Annals of Internal Medicine

In the Clinic

Irritable Bowel
Syndrome
Diagnosis

I
rritable bowel syndrome (IBS) is one of the
most common gastrointestinal disorders, with
a prevalence of 10%20%. It is a chronic con-
dition characterized by abdominal pain in con- Treatment
junction with altered bowel habits and abdomi-
nal distention and bloating. IBS can be clinically
subtyped into IBS with constipation, IBS with diar- Practice Improvement
rhea, or mixed IBS. Recent advances in IBS man-
agement include the new Rome IV criteria for di-
agnosis (released in 2016) and the addition of
new nonpharmacologic and pharmacologic ap-
proaches for treating patients who do not re-
spond to lifestyle and dietary modications.

CME/MOC activity available at Annals.org.

Physician Writers doi:10.7326/AITC201706060

Shahnaz Sultan, MD, MHSc
Ashish Malhotra, MD
From the University of
Minnesota and Minneapolis
Veterans Affairs Medical
Center, Minneapolis,
Minnesota.
CME Objective: To review current evidence for diagnosis, treatment, and practice
improvement of irritable bowel syndrome.
Funding Source: American College of Physicians.
Disclosures: Drs. Sultan and Malhotra, ACP Contributing Authors, report no conicts of
interest. Forms can be viewed at www.acponline.org/authors/icmje/ConictOfInterest
Forms.do?msNum=M17-0573.
With the assistance of additional physician writers, the editors of Annals of Internal
Medicine develop In the Clinic using MKSAP and other resources of the American
College of Physicians.
In the Clinic does not necessarily represent ofcial ACP clinical policy. For ACP clinical
guidelines, please go to https://www.acponline.org/clinical_information/guidelines/.
2017 American College of Physicians

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Diagnosis
1. Lovell RM, Ford AC. Global
prevalence of and risk
factors for irritable bowel
syndrome: a meta-
analysis. Clin Gastroen-
terol Hepatol. 2012;10:
712-721.e4. [PMID:
22426087]
2. Camilleri M. Peripheral
mechanisms in irritable
bowel syndrome [Letter].
N Engl J Med. 2013;368:
578-9. [PMID: 23388017]
3. Ford AC, Marwaha A, Lim
A, Moayyedi P. Systematic
review and meta-analysis
of the prevalence of irrita-
ble bowel syndrome in
individuals with dyspep-
sia. Clin Gastroenterol
Hepatol. 2010;8:401-9.
[PMID: 19631762]
4. Manning AP, Thompson
WG, Heaton KW, Morris
AF. Towards positive diag-
nosis of the irritable
bowel. Br Med J. 1978;2:
653-4. [PMID: 698649]
2017 American College of Physicians
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Irritable bowel syndrome (IBS)
is characterized by abdominal
pain, bloating, and stool irregu-
larity. Symptoms range from
mild to debilitating. Although
this disorder is recognized
worldwide, reported prevalence
rates vary geographically from
1.1% 45%. Prevalence rates of
5%10% are reported in the
United States and most of
What symptoms should
prompt a clinician to
consider IBS?
Although symptoms may vary
from person to person, clinicians
should consider IBS if a patient
has abdominal discomfort or
pain associated with bowel dys-
function. Abnormal stool fre-
quency (>3 bowel movements
per day or <3 bowel movements
per week), excessive straining
during defecation, urgency, and
feeling of incomplete evacuation
are common in patients with IBS
but are nonspecic. Other sug-
gestive symptoms include post-
prandial exacerbation of symp-
toms and excess gas and
atulence. Gastrointestinal symp-
toms that wax and wane for more
than 2 years and are exacerbated
by psychosocial stress should
raise suspicion for IBS. The pres-
ence of other functional gastroin-
testinal disorders (e.g., nonulcer
dyspepsia) as well as functional
extraintestinal symptoms or syn-
dromes, such as chronic fatigue,
bromyalgia, sleep disturbance,
and psychiatric comorbidity, fa-
vor an IBS diagnosis (3).
Three defecation patterns
are characteristic of IBS:
constipation-predominant (IBS-
C), diarrhea-predominant (IBS-D),
and mixed (alternating diarrhea
and constipation) (IBS-M). Deter-
mining a patient's predominant
symptom pattern is useful in
guiding management because
ITC82 In the Clinic
Europe (1). It is more prevalent
in women than in men, and the
pathophysiology is not well-
understood. Potential mecha-
nisms include genetic factors,
immune system alterations,
changes in gut microbiota, al-
terations in bowel motility, vis-
ceral hypersensitivity, functional
brain alterations, and psychoso-
cial comorbidities (2).
the subgroups respond differ-
ently to the various therapeutic
interventions. Individual symp-
tom patterns can change over
time; as a result, whether symp-
tom pattern clearly distin-
guishes among IBS subtypes
is debatable.
Certain clinical features, often
called alarm features or red-ag
symptoms, suggest that the diag-
nosis is something other than IBS
(see the Box: Alarm Features
That Suggest Possible Organic
Disease). Alarm features include
weight loss, nocturnal awakening
due to gastrointestinal symp-
toms, blood in the stool, family
history of colon cancer or inam-
matory bowel disease, recent use
of antibiotics, and fever.
What are the accepted
diagnostic criteria?
History is the main diagnostic
tool for IBS. The Manning criteria
and the Rome criteria are 2 sets
of symptom-based diagnostic
criteria that help to discriminate
between IBS and other disorders
(see the Box: Symptom Criteria
for Irritable Bowel Syndrome).
These criteria, which were devel-
oped for use in research studies,
can be helpful in clinical practice.
Manning and colleagues (4) pro-
posed the rst widely used IBS
criteria in 1978 based on the
symptoms listed in the Box. In
1989, a group of experts met in
Rome and developed another set
Annals of Internal Medicine 6 June 2017
 of consensus-based criteria,
known as the Rome criteria, to
assist in the diagnosis of IBS and
other functional gastrointestinal
disorders (5). The Rome criteria
were based on a broader array of
symptoms than the Manning cri-
teria and additionally considered
both duration and frequency of
symptoms. In 1999, the same
group of experts developed the
Rome II criteria, a modied ver-
sion of the earlier criteria in-
tended to be more adaptable
to clinical practice (5).
The most recent version of the
Rome criteria, Rome IV, was re-
leased in May 2016 (6). IBS is
now dened as recurrent abdom-
inal pain associated with a
change in stool form and/or fre-
quency. The term abdominal
discomfort, which was present in
the Rome III criteria, has been
removed because it was consid-
ered ambiguous. In addition, the
frequency of abdominal pain re-
quired to meet the threshold for
IBS has been changed from at
least 3 days per month in the pre-
ceding 3 months (Rome III) to at
least 1 day per week in the pre-
ceding 3 months (Rome IV). Fi-
nally, the criterion has been
changed from improvement of
abdominal pain with defecation
to abdominal pain related to
defecation to acknowledge that
some patients with IBS may re-
port worsening of abdominal
pain after defecation. Rome IV
continues to specify that some
symptoms must have existed for
at least 6 months and that pa-
tients must fulll the Rome crite-
ria for at least 3 months before
IBS can be diagnosed. Rome IV
also recharacterized IBS as a dis-
order of gut brain interaction
(DGBI) as opposed to a func-
tional gastrointestinal disorder to
offset the ambiguity and stigmati-
zation associated with the term
functional. Furthermore, IBS must
be distinguished from other
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DGBIsalthough symptoms may
overlap, these disorders are con-
sidered separate entities. The
Rome criteria are seen as a work
in progress, and future studies
are needed to conrm the valid-
ity of recent changes and to ex-
amine the usefulness of the crite-
ria in research and clinical
settings (6).
When diagnostic criteria are sat-
ised; warning symptoms are
absent; the history and physical
examination suggest IBS; and the
occult blood test, complete
blood count, complete metabolic
panel, and erythrocyte sedimen-
tation rate are normal, the risk for
overlooking organic disease may
be as low as 1%3%. Thus, expert
consensus is that physicians
should limit evaluation to fulll-
ment of the Rome criteria if no
alarm symptoms are present.
Even without exclusion of alarm
features, the presence of at least
3 of the 6 Manning criteria has an
average sensitivity of approxi-
mately 60% and specicity of ap-
proximately 80%. The criteria's
sensitivity and specicity vary by
study, and diagnostic accuracy is
known to be better in women, in
younger patients, and when
more criteria are fullled (7). Re-
ports show that sensitivity and
specicity of the Rome criteria
range from 69%96% and 72%
85%, respectively. The major
drawback with these reports is
the lack of a gold standard for
IBS diagnosis (8).
What is the utility of the
physical examination?
Although physical examination is
usually normal in patients with
IBS, mild abdominal tenderness
may be present. A digital rectal
examination should be done to
evaluate the possibility of dyssyn-
ergic defecation (which is charac-
terized by paradoxical contrac-
tion of the rectal sphincter on
bearing down and abnormal
In the Clinic ITC83
Alarm Features That Suggest
Possible Organic Disease
Symptoms
Weight loss
Frequent nocturnal awakenings
due to gastrointestinal
symptoms
Fever
Blood in stool
History
New-onset, progressive symptoms
Onset of symptoms after age 50 y
Recent antibiotic use
Family history of colon cancer or
inammatory bowel disease
Physical ndings
Abdominal mass
Stool positive for occult blood
Enlarged lymph nodes
5. Thompson WG, Longstreth
GF, Drossman DA, Heaton
KW, Irvine EJ, Muller-
Lissner SA. Functional
bowel disorders and func-
tional abdominal pain.
Gut. 1999;45 Suppl
2:II43-7. [PMID:
10457044]
6. Drossman DA. Functional
gastrointestinal disorders:
history, pathophysiology,
clinical features and Rome
IV. Gastroenterology.
2016. [PMID: 27144617]
7. Talley NJ, Phillips SF,
Melton LJ, Mulvihill C,
Wiltgen C, Zinsmeister AR.
Diagnostic value of the
Manning criteria in irrita-
ble bowel syndrome. Gut.
1990;31:77-81. [PMID:
2318433]
8. Sood R, Law GR, Ford AC.
Diagnosis of IBS: symp-
toms, symptom-based
criteria, biomarkers or
psychomarkers'? Nat Rev
Gastroenterol Hepatol.
2014;11:683-91. [PMID:
25069544]
2017 American College of Physicians

9. Soh JS, Lee HJ, Jung KW,
Yoon IJ, Koo HS, Seo SY,
et al. The diagnostic value
of a digital rectal examina-
tion compared with high-
resolution anorectal ma-
nometry in patients with
chronic constipation and
fecal incontinence. Am J
Gastroenterol. 2015;110:
1197-204. [PMID:
26032152]
10. Menees SB, Powell C,
Kurlander J, Goel A,
Chey WD. A meta-
analysis of the utility of
C-reactive protein, eryth-
rocyte sedimentation
rate, fecal calprotectin,
and fecal lactoferrin to
exclude inammatory
bowel disease in adults
with IBS. Am J Gastroen-
terol. 2015;110:444-54.
[PMID: 25732419]
11. Cash BD, Rubenstein JH,
Young PE, Gentry A,
Nojkov B, Lee D, et al.
The prevalence of celiac
disease among patients
with nonconstipated
irritable bowel syndrome
is similar to controls.
Gastroenterology. 2011;
141:1187-93. [PMID:
21762658]
12. Begtrup LM, Engsbro AL,
Kjeldsen J, Larsen PV,
Schaffalitzky de Muck-
adell O, Bytzer P, et al. A
positive diagnostic strat-
egy is noninferior to a
strategy of exclusion for
patients with irritable
bowel syndrome. Clin
Gastroenterol Hepatol.
2013;11:956-62.e1.
[PMID: 23357491]
2017 American College of Physicians
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perineal descent, and is impor-
tant to exclude in patients with
constipation) as well as to rule
out rectal cancer (9). Such physi-
cal ndings as fever, weight loss,
lymph node enlargement, ab-
dominal mass, and hepatospleno-
megaly are typically not associated
with IBS and should prompt pur-
suit of other diagnoses.
Which diagnostic tests
are useful?
There are no specic diagnostic
tests for IBS. In patients who fulll
the symptom-based diagnostic
criteria for IBS and have no alarm
features, routine use of diagnos-
tic tests is not recommended.
Obtaining a complete blood
count and complete metabolic
panel and measuring C-reactive
protein is reasonable according
to current literature; these tests
are inexpensive and can reassure
both provider and patient (10). If
the clinical suspicion for thyroid
disease is high, a thyroid prole
should be obtained. A serologic
test for celiac disease (by mea-
suring levels of tissue transglu-
taminase antibody) may be use-
ful in nonconstipated patients
with IBSa recent large multi-
center trial showed that the prev-
alence of celiac disease in pa-
tients with IBS was appreciably
higher than in controls (11).
Endoscopy
Patients with symptoms compati-
ble with IBS, lack of alarm fea-
tures, and unremarkable prelimi-
nary laboratory tests do not
require additional invasive inves-
tigations. Of note, performing
invasive tests does not increase
patient satisfaction or improve
quality of life (12). Colonoscopy
should be considered when
alarm features are present or the
history or laboratory studies raise
concern about an underlying in-
ammatory condition. It should
also be considered based on the
indications for colon cancer
screening, especially in countries
ITC84 In the Clinic
with population screening
programs.
Evaluation of stool samples
Clostridium difcile infection
should be excluded in patients
with IBS-D who have recently re-
ceived antibiotics. Examination of
stool for ova and parasites may
also be helpful in these patients,
especially if travel history sug-
gests potential exposure to para-
sites. In general, bacterial cul-
tures are unlikely to be helpful.
Stool collection over a 24-hour
period for quantication of vol-
ume may be helpful in patients
who report large-volume or wa-
tery diarrhea. Normal stool vol-
ume is 200 mL or less per day.
Volumes exceeding 350 400 mL
suggest causes other than IBS.
Measurement of fecal calprotec-
tin in stool samples can help to
identify patients with intestinal
inammation as an organic cause
of symptoms mimicking IBS. A
recent systematic review showed
that fecal calprotectin levels less
than 40 mcg/g exclude inam-
matory bowel disease in patients
with IBS (10).
Imaging studies
Imaging studies are of limited
value and should be considered
on a case-by-case basis. A at
and upright abdominal radio-
graph during a pain episode may
show unrecognized bowel ob-
struction, aerophagia, or retained
stool. Small bowel barium radi-
ography can diagnose ileal and
jejunal Crohn disease as well as
dilatation or diverticula favoring
small bowel overgrowth. Com-
puted tomography scanning has
low yield if there are no alarm
symptoms.
Role of biomarkers
A biomarker is a characteristic
that can be objectively evaluated
or measured as an indicator of
normal biological processes,
pathogenic processes, or phar-
macologic responses to a thera-
Annals of Internal Medicine 6 June 2017

Symptom Criteria for Irritable
Bowel Syndrome
Rome IV criteria*
Recurrent abdominal pain, on
average 1 d/wk in the past
3 mo, related to 2 of the
following:
Defecation
Change in stool frequency
Change in stool form
(appearance)
Manning criteria
Pain relief with defecation,
often
Looser stool at pain onset,
often
More frequent stools at pain
onset, often
Visible abdominal distention
Mucus per rectum
Feeling of incomplete
evacuation
*Criteria should be fullled for the
past 3 mo with symptom onset 6
mo before diagnosis.
To establish IBS diagnosis,
patient must meet 3 criteria.
peutic intervention (13). A valid
biomarker in IBS can serve many
purposes, such as to facilitate
diagnosis, distinguish IBS from
organic illness, predict progno-
sis, discriminate between various
IBS subtypes to guide individual-
ized treatment, improve drug
development, and monitor thera-
peutic efcacy. Evidence and cur-
rent expert consensus do not
support application of biomark-
ers in routine clinical care of IBS
(14). However, some have ar-
gued that a few biomarkers (such
as colonic transit, bile acid mal-
absorption, and serotonin) are
highly prevalent in certain IBS
subgroups and may be used as a
potential target for therapy in
selected persons, thus leading to
a more personalized treatment
plan (15). Future research and
6 June 2017 Annals of Internal Medicine
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experience with these biomark-
ers will be required to establish
their effectiveness and role in
routine clinical practice.
What other conditions should
be considered during
evaluation of a patient with
possible IBS?
The differential diagnosis of IBS
is extensive (Table 1). Thus,
some clinicians feel obligated to
perform a wide variety of diag-
nostic tests before attributing a
patient's symptoms to IBS. How-
ever, no denitive data support
routine performance of any diag-
nostic tests in patients with po-
tential IBS. Clinicians should con-
sider symptom patterns when
trying to exclude serious diagno-
ses that can masquerade as IBS.
Patients with IBS-C
In patients with IBS-C, clinicians
should consider partial colonic
obstruction or non-IBS causes of
colonic dysmotility. Nonobstruc-
tive causes of colonic symptoms
are dysmotility secondary to
medications, neurologic disease,
hypothyroidism, pelvic oor dys-
function, or colonic inertia (colon
transit >5 days). Colonic dysmo-
tility present without pain or an-
other explanation for symptoms,
such as neurologic disorder, pel-
vic oor disorder, or colonic iner-
tia (<80% evacuation of sitz mark-
ers at day 5, with predominantly
right colon delay), rules out IBS.
In patients younger than 45 years 13. Biomarkers Denitions
with mild, chronic IBS-C; normal Working Group. Bio-
complete blood count; and no
markers and surrogate
endpoints: preferred
alarm features, treatment with denitions and concep-
tual framework. Clin
ber or an osmotic laxative Pharmacol Ther. 2001;
should be offered before further 69:89-95. [PMID:
11240971]
diagnostic testing. 14. Barbara G, Stanghellini
V. Biomarkers in IBS:
when will they replace
Patients with IBS-D symptoms for diagnosis
The differential diagnosis in pa- and management? Gut.
2009;58:1571-5. [PMID:
tients with IBS-D includes inam- 19923339]
15. Camilleri M. Review
matory bowel disease, infection, article: biomarkers and
malabsorption, and effects of personalised therapy in
functional lower gastroin-
medication and diet. Excessive testinal disorders. Ali-
consumption of lactose, fructose, ment Pharmacol Ther.
2015;42:818-28. [PMID:
and caffeine may result in loose 26264216]
In the Clinic ITC85 2017 American College of Physicians
 Table 1. Differential Diagnosis of Irritable Bowel Syndrome*
Disease
Constipation-predominant
symptoms
Strictures due to inammatory
bowel disease, diverticulitis,
ischemia, or cancer
Colonic inertia
Pelvic oor dysfunction
Neurologic disease
Medication
Hypothyroidism
Diarrhea-predominant symptoms
Crohn disease
Ulcerative colitis
Microscopic colitis
Infectious
Clostridium difcile infection
Small bowel bacterial overgrowth
Celiac disease
Lactose intolerance
Hyperthyroidism
Neuroendocrine tumor
Pain-predominant symptoms
Aerophagia, bloating
Intermittent small bowel
obstruction
Acute intermittent porphyria
Ischemia
Chronic pancreatitis
Lymphoma of gastrointestinal
tract
Endometriosis
* CT = computed tomography; 5HIAA = 5-hydroxyindoleacetic acid; VIP = vasoactive intestinal peptide.
Unlikely alone to cause abdominal pain.
2017 American College of Physicians
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Clinical Characteristics
Obstipation, constipation
Very infrequent bowel movements
Straining, self-digitation
Concurrent Parkinson disease, autonomic
dysfunction (Shy-Drager), multiple
sclerosis
Opiates, cholestyramine, calcium-channel
blockers, anticholinergic medications
Other signs and symptoms of
hypothyroidism
Diarrhea, abdominal pain
Likely to have rectal bleeding in addition to
diarrhea, abdominal pain, tenesmus
Watery diarrhea often with nocturnal
symptoms
Abdominal discomfort, diarrhea especially
in the setting of recent travel
Recent antibiotic treatment
Diarrhea, bloating, abdominal distention
Diarrhea, usually steatorrhea, anemia
Symptoms worse with lactose consumption
Loose stools and other features of
hyperthyroidism
Carcinoid, gastrinoma, VIP-producing
tumor
Patient may be anxious (nervous air
swallowing), can be exacerbated by
antireux surgery
More likely with history of previous
abdominal surgeries
Rare; may have elevated liver enzymes and
neurologic symptoms
Intestinal angina especially in patients with
atherosclerosis, food aversion, weight
loss, pain 1540 min after meals
Epigastric pain usually more persistent than
with usual irritable bowel syndrome
Weight loss (typically)
Menstrual-associated symptoms, pelvic
symptoms
ITC86 In the Clinic
Possible Diagnostic Strategies
CT scan, colonoscopy, exible
sigmoidoscopy, barium enema
Radiopaque markers, scintigraphy, wireless
pH and motility capsule
Rectal examination, balloon expulsion study,
anorectal manometry, defecography
History and neurologic examination
Medication history
Serum thyroid-stimulating hormone
Colonoscopy, CT enterography, magnetic
resonance enterography, small bowel
barium radiograph
Colonoscopy
Colonoscopy/exible sigmoidoscopy and
biopsy
Ova and parasites x 3, stool culture, stool
Giardia antigen, metronidazole trial
Stool polymerase chain reaction
Jejunal aspirate, lactulose breath hydrogen
test, antibiotic trial
Tissue transglutaminase antibody,
endoscopy with small bowel biopsy
Avoidance trial, lactose breath test
Serum thyroid-stimulating hormone
Urine 5HIAA, fasting gastrin (followed by
secretin stimulation test), serum VIP
Abdominal radiograph
Abdominal radiograph, CT scan, small
bowel barium radiograph
Serum and urine porphyrins, especially
porphobilinogen, and -aminolevulinic
acid
CT angiography, Doppler ultrasonography,
mesenteric angiography
Abdominal radiograph to assess for
calcications, CT scan, endoscopic
ultrasonography
CT scan, small bowel radiograph
Laparoscopy
Annals of Internal Medicine 6 June 2017
 stools in susceptible patients. For
patients older than 45 years or
those with refractory, severe, or
new-onset symptoms, evaluating
the entire colon may be warrant-
ed; however, clinicians must re-
member that IBS is likely if the
patient satises Rome criteria
and lacks alarm symptoms. Stud-
ies have shown considerable
symptom overlap between IBS-D
and microscopic colitis (16). Al-
though there are no clear guide-
lines on when to perform colono-
scopy with random biopsies to
rule out microscopic colitis in
patients with IBS-D, colonos-
copy with biopsy should be
considered if symptoms con-
tinue despite adequate initial
therapy or in middle-aged or
older patients with new-onset
diarrhea (17).
Patients with pain-predominant
IBS
In patients with refractory pain-
predominant symptoms, a at
and upright abdominal radio-
graph during a pain episode can
help to reveal unrecognized
bowel obstruction, aerophagia,
or retained stool. Serum amylase
and liver enzyme levels may be
measured to exclude pancreatic
and biliary disease if patients
have suggestive symptoms.
Computed tomography scanning
for neoplasms has low yield if
there are no alarm symptoms.
Other rare conditions that may
cause pain-predominant abdomi-
nal symptoms with bowel dys-
function include intestinal angina
(generally associated with weight
loss and occult blood) and endo-
metriosis (generally cyclic with
menstruation). Clinicians should
use their clinical judgment to
guide the degree of evaluation
necessary.
Under what circumstances
should clinicians consider
consultation with a
gastroenterologist?
Consultation is warranted when
patients do not meet Rome or
Manning criteria, when they have
alarm symptoms, and when they
do not respond to initial manage-
ment. Consultation also is neces-
sary if specialized diagnostic pro-
cedures, such as endoscopy, are
needed.

Diagnosis... Clinicians should base the diagnosis of IBS on history and

physical examination, paying careful attention to fulllment of the Rome
criteria and exclusion of alarm features. Patients who fulll the criteria
and have no alarm features may not need additional testing other than
a complete blood count and a fecal occult blood test to establish a pre-
sumptive IBS diagnosis. Testing should be judicious and focus on ex-
cluding specic non-IBS conditions that are consistent with the clinical
presentation of each individual patient.

CLINICAL BOTTOM LINE

16. Guagnozzi D, Arias A,
Lucendo AJ. Systematic
review with meta-analy-
sis: diagnostic overlap of

Treatment microscopic colitis and

functional bowel disor-
ders. Aliment Pharmacol
Treatment of IBS requires a multi- predominant symptoms and their Ther. 2016;43:851-862.
disciplinary approach. Although severity. [PMID: 26913568]
17. Hilpusch F, Johnsen PH,
many patients with mild IBS re- Goll R, Valle PC, Srbye
spond to lifestyle and dietary mod- Is dietary modication effective SW, Abelsen B. Micro-
scopic colitis: a missed
ications, those with ongoing in management of IBS? diagnosis among pa-
tients with moderate to
symptoms require additional Dietary modication has not severe irritable bowel
pharmacologic and behavioral been proved to reduce IBS symp- syndrome. Scand J Gas-
troenterol. 2017;52:173-
therapies depending on the toms; however, it is reasonable to 177. [PMID: 27796144]

6 June 2017 Annals of Internal Medicine In the Clinic ITC87 2017 American College of Physicians

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19. Gibson PR, Shepherd SJ.
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20. Moayyedi P, Quigley EM,
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YA, Schiller LR, et al. The
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Complementary and
alternative medicines in
irritable bowel syn-
drome: an integrative
view. World J Gastroen-
terol. 2014;20:346-62.
[PMID: 24574705]
23. Villoria A, Serra J, Azpiroz
F, Malagelada JR. Physi-
cal activity and intestinal
gas clearance in patients
with bloating. Am J
Gastroenterol. 2006;
101:2552-7. [PMID:
17029608]
24. Schumann D, Anheyer D,
Lauche R, Dobos G, Lang-
horst J, Cramer H. Effect
of yoga in the therapy of
irritable bowel syn-
drome: a systematic
review. Clin Gastroen-
terol Hepatol. 2016;14:
1720-1731. [PMID:
27112106]
2017 American College of Physicians
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consider dietary changes for per-
sons in whom specic foods
seem to trigger symptoms. The
patient should receive general
counseling about avoidance of
foods that can exacerbate symp-
toms, such as excess fats (which
can lead to gas retention); certain
carbohydrates, such as beans,
cabbage, broccoli, and cauli-
ower (which are difcult to di-
gest and can lead to fermenta-
tion and gas formation); and
excess caffeine or carbonated
drinks as well as judicious water
intake (especially in patients with
IBS-C) (18).
Major exclusion diets, such as
a gluten-free diet or a low
FODMAP (fermentable oligosac-
charides, disaccharides, mono-
saccharides, and polyols) diet,
are not routinely recommended.
Consumption of FODMAPs
should generally be limited in
patients who report bloating,
gas, or excess atulence, but evi-
dence supporting elimination
diets is limited. In a small subset
of patients, a low FODMAP diet
may be a reasonable treatment
option; however, this strategy
should only be initiated in con-
sultation with a nutritionist or di-
etitian (19).
Inadequate ber consumption
may contribute to constipation in
patients with IBS-C. Increased
ber intake (dietary or supple-
mental) is often recommended as
a rst-line treatment, although
ber-related gas production can
exacerbate bloating and atu-
lence in patients with IBS. Soluble
ber, such as polycarbophil com-
pounds (e.g., Citrucel or Fiber-
Con) and ispaghula, are pre-
ferred over insoluble ber, such
as bran.
A recent meta-analysis of 14 randomized con-
trolled trials (RCTs) with 906 patients found a
small benet of soluble ber for IBS (relative
risk [RR], 0.83 [95% CI, 0.73 0.94]), with a
number needed to treat of 10. However, ber
ITC88 In the Clinic
consumption varied across studies (5-30 g/d),
and the trials were short (3-16 weeks) (20).
Are there nonpharmacologic
interventions aside from diet
that are useful in management?
Nonpharmacologic interventions
that are effective in reducing IBS
symptoms include patient reas-
surance and education. Clinicians
must reassure patients that their
symptoms are not caused by a
life-threatening disorder, edu-
cate them about the role of psy-
chosocial stressors, and assist
in developing effective self-
management strategies. Patients
do better and use health care
more efciently when it is ac-
knowledged that their symptoms
have physiologic causes that are
poorly understood but real and
that they themselves can control
symptom triggers (21).
Regular exercise is an important
lifestyle adjustment that should
be recommended to patients
with IBS (22). Mild exercise, such
as walking, has been shown to
reduce IBS symptoms and allevi-
ates bloating and gas production
(23). Yoga, consisting of different
postures accompanied by
breathing patterns focusing at-
tention on muscle contraction
and relaxation, has also been
shown to benet patients with
IBS (24). Other forms of stress
management include meditation,
counseling and support, and
adequate sleep.
A recent systematic review of 6 RCTs (n = 273
patients) demonstrated the benecial effects
of yoga over conventional treatments with de-
creased bowel symptoms, decreased IBS se-
verity, and decreased anxiety (24). However,
the individual studies had signicant method-
ological aws.
What is the role of behavioral
therapy or psychotherapy?
The overlap of psychological dis-
orders with IBS has led to the in-
vestigation of several behavioral
therapies to help reduce IBS
symptoms. The 4 major psycho-
Annals of Internal Medicine 6 June 2017
 logically based therapies for pa-
tients with IBS are cognitive be-
havioral therapy (CBT),
psychodynamic (interpersonal)
therapy, hypnotherapy (gut-
directed hypnosis), and
mindfulness-based therapy.
Although the evidence is mixed
with regard to long-term im-
provement in gastrointestinal
symptoms with successful treat-
ment of psychiatric comorbidities
and behavioral therapies, data
show that CBT, psychotherapy,
and hypnotherapy are more ef-
fective than usual care in reliev-
ing global symptoms of IBS (low-
quality evidence) (25). The best
available evidence is for CBT,
which teaches patients tech-
niques for changing their behav-
ior and thought processes about
their condition. CBT has been
shown to improve quality of life
and reduce symptom severity in
patients with IBS, especially with
regard to pain perception and
comorbid depressive and anxiety
disorders. The number needed
to treat for CBT is 3 patients,
which is superior to most drug
therapies (25). Limited small
studies suggest that integrating
both conventional pharmaco-
therapy and behavioral therapies
may provide the best symptom
relief and highest quality of life to
patients with IBS (22). The Na-
tional Institute for Health and
Care Excellence guidelines rec-
ommend adjunctive psychother-
apy for patients whose symptoms
do not respond to pharmaco-
therapy after 12 months or who
have continued symptoms (26).
Which pharmacologic
therapies are effective?
Current pharmacologic treat-
ments (Table 2) are generally
aimed at improving 1 or more of
the predominant symptoms, such
as abdominal pain or bloating,
constipation, or diarrhea.
6 June 2017 Annals of Internal Medicine
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Treatments aimed at improving
global symptoms, abdominal
pain, or bloating
Antispasmodics. Antispasmodics
are indicated on an as-needed
basis as a rst-line treatment to
alleviate abdominal spasms and
cramps associated with IBS. Al-
though antispasmodic agents are
pharmacologically diverse, they
all reduce pain by reducing
smooth muscle contraction and
may have an effect on visceral
hypersensitivity (27). Only 3 of
these agents dicyclomine, hyo-
scyamine, and peppermint oil
are available in the United States.
Whether antispasmodics are
more efcacious in specic IBS
subtypes is unclear, but regular
use in patients with constipation
may be limited due to anticholin-
25. Ford AC, Quigley EM,
ergic effects. Although these Lacy BE, Lembo AJ, Saito
medications are often recom- YA, Schiller LR, et al.
Effect of antidepressants
mended for treatment of post- and psychological thera-
pies, including hypno-
prandial IBS symptoms, use for
therapy, in irritable
this indication has not been spe- bowel syndrome: sys-
tematic review and meta-
cically evaluated in clinical trials. analysis. Am J Gastroen-
terol. 2014;109:1350-
The most common adverse
65; quiz 1366. [PMID:
events are dry mouth, dizziness, 24935275]
26. National Institute for
and blurred vision. Health and Care Excel-
lence. Irritable bowel
A meta-analysis of 22 RCTs (n = 2893 pa- syndrome in adults.
Diagnosis and manage-
tients) with 12 antispasmodics found that ment of irritable bowel
these agents led to clinically meaningful im- syndrome in primary
care. (Clinical guideline
provement in global symptoms and abdom- 61.) 2013.
27. Khalif IL, Quigley
inal pain (RR, 0.74 [CI, 0.59 0.93]). The ef- EM, Makarchuk PA,
fect of individual agents was difcult to Golovenko OV,
Podmarenkova LF,
interpret given the small number of studies Dzhanayev YA. Interac-
evaluating each drug. Although the overall tions between symptoms
and motor and visceral
quality of evidence was low, this meta- sensory responses of
analysis supports the utility of antispasmod- irritable bowel syndrome
ics in IBS management (28).
patients to spasmolytics
(antispasmodics). J Gas-
trointestin Liver Dis.
2009;18:17-22. [PMID:
Antidepressants. Low-dose anti- 19337628]
depressants are recommended 28. Ruepert L, Quartero AO,
de Wit NJ, van der Hei-
in patients who are refractory to jden GJ, Rubin G, Muris
antispasmodics and dietary alter- JW. Bulking agents,
antispasmodics and
ations. Tricyclic antidepressants antidepressants for the
(TCAs) and selective serotonin treatment of irritable
bowel syndrome. Co-
reuptake inhibitors are com- chrane Database Syst
Rev. 2011:CD003460.
monly used to treat depression, [PMID: 21833945]
anxiety, and neuropathic pain; 29. Gershon MD, Tack J. The
serotonin signaling sys-
however, the mechanism of ac- tem: from basic under-
standing to drug devel-
tion of these drugs in IBS is un- opment for functional GI
clear (29). They may take several disorders. Gastroenterol-
ogy. 2007;132:397-414.
weeks to work, and the required [PMID: 17241888]
In the Clinic ITC89 2017 American College of Physicians
 Table 2. Medications Commonly Used to Treat Irritable Bowel Syndrome
Class/Examples Mechanism of Action Benets Adverse Events
Treatments aimed at
improving global
symptoms, abdominal
pain, or bloating
Antispasmodics: Reduce smooth muscle contractions Useful for treatment of abdominal Dry mouth, dizziness,
Dicyclomine, and possibly reduce visceral spasms and cramps associated blurred vision
hyoscyamine, hypersensitivity with IBS; can be taken on an
peppermint oil as-needed basis
Antidepressants: May have analgesic properties in Effective in improving global Dry mouth and
Tricyclics, SSRIs addition to mood-improving symptoms and abdominal pain. drowsiness. Tricyclics
effects, but exact mechanism of SSRIs may be benecial in can reduce intestinal
action is unclear individuals with coexisting transit and exacerbate
depression constipation
Antibiotic: Rifaximin Alters gut microbiota Given as a 2-wk course. Shown to No adverse events
improve global IBS symptoms
and particularly bloating

Treatments aimed at
IBS-C
Osmotic laxative: Causes water to be retained in the
Polyethylene glycol colon leading to softer stools and
increased stool frequency
Guanylate cyclase C Induces intestinal chloride and
agonist: Linaclotide bicarbonate secretion via
activation of the cystic brosis
transmembrane conductance
regulator, resulting in acceleration
of intestinal transit; may also have
an analgesic effect
Used as rst-line treatment for Generally well-tolerated,
IBS-C. Effective in improving may worsen bloating
symptoms associated with
constipation, including
improved stool consistency,
increased frequency, and
decreased straining
Effective as second-line treatment Most common treatment-
in IBS-C patients. Shown to related adverse event
reduce abdominal pain, leading to discontinua-
improve constipation, improve tion was diarrhea
global symptoms, and improve
health-related quality of life

Treatments aimed at
IBS-D
Antidiarrheal: Inhibits peristalsis leading to Effective as rst-line treatment in Generally well-tolerated
Loperamide prolonged transit time and IBS-D or mixed IBS. Shown to
reduced stool frequency reduce stool frequency but
has no effect on global IBS
symptoms, abdominal pain,
or bloating
Selective 5-HT3 Decreases colonic motility and Approved for use in women who Ischemic colitis, severe
receptor antagonist: secretion have had severe IBS-D >6 mo constipation (leading
Alosetron and failure of conventional to an alosetron
treatment. Improves global prescribing program)
symptoms, abdominal pain,
and stool consistency
-opioid receptor Leads to slower gastrointestinal Newer agent effective in Nausea, constipation,
agonist and -opioid transit and decreased visceral improving abdominal pain abdominal pain, and
receptor antagonist: pain and diarrhea pancreatitis
Eluxadoline

HT3 = hydroxytryptamine3; IBS-C = constipation-predominant irritable bowel syndrome; IBS-D = diarrhea-predominant irritable
bowel syndrome; SSRI = selective serotonin reuptake inhibitor.

dosage is much lower than that
used to treat depression. TCAs
can be combined with antispas-
modics and, when taken at night,
may improve sleep due to the
side effects of fatigue and drows-
iness. These drugs are generally
started at low doses and in-
creased gradually. Selective sero-
tonin reuptake inhibitors may be
most helpful in persons with IBS
and depression and may help
improve the patient's perception
of illness and overall well-being.

2017 American College of Physicians ITC90 In the Clinic Annals of Internal Medicine 6 June 2017

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 A recent systematic review of 8 RCTs examined
various TCAs (amitriptyline, desipramine, tri-
mipramine, imipramine, and doxepin) in 523
patients with several subtypes of IBS. It found
an improvement in global symptoms and ab-
dominal pain, although the overall quality of
evidence was low. Adverse effects, including
dry mouth and drowsiness, were common and
often led to treatment withdrawal (30).
Manipulation of gut microora.
Alterations in gut ora have been
identied in patients with IBS,
and small intestinal bacterial
overgrowth may play a role in
symptoms (31). Rifaximin is a
poorly absorbed antibiotic that
has been shown to globally im-
prove IBS symptoms as well as
bloating, with a number needed
to treat of 11 patients (30). In
contrast to other treatments,
which are taken daily, rifaximin is
administered at 550 mg 3 times
per day for 14 days. Its efcacy
older adults and those with renal
impairment because of the risk
for electrolyte abnormalities and
dehydration. Lactulose, also an
osmotic laxative, should be
avoided in patients with IBS be-
cause it is broken down by co-
lonic ora and produces exces-
sive gas. Polyethylene glycol, a
long-chain polymer of ethylene
oxide, is a large molecule that
causes water to be retained in
the colon, which softens the stool
and increases the number of
bowel movements. It is approved
by the U.S. Food and Drug Ad-
30. Chang L, Lembo A, Sul-
ministration (FDA) for short-term tan S. American Gastro-
(2-week) treatment in adults and enterological Association
Institute Technical Re-
children with occasional consti- view on the pharmaco-
logical management of
pation and is commonly pre-
irritable bowel syn-
scribed for patients with IBS (34). drome. Gastroenterol-
ogy. 2014;147:1149-
It is considered safe and effective 72.e2. [PMID:
25224525]
for moderate to severe constipa- 31. Shanahan F, Quigley EM.

may diminish over time, necessi- tion when used daily or as needed. Manipulation of the
microbiota for treatment
tating repeated treatment. Probi- of IBS and IBD-
Linaclotide, a minimally ab- challenges and contro-
otics may work through direct sorbed guanylate cyclase C ago- versies. Gastroenterol-
ogy. 2014;146:1554-63.
alteration of microbiota or indi- nist, induces secretion of intesti- [PMID: 24486051]
rectly via gut immune modula- nal chloride and bicarbonate via
32. Ford AC, Quigley EM,
Lacy BE, Lembo AJ, Saito
tion, but their exact mechanism is activation of the cystic brosis YA, Schiller LR, et al.
not yet known (31). Efcacy of prebiotics,
transmembrane conductance probiotics, and synbiotics
in irritable bowel syn-
Low-quality data show a modest regulator, resulting in accelera- drome and chronic idio-
tion of intestinal transit; it also pathic constipation:
benet of probiotics on global systematic review and
IBS as well as abdominal pain, has an analgesic effect (35). Lina- meta-analysis. Am J
Gastroenterol. 2014;
bloating, and atulence, with a clotide is approved for treatment 109:1547-61; quiz
number needed to treat of 4; of IBS-C at a dosage of 290 1546, 1562. [PMID:
25070051]
however, these studies have mcg/d and can be used as 33. Mazurak N, Broelz E,
Storr M, Enck P. Probiotic
methodological limitations (32). second-line therapy after laxa- therapy of the irritable
Furthermore, determining who is tives have failed in patients with bowel syndrome: why is
the evidence still poor
most likely to benet, the optimal moderate to severe symptoms. and what can be done
about it? J Neurogastro-
formulation of organisms, and the It is effective in reducing ab- enterol Motil. 2015;21:
optimal dose and duration of treat- dominal pain as well as consti- 471-85. [PMID:
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ment is not well-understood (33). pation symptoms; however, the 34. McGraw T. Safety of
polyethylene glycol 3350
maximal effect on abdominal solution in chronic con-
Treatments for IBS-C
pain relief may take up to 12 stipation: randomized,
In patients with IBS-C, osmotic placebo-controlled trial.
weeks. Diarrhea is the most Clin Exp Gastroenterol.
laxatives, such as polyethylene 2016;9:173-80. [PMID:
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Hughes PA, Martin CM,
movements and improve consti- ally mild to moderate. Ge P, Shea CM, et al.
Linaclotide inhibits co-
pation symptoms (34). Hyper- High-quality evidence supports use of linac- lonic nociceptors and
relieves abdominal pain
tonic osmotic laxatives, such as lotide for the treatment of patients with via guanylate cyclase-C
milk of magnesia, magnesium IBS-C, based on 3 RCTs involving 1773 pa- and extracellular cyclic
guanosine 3,5-
citrate, and sodium phosphate, tients. Patients treated with linaclotide had monophosphate. Gastro-
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6 June 2017 Annals of Internal Medicine In the Clinic ITC91 2017 American College of Physicians

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36. Drossman DA, Chey WD,
Johanson JF, Fass R,
Scott C, Panas R, et al.
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tone in patients with
constipation-associated
irritable bowel syn-
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controlled studies. Ali-
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37. Efskind PS, Bernklev T,
Vatn MH. A double-blind
placebo-controlled trial
with loperamide in irrita-
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Scand J Gastroenterol.
1996;31:463-8. [PMID:
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38. Lavo B, Stenstam M,
Nielsen AL. Loperamide
in treatment of irritable
bowel syndromea
double-blind placebo
controlled study. Scand J
Gastroenterol Suppl.
1987;130:77-80. [PMID:
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39. Hovdenak N. Lopera-
mide treatment of the
irritable bowel syn-
drome. Scand J Gastro-
enterol Suppl. 1987;
130:81-4. [PMID:
3306904]
40. Tong K, Nicandro JP,
Shringarpure R, Chuang
E, Chang L. A 9-year
evaluation of temporal
trends in alosetron post-
marketing safety under
the risk management
program. Therap Adv
Gastroenterol. 2013;6:
344-57. [PMID:
24003335]
41. Dove LS, Lembo A, Ran-
dall CW, Fogel R, Andrae
D, Davenport JM, et al.
Eluxadoline benets
patients with irritable
bowel syndrome with
diarrhea in a phase 2
study. Gastroenterology.
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[PMID: 23583433]
42. Lembo AJ, Lacy BE, Zuck-
erman MJ, Schey R,
Dove LS, Andrae DA,
et al. Eluxadoline for
irritable bowel syndrome
with diarrhea. N Engl J
Med. 2016;374:242-53.
[PMID: 26789872]
43. Foxx-Orenstein AE. New
and emerging therapies
for the treatment of
irritable bowel syn-
drome: an update for
gastroenterologists.
Therap Adv Gastroen-
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[PMID: 27134665]
2017 American College of Physicians
Downloaded From: http://annals.org/pdfaccess.ashx?url=/data/journals/aim/936261/ by a University of California San Diego User on 06/05/2017
proved symptoms, and improved health-
related quality of life (30).
Lubiprostone, a type 2 chloride-
channel activator, stimulates
uid secretion and accelerates
intestinal transit (36). It is FDA-
approved at a dose of 8 mcg
twice daily for treatment of adult
women with IBS-C. Lubiprostone
has been shown to improve
global symptoms in patients
with IBS-C (30).
Treatments for IBS-D
Loperamide, a nonabsorbable
synthetic -opioidreceptor ago-
nist, is a rst-line agent for treat-
ment of diarrhea in patients with
IBS-D. It inhibits peristalsis, result-
ing in prolonged intestinal transit
(37). It can be taken as needed or
on a scheduled basis, depending
on the severity and frequency of
symptoms. Two small, double-
blind RCTs (38, 39) have evalu-
ated loperamide in patients with
IBS. It was effective in reducing
diarrhea; however, the overall
quality of evidence was low and
data are lacking with regard to
efcacy in relieving specic gas-
trointestinal symptoms, such as
abdominal pain. No identied
safety concerns have been asso-
ciated with repeated use of lop-
eramide (30).
Alosetron, a selective 5-hydroxy-
tryptamine3receptor antagonist,
reduces pain and diarrhea in pa-
tients with IBS-D by increasing
colonic compliance and reducing
intestinal transit. Alosetron was
originally approved by the FDA
in 2000 for treatment of IBS-D in
women; however, it was volun-
tarily withdrawn from the market
due to serious adverse events,
namely ischemic colitis and seri-
ous complications of constipa-
tion. In 2002, the FDA approved
reintroduction under a risk man-
agement program and restricted
use to women with severe symp-
toms (frequent and severe ab-
dominal pain or discomfort, fre-
ITC92 In the Clinic
quent bowel urgency or fecal
incontinence, and disability or
restriction of daily activities due
to IBS) who have not responded
to conventional therapy. In a
9-year follow-up postmarketing
safety study, the incidence of
ischemic colitis was 1.03 cases
per 1000 patient-years and the
incidence rate of serious compli-
cations of constipation was 0.25
case per 1000 patient-years (40).
Overall, moderate-quality evi-
dence suggests that alosetron
results in clinically meaningful
improvements in global symp-
toms and reduces abdominal
pain and discomfort.
Eight RCTs in 4227 patients compared the ef-
cacy of alosetron versus placebo in patients
with predominantly IBS-D and found a reduc-
tion in abdominal pain (RR, 0.83 [CI, 0.79
0.88]), and 2 RCTs in 1506 patients showed a
clinically meaningful improvement in global
symptoms (30).
Eluxadoline is a newer -opioid
receptor agonist and -opioid
receptor antagonist that was ap-
proved in May 2015 to treat
IBS-D. The recommended dose is
100 mg taken orally twice daily
with food. Adverse effects in-
clude nausea, abdominal pain,
constipation, pancreatitis, and
sphincter of Oddi dysfunction
(41).
In 2 phase 3 RCTs (n = 2427 patients), treat-
ment with eluxadoline (75 or 100 mg) twice
daily improved abdominal pain and stool consis-
tency and decreased episodes of urgency and in-
continence during the 3-month treatment period
(42).
New drugs
Several new drugs are being
studied for the treatment of IBS
(43). Ramosetron, a serotonin
receptor antagonist, may be bene-
cial in patients with IBS-D. Pleca-
natide, a guanylate cyclase C ago-
nist, may be benecial in patients
with IBS-C. Furthermore, IBS ther-
apy is moving from a symptom-
based to a hypothesis-based
approach. Rather than treating
symptoms, these new ap-
Annals of Internal Medicine 6 June 2017
 Table 3. Alternative and Herbal Therapies for Irritable Bowel Syndrome
Therapy Proposed Action Notes (Reference)
Peppermint oil Inhibits smooth muscle contraction and functions as Multiple RCTs show superiority to placebo for
an antispasmodic global improvement of symptoms and
improvement in abdominal pain. The most
common side effect was heartburn (46)
STW5 (Iberogast) A liquid, multidrug, herbal supplement containing Several studies have been done in functional
bitter candytuft, angelica root, chamomile owers, gut disorders. In 1 RCT, STW5 was associated
caraway fruit, St. Mary's thistle, lemon balm leaves, with a reduction in abdominal pain and
peppermint leaves, celandine, and licorice root global symptoms (44)
Padma Lax Tibetan herbal formula Associated with improvement in global
symptoms in 1 RCT (n = 61 patients) (47)
Traditional Herbal formula consisting of multiple dried herbs In 1 RCT (n = 119 patients), a standard Chinese
Chinese herbal formula as well as an individualized
medicine formula designed by a Chinese medical
herbalist was associated with improvement
in symptoms (48)

RCT = randomized controlled trial.

proaches aim to treat the under- There are no specic data on

lying pathophysiology. Agents
being investigated include a
-opioidreceptor antagonist
with peripheral analgesic effects
(asimadoline), a neurokinin-2
receptor antagonist (ibodutant),
luminal adsorbents for IBS-D
(AST-120), bile acid binders for
IBS-C (chenodeoxycholic acid),
and mast cell stabilizers (keto-
tifen). Finally, fecal transplanta-
tion and sacral nerve stimulation
are also being explored.
Is there evidence to support the
effectiveness of alternative
medicine or herbal treatments?
Patients with IBS frequently try
which to base a recommendation
on the frequency or components 44. Ottillinger B, Storr M,
of follow-up for patients with IBS. Malfertheiner P, All-
escher HD. STW 5 (Ibe-
A commonsense approach in- rogast)a safe and
effective standard in the
cludes monitoring for alarm fea- treatment of functional
tures and progression of symp- gastrointestinal disor-
ders. Wien Med
toms and managing psychosocial Wochenschr. 2013;163:
stressors. The typical symptom 65-72. [PMID:
23263639]
course in IBS is chronic and uctu- 45. Madisch A, Holtmann G,
Plein K, Hotz J. Treat-
ating. Clinicians should consider ment of irritable bowel
additional diagnostic tests or refer- syndrome with herbal
preparations: results of a
ral if alarm features develop or if double-blind, random-
symptoms are refractory and per- ized, placebo-controlled,
multi-centre trial. Ali-
sistent. Clinicians should empha- ment Pharmacol Ther.
size to patients that the long-term 2004;19:271-9. [PMID:
14984373]
prognosis is good, which may help 46. Khanna R, MacDonald
JK, Levesque BG. Pep-
reduce distress. permint oil for the treat-
ment of irritable bowel

nontraditional or herbal thera- When should the clinician syndrome: a systematic

review and meta-
pies, particularly if traditional ap- consider consulting a specialist? analysis. J Clin Gastroen-
terol. 2014;48:505-12.
proaches to treatment do not When management strategies are [PMID: 24100754]
relieve their symptoms. Although not effective, clinicians should con- 47. Sallon S, Ben-Arye E,
Davidson R, Shapiro H,
many herbal therapies are mar- sider consulting a gastroenterolo- Ginsberg G, Ligumsky M.
gist. Gastroenterologists may have A novel treatment for
keted for IBS, only STW5 (Ibe- constipation-
rogast) (44, 45), peppermint oil greater knowledge of treatment predominant irritable
bowel syndrome using
(46), Padma Lax (47), and tradi- options because of their increased Padma Lax, a Tibetan
tional Chinese medicine have familiarity with the disorder. Clini- herbal formula. Diges-
tion. 2002;65:161-71.
shown promise in clinical trials cians should consider referral to a [PMID: 12138321]
mental health professional for pa- 48. Bensoussan A, Kellow JE,
(48) (Table 3). Bourchier SJ, Fahey P,
tients with refractory symptoms Shim L, Malcolm A, et al.
What components of care leading to impaired quality of life Efcacy of a Chinese
herbal medicine in pro-
should the clinician integrate or major depression, anxiety disor- viding adequate relief of
constipation-
into follow-up? der, or somatization disorders. predominant irritable
bowel syndrome: a ran-
domized controlled trial.
Clin Gastroenterol Hepa-
tol. 2015;13:1946-
54.e1. [PMID:
26133902]

6 June 2017 Annals of Internal Medicine In the Clinic ITC93 2017 American College of Physicians

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 Treatment... General measures, such as establishing an effective
patientprovider relationship, educating patients about IBS, and imple-
menting lifestyle changes (including dietary advice and stress manage-
ment), are essential to effective IBS management. If lifestyle changes do
not completely relieve IBS symptoms, several medications may be help-
ful. Drug therapy should target the individual patient's symptom pat-
tern, and options include antispasmodics, laxatives, antidiarrheal
agents, 5-hydroxytryptamine3receptor antagonists, antidepressants,
and manipulation of microora.

CLINICAL BOTTOM LINE

Practice Improvement
What do professional Bowel Syndrome (50), and the
organizations recommend for 2008 National Institute for Health
the care of patients with IBS? and Care Excellence guidelines
Several clinical practice guide- from the United Kingdom (26).
lines have been developed to Are there performance
help providers manage patients measures related to the
with IBS. These include the 2014
care of patients with IBS?
American Gastroenterological
Current proposed performance
Association Institute Technical
measures in the United States do
Review and Guideline on the
not include any measures speci-
Pharmacological Management of
cally related to the care of pa-
Irritable Bowel Syndrome (30,
tients with IBS; however, the
49), the American College of
quality of the physicianpatient
Gastroenterology Monograph on
interaction is paramount.
the Management of Irritable

49. Weinberg DS, Smalley

W, Heidelbaugh JJ,
Sultan S; American Gas-
troenterological Associa-
tion. American Gastroen-
terological Association
Institute Guideline on
the pharmacological
management of irritable
bowel syndrome. Gastro-
enterology. 2014;147:
1146-8. [PMID:
25224526]
50. Ford AC, Moayyedi P,
Lacy BE, Lembo AJ, Saito
YA, Schiller LR, et al; Task
Force on the Manage-
ment of Functional
Bowel Disorders. Ameri-
can College of Gastroen-
terology monograph on
the management of
irritable bowel syndrome
and chronic idiopathic
constipation. Am J Gas-
troenterol. 2014;109
Suppl 1:S2-26; quiz S27.
[PMID: 25091148] doi:10
.1038/ajg.2014.187

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 In the Clinic Patient Information
https://www.gastro.org/patient-center/IBS_Brochure

Tool Kit
_Online.pdf
Information from the American College of

IntheClinic
Gastroenterology.
www.mayoclinic.org/diseases-conditions/irritable-bowel
-syndrome/basics/denition/con-20024578
Detailed information on symptoms, risk factors,
preparing for the doctor's appointment, and general
Irritable Bowel clinical information from the Mayo Clinic.

Syndrome https://www.niddk.nih.gov/health-information
/digestive-diseases/irritable-bowel-syndrome
Information from the National Institutes of Health.
https://www.healthinfotranslations.org/pdfDocs
/IBS_SP.pdf
English and Spanish descriptions of irritable bowel
syndrome.

Clinical Guidelines
www.gastro.org/guidelines
Clinical practice guidelines from the American
Gastroenterological Association.
www.worldgastroenterology.org/guidelines/global
-guidelines/irritable-bowel-syndrome-ibs/irritable
-bowel-syndrome-ibs-english
Clinical practice guidelines from the World
Gastroenterology Organisation.
www.gastrojournal.org/article/S0016-5085(14)01089-0
/abstract
Guideline from the American College of Gastroenterol-
ogy.

6 June 2017 Annals of Internal Medicine ITC95 2017 American College of Physicians

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 WHAT YOU SHOULD In the Clinic
Annals of Internal Medicine
KNOW ABOUT IRRITABLE
BOWEL SYNDROME
What Is Irritable Bowel
Syndrome?
Irritable bowel syndrome (IBS) is a problem that af-
fects your large intestine. Symptoms include stom-
ach pain, cramps, discomfort, bloating, and abnor-
mal bowel movements. It is more common in
women than in men. Its exact cause is unknown.

What Are the Warning Signs?

People with IBS can have many different symp-
toms. In general, warning signs include stomach
pain or discomfort that happens along with diar-
rhea, constipation, or both. Other symptoms
may include the following:
An abnormal number of bowel movements
More than 3 per day
Fewer than 3 per week
Urgency of bowel movements
Straining during bowel movements
Feeling that a bowel movement is not nished
More gas than usual
Tiredness
Muscle pain
Trouble sleeping
If these symptoms occur with weight loss, fever,
blood in the stool, or recent use of antibiotics,
IBS is usually not the cause.

How Is It Diagnosed? Foods that are low in ber (which can cause

Patient Information
There is no specic test for IBS. Your doctor will ask you constipation)
about your medical history and your symptoms and Other possible ways to treat IBS include the
may do a physical examination to make a diagnosis. following:
Endoscopy or imaging tests, such as CT scans, are Stress management, such as
usually not needed to diagnose IBS. Your doctor Counseling
may ask you to have certain tests to make sure there Meditation
is not another disease causing the symptoms, Regular exercise
especially if you have any of the following: Yoga
Weight loss, bloody stool, fever, or waking up Getting enough sleep
at night due to pain Behavioral therapies (if the IBS is related to a
Recent use of antibiotics psychological condition)
A family history of colon cancer or Medicines that target your symptoms
inammatory bowel disease.
Questions for My Doctor
How Is It Treated? What can trigger IBS?
Changing what you eat can sometimes help. What food or drinks should I stay away from?
Foods to avoid include the following: What other lifestyle changes do I need to make?
Fatty foods Is there a medicine I can take to treat my
Certain vegetables like beans, cabbage, symptoms?
broccoli, and cauliower What are the side effects of the medicine I will
Drinks with a lot of caffeine or carbonation be taking?
(such as soda) Could stress be causing my IBS?
Foods that are very high in ber (which can Should I have an imaging study to see if it
cause gas or bloating) really is IBS?

For More Information

MedlinePlus
https://medlineplus.gov/irritablebowelsyndrome.html
American Academy of Family Physicians
https://familydoctor.org/condition/irritable-bowel-syndrome-ibs
/#overview
American Gastroenterological Association
www.gastro.org/info_for_patients/irritable-bowel-syndrome-ibs
-101-what-is-irritable-bowel-syndrome

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