ibs Dr Drossman has a profile here. I am not sure but I think they left out he is the head of the GI section for the Merck Manual. http://www.med.unc.edu/medicine/fgidc/drossman.htm ------------------Moderator of the Cognitive Behavioral Therapy, Anxiety and Hypnotherapy forumI work with Mike and the IBS Audio Program. www.ibshealth.com www.ibsaudioprogram.com
echris, this is published, but the abstrat is from Medscape and it is also in the IFFGD newsletter. I had to get permisson to post it here, but I felt it was worth reading for everyone. This is the whole article.The UNC is the top IBS center. Dr DRossman is one if not the top Dr on IBS.You can find more articles here, but you have to register. Its free though and a valuable resource. http://www.medscape.com/server-java/Search...l?QueryText=ibs Dr Drossman has a profile here. I am not sure but I think they left out he is the head of the GI section for the Merck Manual. http://www.med.unc.edu/medicine/fgidc/drossman.htm ------------------Moderator of the Cognitive Behavioral Therapy, Anxiety and Hypnotherapy forumI work with Mike and the IBS Audio Program. www.ibshealth.com www.ibsaudioprogram.com
Eric:I know. I called his office and they said that his first opening for a new patient was a year from now. That's quite a wait (and I'm a health care provider)!echris
Eric:I know. I called his office and they said that his first opening for a new patient was a year from now. That's quite a wait (and I'm a health care provider)!echris
echris, I know its a year wait to and see him. The good thing is he is the best and worth it, however there maybe other doctors there you can see sooner that work with him, as he over sees most cases I believe.Also, hopefully and I am sure he could help you and maybe even fix you depending on the problem, but some people may wait to see him and find out he cannot cure them as there is no cure yet, but he and others are working on it and as far as information on IBS well he writes it. Seeing him in person is a good thing and he is extremely nice as a person and that in itself is a big plus, he won't just dimiss you, but work with you.------------------Moderator of the Cognitive Behavioral Therapy, Anxiety and Hypnotherapy forumI work with Mike and the IBS Audio Program. www.ibshealth.com www.ibsaudioprogram.com
echris, I know its a year wait to and see him. The good thing is he is the best and worth it, however there maybe other doctors there you can see sooner that work with him, as he over sees most cases I believe.Also, hopefully and I am sure he could help you and maybe even fix you depending on the problem, but some people may wait to see him and find out he cannot cure them as there is no cure yet, but he and others are working on it and as far as information on IBS well he writes it. Seeing him in person is a good thing and he is extremely nice as a person and that in itself is a big plus, he won't just dimiss you, but work with you.------------------Moderator of the Cognitive Behavioral Therapy, Anxiety and Hypnotherapy forumI work with Mike and the IBS Audio Program. www.ibshealth.com www.ibsaudioprogram.com
Bump, one more time.------------------Moderator of the Cognitive Behavioral Therapy, Anxiety and Hypnotherapy forumI work with Mike and the IBS Audio Program. www.ibshealth.com www.ibsaudioprogram.com
Bump, one more time.------------------Moderator of the Cognitive Behavioral Therapy, Anxiety and Hypnotherapy forumI work with Mike and the IBS Audio Program. www.ibshealth.com www.ibsaudioprogram.com
It seems as if Dr Drossman doesnt consider urgency to be the same as discomfort. (as Kmottus has suggested)The most frequently reported symptom in IBS is pain or discomfort in the abdomen.... Other symptoms -- includingbloating, urgency... are present frequently
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