How do you spell relief for irritable bowel syndrome?

“I’ve always had some stomach pain,” says Mary Jane, a 36-year-old patient, whom you are seeing for the first time. “But this is becoming unmanageable.”

You see from Mary Jane’s chart that she has been to your group practice twice over the last few years with complaints of diarrhea that were diagnosed as gastroenteritis. She tells you that after each visit, it got “a little better,” but it “never really went away.”

She also tells you that her stomach bothers her a few days every month, but that it feels a little better after she defecates. She says that she thinks she may be sensitive to certain foods.

“Things are getting worse,” she tells you. “The bloating, pain, and diarrhea have gotten to the point that I can’t go anywhere without worrying where the nearest bathroom is.”

“I’ve already had my gallbladder and appendix removed,” she says, “but I still feel lousy.”

On exam, Mary Jane appears to be in good health. She is afebrile and has a normal abdominal exam, except for very mild diffuse tenderness. She tells you that she has not traveled to any locations where access to clean food or water is suspect. Her stool is heme negative. Urine dip is negative and she is not pregnant.

“Do you know what’s the matter with me?” she asks you. “Or do I need to see a specialist?”

No need for a specialist

Your patient meets the criteria for irritable bowel syndrome (IBS) set by Rome III, an international panel of experts in the field of functional gastrointestinal disorders. She’s had recurrent abdominal pain/discomfort for at least 6 months, and she’s had symptoms at least 3 days a month for the last 3 months (TABLE 1).¹

Mary Jane tells you that she is relieved to finally get a diagnosis, having struggled for some time with stomach pain that never really went away. Her experience is not unusual: The wide range of concomitant gastrointestinal and extraintestinal symptoms in IBS patients make the initial diagnosis difficult.^2,3 She’s also relieved to learn from you that contrary to popular belief, IBS has a physiologic basis and that psychosocial stressors merely aggravate an already painful and dysfunctional bowel. (See and Irritable bowel syndrome: Not just a functional disorder^4-7)

We have a number of treatment options to offer patients like Mary Jane, including alosetron, tegaserod, lubiprostone, selective serotonin reuptake inhibitors (SSRIs), and tricyclic antidepressants, as well as complementary therapies (such as probiotics) and behavioral therapy. But before we review the evidence behind the different options, let’s take a look at the factors that may be at work in IBS, and the things you’ll want to pay special attention to during your assessment.

TABLE 1
Is it IBS? Rome III criteria provide guidance¹

Infection, bacterial overgrowth may play a role

Between 4% and 26% of patients contract IBS for the first time after gastroenteritis.⁸ Tissue from patients with post-infectious IBS shows chronic mucosal lymphocytosis^9,10 associated with enterochromaffin cell hyperplasia.¹¹ Spiller et al¹² noted these changes, as well as an increase in gut permeability, for more than 1 year after the resolution of Campylobacter enteritis. Using prednisolone for early intervention suppressed T-cell lymphocyte counts but not IBS symptoms.¹³

The role of bacterial overgrowth in IBS is controversial. Pimentel et al¹⁴ reported that 78% of 202 IBS patients had small intestinal bacterial overgrowth. After treatment, almost half no longer met the Rome criteria for IBS and showed a statistically significant improvement in diarrhea and abdominal pain but not in straining, urgency, or bloating.