Irritable bowel syndrome (IBS) is a functional bowel disease characterized by chronic abdominal pain and altered bowel habits without an identifiable organic cause. The etiology and pathophysiology of this disease are not well understood, and there are many factors that may contribute. Irritable bowel syndrome is a diagnosis of exclusion, and organic causes should be ruled out. Once diagnosed, the emphasis is on education and reassurance. Dietary modifications and symptom-control measures may also be instituted, depending on the predominant symptoms.
The onset of symptoms usually begins in adolescence and young adulthood. Approximately 50% of patientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship report symptoms before the age of 35.
60%–70% of cases are women.
PrevalencePrevalenceThe total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time.Measures of Disease Frequency in North America is 10%–15%.
Pathophysiology[1,4,8]
Although no specific organic cause has been identified, there are several possible pathogenic mechanisms.
↑ Frequency of luminal contractions in the intestines
Irregularity of luminal contractions
Slow transit → irritable bowel syndromeIrritable bowel syndromeIrritable bowel syndrome (IBS) is a functional bowel disease characterized by chronic abdominal pain and altered bowel habits without an identifiable organic cause. The etiology and pathophysiology of this disease are not well understood, and there are many factors that may contribute. Irritable Bowel Syndrome (IBSIBSIrritable bowel syndrome (IBS) is a functional bowel disease characterized by chronic abdominal pain and altered bowel habits without an identifiable organic cause. The etiology and pathophysiology of this disease are not well understood, and there are many factors that may contribute. Irritable Bowel Syndrome) with constipationConstipationConstipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation
↑ MotorMotorNeurons which send impulses peripherally to activate muscles or secretory cells.Nervous System: Histology response to cholecystokininCholecystokininA peptide, of about 33 amino acids, secreted by the upper intestinal mucosa and also found in the central nervous system. It causes gallbladder contraction, release of pancreatic exocrine (or digestive) enzymes, and affects other gastrointestinal functions. Cholecystokinin may be the mediator of satiety.Gastrointestinal Secretions and meals → IBSIBSIrritable bowel syndrome (IBS) is a functional bowel disease characterized by chronic abdominal pain and altered bowel habits without an identifiable organic cause. The etiology and pathophysiology of this disease are not well understood, and there are many factors that may contribute. Irritable Bowel Syndrome with diarrheaDiarrheaDiarrhea is defined as ≥ 3 watery or loose stools in a 24-hour period. There are a multitude of etiologies, which can be classified based on the underlying mechanism of disease. The duration of symptoms (acute or chronic) and characteristics of the stools (e.g., watery, bloody, steatorrheic, mucoid) can help guide further diagnostic evaluation. Diarrhea
Visceral hyperalgesiaHyperalgesiaAn increased sensation of pain or discomfort produced by minimally noxious stimuli due to damage to soft tissue containing nociceptors or injury to a peripheral nerve.Pain: Types and Pathways:
Hypothesized to be due to ↑ receptorReceptorReceptors are proteins located either on the surface of or within a cell that can bind to signaling molecules known as ligands (e.g., hormones) and cause some type of response within the cell.Receptors stimulation in the gut wall
↑ LymphocytesLymphocytesLymphocytes are heterogeneous WBCs involved in immune response. Lymphocytes develop from the bone marrow, starting from hematopoietic stem cells (HSCs) and progressing to common lymphoid progenitors (CLPs). B and T lymphocytes and natural killer (NK) cells arise from the lineage.Lymphocytes: Histology and mast cellsMast cellsGranulated cells that are found in almost all tissues, most abundantly in the skin and the gastrointestinal tract. Like the basophils, mast cells contain large amounts of histamine and heparin. Unlike basophils, mast cells normally remain in the tissues and do not circulate in the blood. Mast cells, derived from the bone marrow stem cells, are regulated by the stem cell factor.Innate Immunity: Phagocytes and Antigen Presentation have been noted in the bowel → possible ↑ release of mediators that stimulate the enteric nervous systemEnteric nervous systemTwo ganglionated neural plexuses in the gut wall which form one of the three major divisions of the autonomic nervous system. The enteric nervous system innervates the gastrointestinal tract, the pancreas, and the gallbladder. It contains sensory neurons, interneurons, and motor neurons. Thus the circuitry can autonomously sense the tension and the chemical environment in the gut and regulate blood vessel tone, motility, secretions, and fluid transport. The system is itself governed by the central nervous system and receives both parasympathetic and sympathetic innervation.Autonomic Nervous System: Anatomy
Post-infectious changes:
↑ T cellsT cellsLymphocytes responsible for cell-mediated immunity. Two types have been identified – cytotoxic (t-lymphocytes, cytotoxic) and helper T-lymphocytes (t-lymphocytes, helper-inducer). They are formed when lymphocytes circulate through the thymus gland and differentiate to thymocytes. When exposed to an antigen, they divide rapidly and produce large numbers of new T cells sensitized to that antigen.T cells: Types and Functions and enteroendocrine cellsEnteroendocrine cellsCells found throughout the lining of the gastrointestinal tract that contain and secrete regulatory peptide hormones and/or biogenic amines.Gastrointestinal Secretions → ↑ serotoninSerotoninA biochemical messenger and regulator, synthesized from the essential amino acid l-tryptophan. In humans it is found primarily in the central nervous system, gastrointestinal tract, and blood platelets. Serotonin mediates several important physiological functions including neurotransmission, gastrointestinal motility, hemostasis, and cardiovascular integrity.Receptors and Neurotransmitters of the CNS levels → ↑ gastrointestinal (GI) motilityMotilityThe motor activity of the gastrointestinal tract.Gastrointestinal Motility and sensitivity
Antibiotic use may also play a role.
Psychosocial abnormalities:
> 50% of IBSIBSIrritable bowel syndrome (IBS) is a functional bowel disease characterized by chronic abdominal pain and altered bowel habits without an identifiable organic cause. The etiology and pathophysiology of this disease are not well understood, and there are many factors that may contribute. Irritable Bowel SyndromepatientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship have underlying depression, anxietyAnxietyFeelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders.Generalized Anxiety Disorder, or somatizationSomatizationSomatic Symptom Disorder disorders.
Stress → may ↑ corticotropin-releasing factor activity (mediator of the stress response) → ↑ abdominal painAbdominal PainAcute Abdomen and colonic motilityMotilityThe motor activity of the gastrointestinal tract.Gastrointestinal Motility → ↑ IBSIBSIrritable bowel syndrome (IBS) is a functional bowel disease characterized by chronic abdominal pain and altered bowel habits without an identifiable organic cause. The etiology and pathophysiology of this disease are not well understood, and there are many factors that may contribute. Irritable Bowel Syndrome symptoms
Food allergiesAllergiesA medical specialty concerned with the hypersensitivity of the individual to foreign substances and protection from the resultant infection or disorder.Selective IgA Deficiency, malabsorptionMalabsorptionGeneral term for a group of malnutrition syndromes caused by failure of normal intestinal absorption of nutrients.Malabsorption and Maldigestion, and sensitivity
The mind-gut interaction contributing to the pathophysiology of IBS: stress, anxiety, and depression influence the CNS, autonomic nervous system (ANS), and enteric nervous system. This may affect the smooth muscles in the intestines, leading to the symptoms of IBS.
Irritable bowel syndromeIrritable bowel syndromeIrritable bowel syndrome (IBS) is a functional bowel disease characterized by chronic abdominal pain and altered bowel habits without an identifiable organic cause. The etiology and pathophysiology of this disease are not well understood, and there are many factors that may contribute. Irritable Bowel Syndrome is classified based on the clinical presentation.
IBSIBSIrritable bowel syndrome (IBS) is a functional bowel disease characterized by chronic abdominal pain and altered bowel habits without an identifiable organic cause. The etiology and pathophysiology of this disease are not well understood, and there are many factors that may contribute. Irritable Bowel Syndrome with predominant diarrheaDiarrheaDiarrhea is defined as ≥ 3 watery or loose stools in a 24-hour period. There are a multitude of etiologies, which can be classified based on the underlying mechanism of disease. The duration of symptoms (acute or chronic) and characteristics of the stools (e.g., watery, bloody, steatorrheic, mucoid) can help guide further diagnostic evaluation. Diarrhea (IBS-D):
Loose or watery stools
Frequent bowel movements (> 3/day)
Fecal urgency +/– incontinence
IBSIBSIrritable bowel syndrome (IBS) is a functional bowel disease characterized by chronic abdominal pain and altered bowel habits without an identifiable organic cause. The etiology and pathophysiology of this disease are not well understood, and there are many factors that may contribute. Irritable Bowel Syndrome with predominant constipationConstipationConstipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation (IBS-C):
IBSIBSIrritable bowel syndrome (IBS) is a functional bowel disease characterized by chronic abdominal pain and altered bowel habits without an identifiable organic cause. The etiology and pathophysiology of this disease are not well understood, and there are many factors that may contribute. Irritable Bowel Syndrome with mixed bowel habits (IBS-M): presents with both diarrheaDiarrheaDiarrhea is defined as ≥ 3 watery or loose stools in a 24-hour period. There are a multitude of etiologies, which can be classified based on the underlying mechanism of disease. The duration of symptoms (acute or chronic) and characteristics of the stools (e.g., watery, bloody, steatorrheic, mucoid) can help guide further diagnostic evaluation. Diarrhea and constipationConstipationConstipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation
Unclassified IBSIBSIrritable bowel syndrome (IBS) is a functional bowel disease characterized by chronic abdominal pain and altered bowel habits without an identifiable organic cause. The etiology and pathophysiology of this disease are not well understood, and there are many factors that may contribute. Irritable Bowel Syndrome: insufficient abnormality in the stool consistencyConsistencyDermatologic Examination or frequency to meet criteria for the other types
Somatic symptomsSomatic symptomsMajor Depressive Disorder (e.g., generalized painPainAn unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons.Pain: Types and Pathways, fatigueFatigueThe state of weariness following a period of exertion, mental or physical, characterized by a decreased capacity for work and reduced efficiency to respond to stimuli.Fibromyalgia)
DyspareuniaDyspareuniaRecurrent genital pain occurring during, before, or after sexual intercourse in either the male or the female.Primary Ovarian Insufficiency
Increased urinary frequency and urgency
Alarm features that suggest an alternative diagnosis and warrant further investigations:
Weight lossWeight lossDecrease in existing body weight.Bariatric Surgery or anorexiaAnorexiaThe lack or loss of appetite accompanied by an aversion to food and the inability to eat. It is the defining characteristic of the disorder anorexia nervosa.Anorexia Nervosa
FeverFeverFever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever
Nocturnal diarrheaDiarrheaDiarrhea is defined as ≥ 3 watery or loose stools in a 24-hour period. There are a multitude of etiologies, which can be classified based on the underlying mechanism of disease. The duration of symptoms (acute or chronic) and characteristics of the stools (e.g., watery, bloody, steatorrheic, mucoid) can help guide further diagnostic evaluation. Diarrhea
AnemiaAnemiaAnemia is a condition in which individuals have low Hb levels, which can arise from various causes. Anemia is accompanied by a reduced number of RBCs and may manifest with fatigue, shortness of breath, pallor, and weakness. Subtypes are classified by the size of RBCs, chronicity, and etiology. Anemia: Overview and Types
Severe constipationConstipationConstipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation or diarrheaDiarrheaDiarrhea is defined as ≥ 3 watery or loose stools in a 24-hour period. There are a multitude of etiologies, which can be classified based on the underlying mechanism of disease. The duration of symptoms (acute or chronic) and characteristics of the stools (e.g., watery, bloody, steatorrheic, mucoid) can help guide further diagnostic evaluation. Diarrhea
Progressive symptoms
Acute onset of disease, or onset in older patientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship
Diagnosis
Criteria for diagnosis[8,9,11,12]
Irritable bowel syndromeIrritable bowel syndromeIrritable bowel syndrome (IBS) is a functional bowel disease characterized by chronic abdominal pain and altered bowel habits without an identifiable organic cause. The etiology and pathophysiology of this disease are not well understood, and there are many factors that may contribute. Irritable Bowel Syndrome is a diagnosis of exclusion, but the Rome IV criteriaRome Iv CriteriaElimination Disorders (calculator) help provide a standardized diagnosis:
Recurrent abdominal painAbdominal PainAcute Abdomen that lasts at least 1 day per week during the previous 3 months
PainPainAn unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons.Pain: Types and Pathways related to defecationDefecationThe normal process of elimination of fecal material from the rectum.Gastrointestinal Motility
Change in stool frequency
Change in stool appearance or form
Underlying organic disease (e.g., colonColonThe large intestines constitute the last portion of the digestive system. The large intestine consists of the cecum, appendix, colon (with ascending, transverse, descending, and sigmoid segments), rectum, and anal canal. The primary function of the colon is to remove water and compact the stool prior to expulsion from the body via the rectum and anal canal. Colon, Cecum, and Appendix: Anatomy cancer) has been excluded, especially in cases with warning signs (i.e., alarming features), which include:
Age ≥ 50 years, without prior colonColonThe large intestines constitute the last portion of the digestive system. The large intestine consists of the cecum, appendix, colon (with ascending, transverse, descending, and sigmoid segments), rectum, and anal canal. The primary function of the colon is to remove water and compact the stool prior to expulsion from the body via the rectum and anal canal. Colon, Cecum, and Appendix: Anatomy cancer screeningScreeningPreoperative Care
IronIronA metallic element with atomic symbol fe, atomic number 26, and atomic weight 55. 85. It is an essential constituent of hemoglobins; cytochromes; and iron-binding proteins. It plays a role in cellular redox reactions and in the transport of oxygen.Trace Elements deficiency anemiaAnemiaAnemia is a condition in which individuals have low Hb levels, which can arise from various causes. Anemia is accompanied by a reduced number of RBCs and may manifest with fatigue, shortness of breath, pallor, and weakness. Subtypes are classified by the size of RBCs, chronicity, and etiology. Anemia: Overview and Types
Family historyFamily HistoryAdult Health Maintenance of inflammatory bowel disease or colorectal cancerColorectal cancerColorectal cancer (CRC) is the 2nd leading cause of cancer-related deaths in the United States. Colorectal cancer is a heterogeneous disease that arises from genetic and epigenetic abnormalities, with influence from environmental factors. Colorectal Cancer
Recent changes in bowel habits
A palpable abdominal massMassThree-dimensional lesion that occupies a space within the breastImaging of the Breast or lymphadenopathyLymphadenopathyLymphadenopathy is lymph node enlargement (> 1 cm) and is benign and self-limited in most patients. Etiologies include malignancy, infection, and autoimmune disorders, as well as iatrogenic causes such as the use of certain medications. Generalized lymphadenopathy often indicates underlying systemic disease. Lymphadenopathy
Abnormal bowel movements[9]
To define abnormal bowel movements, the Bristol Stool Form ScaleScaleDermatologic Examination is used. Types 1 and 2 (found in IBS-C) and 6 and 7 (found in IBS-D) are considered abnormal:
Type 5: Soft blobs with clear-cut edges (easily passed)
Type 6: Fluffy pieces with ragged edges, a mushy stool
Type 7: Watery, no solid pieces, entirely liquid
Bristol Stool Form Scale.
Image by Lecturio.
Tests to rule out organic disease
Work-up will be guided by the patient’s clinical presentation. Those who meet the diagnostic criteria and do not have other alarm features (or warning signs) require limited tests.[8,9,10]
Laboratory tests:[11,15]
Complete blood count → screen for ironIronA metallic element with atomic symbol fe, atomic number 26, and atomic weight 55. 85. It is an essential constituent of hemoglobins; cytochromes; and iron-binding proteins. It plays a role in cellular redox reactions and in the transport of oxygen.Trace Elements deficiency anemiaAnemiaAnemia is a condition in which individuals have low Hb levels, which can arise from various causes. Anemia is accompanied by a reduced number of RBCs and may manifest with fatigue, shortness of breath, pallor, and weakness. Subtypes are classified by the size of RBCs, chronicity, and etiology. Anemia: Overview and Types → malignancyMalignancyHemothorax, celiac diseaseCeliac diseaseCeliac disease (also known as celiac sprue or gluten enteropathy) is an autoimmune reaction to gliadin, which is a component of gluten. Celiac disease is closely associated with HLA-DQ2 and HLA-DQ8. The immune response is localized to the proximal small intestine and causes the characteristic histologic findings of villous atrophy, crypt hyperplasia, and intraepithelial lymphocytosis. Celiac Disease
Immunoglobulin A (IgAIgARepresents 15-20% of the human serum immunoglobulins, mostly as the 4-chain polymer in humans or dimer in other mammals. Secretory iga is the main immunoglobulin in secretions.Immunoglobulins: Types and Functions) tissue transglutaminase or endomysial antibodiesAntibodiesImmunoglobulins (Igs), also known as antibodies, are glycoprotein molecules produced by plasma cells that act in immune responses by recognizing and binding particular antigens. The various Ig classes are IgG (the most abundant), IgM, IgE, IgD, and IgA, which differ in their biologic features, structure, target specificity, and distribution.Immunoglobulins: Types and Functions → screen for celiac diseaseCeliac diseaseCeliac disease (also known as celiac sprue or gluten enteropathy) is an autoimmune reaction to gliadin, which is a component of gluten. Celiac disease is closely associated with HLA-DQ2 and HLA-DQ8. The immune response is localized to the proximal small intestine and causes the characteristic histologic findings of villous atrophy, crypt hyperplasia, and intraepithelial lymphocytosis. Celiac Disease
Thyroid-stimulating hormoneThyroid-stimulating hormoneA glycoprotein hormone secreted by the adenohypophysis. Thyrotropin stimulates thyroid gland by increasing the iodide transport, synthesis and release of thyroid hormones (thyroxine and triiodothyronine).Thyroid Hormones → hyperthyroidismHyperthyroidismHypersecretion of thyroid hormones from the thyroid gland. Elevated levels of thyroid hormones increase basal metabolic rate.Thyrotoxicosis and Hyperthyroidism or hypothyroidismHypothyroidismHypothyroidism is a condition characterized by a deficiency of thyroid hormones. Iodine deficiency is the most common cause worldwide, but Hashimoto’s disease (autoimmune thyroiditis) is the leading cause in non-iodine-deficient regions. Hypothyroidism
Stool test for GiardiaGiardiaA genus of flagellate intestinal eukaryotes parasitic in various vertebrates, including humans. Characteristics include the presence of four pairs of flagella arising from a complicated system of axonemes and cysts that are ellipsoidal to ovoidal in shape.Nitroimidazoles (only in patientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship with IBS-D if there is a high pretest probabilityProbabilityProbability is a mathematical tool used to study randomness and provide predictions about the likelihood of something happening. There are several basic rules of probability that can be used to help determine the probability of multiple events happening together, separately, or sequentially.Basics of Probability of infection)
Abdominal radiography:
Performed in patientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship with constipationConstipationConstipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation
Rules out stool impaction
Determines the severity of constipationConstipationConstipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation
ColonoscopyColonoscopyEndoscopic examination, therapy or surgery of the luminal surface of the colon.Colorectal Cancer Screening with biopsyBiopsyRemoval and pathologic examination of specimens from the living body.Ewing Sarcoma:
The procedure is generally reserved for those with warning features and diarrheaDiarrheaDiarrhea is defined as ≥ 3 watery or loose stools in a 24-hour period. There are a multitude of etiologies, which can be classified based on the underlying mechanism of disease. The duration of symptoms (acute or chronic) and characteristics of the stools (e.g., watery, bloody, steatorrheic, mucoid) can help guide further diagnostic evaluation. Diarrhea to rule out:
Microscopic colitisColitisInflammation of the colon section of the large intestine, usually with symptoms such as diarrhea (often with blood and mucus), abdominal pain, and fever.Pseudomembranous Colitis[11]
Additional studies:[8,11]
Abdominal CT: performed in those with a suspected structural lesion
Anorectal physiology tests (such as manometryManometryMeasurement of the pressure or tension of liquids or gases with a manometer.Achalasia) performed in those with:
Chronic constipationConstipationConstipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation
Obstructive defecationDefecationThe normal process of elimination of fecal material from the rectum.Gastrointestinal Motility (paradoxical anal contraction on straining)
Suspected pelvic floorPelvic floorSoft tissue formed mainly by the pelvic diaphragm, which is composed of the two levator ani and two coccygeus muscles. The pelvic diaphragm lies just below the pelvic aperture (outlet) and separates the pelvic cavity from the perineum. It extends between the pubic bone anteriorly and the coccyx posteriorly.Vagina, Vulva, and Pelvic Floor: Anatomy disorder
Pelvic exam with transvaginal and transabdominal ultrasonography:
Consider in postmenopausal women with new-onset constipationConstipationConstipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation to rule out ovarian cancerOvarian cancerOvarian cancer is a malignant tumor arising from the ovarian tissue and is classified according to the type of tissue from which it originates. The 3 major types of ovarian cancer are epithelial ovarian carcinomas (EOCs), ovarian germ cell tumors (OGCTs), and sex cord-stromal tumors (SCSTs). Ovarian Cancer
Other potential symptoms of ovarian cancerOvarian cancerOvarian cancer is a malignant tumor arising from the ovarian tissue and is classified according to the type of tissue from which it originates. The 3 major types of ovarian cancer are epithelial ovarian carcinomas (EOCs), ovarian germ cell tumors (OGCTs), and sex cord-stromal tumors (SCSTs). Ovarian Cancer include lower abdominal painAbdominal PainAcute Abdomen, bloatingBloatingConstipation, and distention.
Rule out bileBileAn emulsifying agent produced in the liver and secreted into the duodenum. Its composition includes bile acids and salts; cholesterol; and electrolytes. It aids digestion of fats in the duodenum.Gallbladder and Biliary Tract: Anatomy acid diarrheaDiarrheaDiarrhea is defined as ≥ 3 watery or loose stools in a 24-hour period. There are a multitude of etiologies, which can be classified based on the underlying mechanism of disease. The duration of symptoms (acute or chronic) and characteristics of the stools (e.g., watery, bloody, steatorrheic, mucoid) can help guide further diagnostic evaluation. Diarrhea in those presenting with IBS-D and cholecystectomyCholecystectomyCholecystectomy is a surgical procedure performed with the goal of resecting and extracting the gallbladder. It is one of the most common abdominal surgeries performed in the Western world. Cholecystectomy is performed for symptomatic cholelithiasis, cholecystitis, gallbladder polyps > 0.5 cm, porcelain gallbladder, choledocholithiasis and gallstone pancreatitis, and rarely, for gallbladder cancer. Cholecystectomy.[13]
Therapeutic trial of bileBileAn emulsifying agent produced in the liver and secreted into the duodenum. Its composition includes bile acids and salts; cholesterol; and electrolytes. It aids digestion of fats in the duodenum.Gallbladder and Biliary Tract: Anatomy acid sequestrant (done in the US)
In the UK, 23-seleno-25-homotaurocholic acid scanning (not available in the US) is performed.
Management may vary depending on practice location. The following information is based on US and UK literature and guidelines for adult patientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship.
Most patientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship can follow a normal diet.
May exclude gas-producing foods (e.g., beans, brussel sprouts)
Low-FODMAP (fermentable oligosaccharidesOligosaccharidesCarbohydrates consisting of between two (disaccharides) and ten monosaccharides connected by either an alpha- or beta-glycosidic link. They are found throughout nature in both the free and bound form.Basics of Carbohydrates, disaccharidesDisaccharidesOligosaccharides containing two monosaccharide units linked by a glycosidic bond.Basics of Carbohydrates, monosaccharidesMonosaccharidesSingle chain carbohydrates that are the most basic units of carbohydrates. They are typically colorless crystalline substances with a sweet taste and have the same general formula CNH2NON.Basics of Carbohydrates, and polyols) diet
Trial of a low FODMAP diet should be supervised by a trained dietitian.
The FODMAP diet leads to ↑ GI water secretionSecretionCoagulation Studies and fermentation in the colonColonThe large intestines constitute the last portion of the digestive system. The large intestine consists of the cecum, appendix, colon (with ascending, transverse, descending, and sigmoid segments), rectum, and anal canal. The primary function of the colon is to remove water and compact the stool prior to expulsion from the body via the rectum and anal canal. Colon, Cecum, and Appendix: Anatomy → ↑ short-chain fatty acidsShort-chain fatty acidsDigestion and Absorption and gases → distention and meal-triggered symptoms
Responders will show symptom improvement within 2‒6 weeks.
Dietary or supplemental fiber:
Soluble fiber (psyllium/ispaghula) improves both IBS-D and IBS-C.
Avoid insoluble fiber (wheat bran), which can exacerbate painPainAn unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons.Pain: Types and Pathways and bloatingBloatingConstipation.
Avoid/restrict alcohol and caffeineCaffeineA methylxanthine naturally occurring in some beverages and also used as a pharmacological agent. Caffeine’s most notable pharmacological effect is as a central nervous system stimulant, increasing alertness and producing agitation. Several cellular actions of caffeine have been observed, but it is not entirely clear how each contributes to its pharmacological profile. Among the most important are inhibition of cyclic nucleotide phosphodiesterases, antagonism of adenosine receptors, and modulation of intracellular calcium handling.Stimulants.
Maintain proper hydration.
Pharmacologic agents, based on symptoms
IBS-D:
LoperamideLoperamideOne of the long-acting synthetic antidiarrheals; it is not significantly absorbed from the gut, and has no effect on the adrenergic system or central nervous system, but may antagonize histamine and interfere with acetylcholine release locally.Antidiarrheal Drugs (antidiarrhealAntidiarrhealAntidiarrheal agents include several drug classes, including opioid agonists, somatostatin analogues, adsorbents, and bile acid sequestrants. These medications mainly work through antimotility and/or antisecretory effects. Antidiarrheal Drugs):[7,10–12]
Reasonable 1st-line treatment
Acts on the μ-opioid receptorsReceptorsReceptors are proteins located either on the surface of or within a cell that can bind to signaling molecules known as ligands (e.g., hormones) and cause some type of response within the cell.Receptors (opioidOpioidCompounds with activity like opiate alkaloids, acting at opioid receptors. Properties include induction of analgesia or narcosis.ConstipationreceptorReceptorReceptors are proteins located either on the surface of or within a cell that can bind to signaling molecules known as ligands (e.g., hormones) and cause some type of response within the cell.Receptors agonist):[8]
Adverse effects: abdominal painAbdominal PainAcute Abdomen, constipationConstipationConstipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation, bloatingBloatingConstipation
CholestyramineCholestyramineA strongly basic anion exchange resin whose main constituent is polystyrene trimethylbenzylammonium cl(-) anion.Lipid Control Drugs
ColesevelamColesevelamAn allylamine derivative that binds bile acids in the intestine and is used as an anticholesteremic agent in the treatment of hypercholesterolemia and hyperlipidemias.Lipid Control Drugs
IBS-D may have idiopathicIdiopathicDermatomyositisbileBileAn emulsifying agent produced in the liver and secreted into the duodenum. Its composition includes bile acids and salts; cholesterol; and electrolytes. It aids digestion of fats in the duodenum.Gallbladder and Biliary Tract: Anatomy acid malabsorptionMalabsorptionGeneral term for a group of malnutrition syndromes caused by failure of normal intestinal absorption of nutrients.Malabsorption and Maldigestion (I-BAM) contributing to symptoms.
Use is controversial in IBD.
10% of patientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship with IBS-D have severe I-BAM, and 32% have moderately severe I-BAM.
5-Hydroxytryptamine5-hydroxytryptamineA biochemical messenger and regulator, synthesized from the essential amino acid l-tryptophan. In humans it is found primarily in the central nervous system, gastrointestinal tract, and blood platelets. Serotonin mediates several important physiological functions including neurotransmission, gastrointestinal motility, hemostasis, and cardiovascular integrity.Receptors and Neurotransmitters of the CNS 3 (5-HT3) receptorReceptorReceptors are proteins located either on the surface of or within a cell that can bind to signaling molecules known as ligands (e.g., hormones) and cause some type of response within the cell.Receptors antagonists:[8,11,14]
Options:
OndansetronOndansetronA competitive serotonin type 3 receptor antagonist. It is effective in the treatment of nausea and vomiting caused by cytotoxic chemotherapy drugs, including cisplatin, and has reported anxiolytic and neuroleptic properties.Antiemetics
Restricted to women with severe IBS-D in a risk-management program for whom conventional therapy has failed
Serious adverse effects: constipationConstipationConstipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation and ischemic colitisIschemic colitisInflammation of the colon due to colonic ischemia resulting from alterations in systemic circulation or local vasculature.Large Bowel Obstruction
Can improve diarrheaDiarrheaDiarrhea is defined as ≥ 3 watery or loose stools in a 24-hour period. There are a multitude of etiologies, which can be classified based on the underlying mechanism of disease. The duration of symptoms (acute or chronic) and characteristics of the stools (e.g., watery, bloody, steatorrheic, mucoid) can help guide further diagnostic evaluation. Diarrhea and abdominal painAbdominal PainAcute Abdomen
OndansetronOndansetronA competitive serotonin type 3 receptor antagonist. It is effective in the treatment of nausea and vomiting caused by cytotoxic chemotherapy drugs, including cisplatin, and has reported anxiolytic and neuroleptic properties.Antiemetics:
Established safety profile
Improves diarrheaDiarrheaDiarrhea is defined as ≥ 3 watery or loose stools in a 24-hour period. There are a multitude of etiologies, which can be classified based on the underlying mechanism of disease. The duration of symptoms (acute or chronic) and characteristics of the stools (e.g., watery, bloody, steatorrheic, mucoid) can help guide further diagnostic evaluation. Diarrhea but not abdominal painAbdominal PainAcute Abdomen
Eluxadoline:[7,8,11,15]
Mixed opioidOpioidCompounds with activity like opiate alkaloids, acting at opioid receptors. Properties include induction of analgesia or narcosis.ConstipationreceptorReceptorReceptors are proteins located either on the surface of or within a cell that can bind to signaling molecules known as ligands (e.g., hormones) and cause some type of response within the cell.Receptors drug: μ-opioid receptorReceptorReceptors are proteins located either on the surface of or within a cell that can bind to signaling molecules known as ligands (e.g., hormones) and cause some type of response within the cell.Receptors agonist, κ-opioid receptorReceptorReceptors are proteins located either on the surface of or within a cell that can bind to signaling molecules known as ligands (e.g., hormones) and cause some type of response within the cell.Receptors agonist and ẟ-opioid receptorReceptorReceptors are proteins located either on the surface of or within a cell that can bind to signaling molecules known as ligands (e.g., hormones) and cause some type of response within the cell.Receptors antagonist
2nd-line option for severe IBS-D (not responding to initial treatments)
Effective in controlling diarrheaDiarrheaDiarrhea is defined as ≥ 3 watery or loose stools in a 24-hour period. There are a multitude of etiologies, which can be classified based on the underlying mechanism of disease. The duration of symptoms (acute or chronic) and characteristics of the stools (e.g., watery, bloody, steatorrheic, mucoid) can help guide further diagnostic evaluation. Diarrhea, but less effective at relieving abdominal painAbdominal PainAcute Abdomen
Contraindicated in patientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship:
Without a gallbladderGallbladderThe gallbladder is a pear-shaped sac, located directly beneath the liver, that sits on top of the superior part of the duodenum. The primary functions of the gallbladder include concentrating and storing up to 50 mL of bile. Gallbladder and Biliary Tract: Anatomy
With alcohol abuse (> 3 drinks per day) or severe liverLiverThe liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver: Anatomy impairment
PancreatitisPancreatitisInflammation of the pancreas. Pancreatitis is classified as acute unless there are computed tomographic or endoscopic retrograde cholangiopancreatographic findings of chronic pancreatitis. The two most common forms of acute pancreatitis are alcoholic pancreatitis and gallstone pancreatitis.Acute Pancreatitis
Sphincter of Oddi spasm
Adverse effects: constipationConstipationConstipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation, nauseaNauseaAn unpleasant sensation in the stomach usually accompanied by the urge to vomit. Common causes are early pregnancy, sea and motion sickness, emotional stress, intense pain, food poisoning, and various enteroviruses.Antiemetics, abdominal painAbdominal PainAcute Abdomen
RifaximinRifaximinA synthetic rifamycin derivative and anti-bacterial agent that is used for the treatment of gastroenteritis caused by Escherichia coli infections. It may also be used in the treatment of hepatic encephalopathy.Hepatic Encephalopathy:[7,8,11,12,15]
Helps with diarrheaDiarrheaDiarrhea is defined as ≥ 3 watery or loose stools in a 24-hour period. There are a multitude of etiologies, which can be classified based on the underlying mechanism of disease. The duration of symptoms (acute or chronic) and characteristics of the stools (e.g., watery, bloody, steatorrheic, mucoid) can help guide further diagnostic evaluation. Diarrhea and bloatingBloatingConstipation
Retreatment up to twice with the same regimen can be given if symptoms recur.
Adverse effects: upper respiratory infectionUpper respiratory infectionRhinitis, nauseaNauseaAn unpleasant sensation in the stomach usually accompanied by the urge to vomit. Common causes are early pregnancy, sea and motion sickness, emotional stress, intense pain, food poisoning, and various enteroviruses.Antiemetics, urinary tractUrinary tractThe urinary tract is located in the abdomen and pelvis and consists of the kidneys, ureters, urinary bladder, and urethra. The structures permit the excretion of urine from the body. Urine flows from the kidneys through the ureters to the urinary bladder and out through the urethra.Urinary Tract: Anatomy infection
Table: Medications for IBS-D[7,11,13,14]
Medication
Typical dose (adult)
LoperamideLoperamideOne of the long-acting synthetic antidiarrheals; it is not significantly absorbed from the gut, and has no effect on the adrenergic system or central nervous system, but may antagonize histamine and interfere with acetylcholine release locally.Antidiarrheal Drugs
Initial dose: 4 mg
Followed by: 2 mg after each loose stool
Maximum: 16 mg/day
Maintenance: usually 4–8 mg total per day
CholestyramineCholestyramineA strongly basic anion exchange resin whose main constituent is polystyrene trimethylbenzylammonium cl(-) anion.Lipid Control Drugs
2–4 g/day
ColesevelamColesevelamAn allylamine derivative that binds bile acids in the intestine and is used as an anticholesteremic agent in the treatment of hypercholesterolemia and hyperlipidemias.Lipid Control Drugs
3.75 g daily
OndansetronOndansetronA competitive serotonin type 3 receptor antagonist. It is effective in the treatment of nausea and vomiting caused by cytotoxic chemotherapy drugs, including cisplatin, and has reported anxiolytic and neuroleptic properties.Antiemetics
4–8 mg up to 3 times daily
Alosetron
0.5 mg 2 times daily
Eluxadoline
100 mg 2 times daily
Can decrease to 75 mg 2 times daily if higher dose not tolerated
RifaximinRifaximinA synthetic rifamycin derivative and anti-bacterial agent that is used for the treatment of gastroenteritis caused by Escherichia coli infections. It may also be used in the treatment of hepatic encephalopathy.Hepatic Encephalopathy
550 mg 3 times daily for 14 days
IBS-C:[6,8,11]
Polyethylene glycolPolyethylene GlycolLaxatives (osmotic laxativeLaxativeAgents that produce a soft formed stool, and relax and loosen the bowels, typically used over a protracted period, to relieve constipation.Hypokalemia):
1st-line therapy (over-the-counter) for occasional constipationConstipationConstipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation, though efficacy in relieving IBS-C abdominal painAbdominal PainAcute Abdomen has not been proven[15]
Long-chain polymer of ethylene oxide
Inexpensive, widely available, with a good safety profile
Adverse effect: nauseaNauseaAn unpleasant sensation in the stomach usually accompanied by the urge to vomit. Common causes are early pregnancy, sea and motion sickness, emotional stress, intense pain, food poisoning, and various enteroviruses.Antiemetics
Linaclotide (guanylate cyclase-C [GC-C] agonist):
2nd-line treatment
Nonabsorbed 14-amino acid peptide → stimulates the GC-C receptorReceptorReceptors are proteins located either on the surface of or within a cell that can bind to signaling molecules known as ligands (e.g., hormones) and cause some type of response within the cell.Receptors on enterocytes → intestinal chlorideChlorideInorganic compounds derived from hydrochloric acid that contain the Cl- ion.Electrolytes and bicarbonateBicarbonateInorganic salts that contain the -HCO3 radical. They are an important factor in determining the ph of the blood and the concentration of bicarbonate ions is regulated by the kidney. Levels in the blood are an index of the alkali reserve or buffering capacity.ElectrolytessecretionSecretionCoagulation Studies
Adverse effect: diarrheaDiarrheaDiarrhea is defined as ≥ 3 watery or loose stools in a 24-hour period. There are a multitude of etiologies, which can be classified based on the underlying mechanism of disease. The duration of symptoms (acute or chronic) and characteristics of the stools (e.g., watery, bloody, steatorrheic, mucoid) can help guide further diagnostic evaluation. Diarrhea
Plecanatide (guanylate cyclase-C [GC-C] agonist):
2nd-line treatment
16-amino acid peptide → stimulates the GC-C- receptorReceptorReceptors are proteins located either on the surface of or within a cell that can bind to signaling molecules known as ligands (e.g., hormones) and cause some type of response within the cell.Receptors on enterocytes → fluid and electrolyte secretionSecretionCoagulation Studies
Adverse effect: diarrheaDiarrheaDiarrhea is defined as ≥ 3 watery or loose stools in a 24-hour period. There are a multitude of etiologies, which can be classified based on the underlying mechanism of disease. The duration of symptoms (acute or chronic) and characteristics of the stools (e.g., watery, bloody, steatorrheic, mucoid) can help guide further diagnostic evaluation. Diarrhea
Tegaserod (5-hydroxytryptamine5-hydroxytryptamineA biochemical messenger and regulator, synthesized from the essential amino acid l-tryptophan. In humans it is found primarily in the central nervous system, gastrointestinal tract, and blood platelets. Serotonin mediates several important physiological functions including neurotransmission, gastrointestinal motility, hemostasis, and cardiovascular integrity.Receptors and Neurotransmitters of the CNS 4 (5-HT4) receptorReceptorReceptors are proteins located either on the surface of or within a cell that can bind to signaling molecules known as ligands (e.g., hormones) and cause some type of response within the cell.Receptors partial agonist):
Stimulates GI motilityGI MotilityThe primary functions of the GI tract are digestion and absorption, which require coordinated contractions of the smooth muscles present in the GI tract. Peristaltic waves, segmentation contractions, and the migrating motor complex are all important contraction patterns that help to mix contents, get them in contact with the intestinal walls, and propel material down the tract at appropriate times and in appropriate amounts.Gastrointestinal Motility and ↑ fluid in the intestine
Was previously withdrawn from the market, but now with limited use (safety in men or women > 65 not established; ↑ cardiovascular event)
Use only for women < 65 years without a history of cardiovascular ischemic events (such as myocardial infarctionMyocardial infarctionMI is ischemia and death of an area of myocardial tissue due to insufficient blood flow and oxygenation, usually from thrombus formation on a ruptured atherosclerotic plaque in the epicardial arteries. Clinical presentation is most commonly with chest pain, but women and patients with diabetes may have atypical symptoms.Myocardial Infarction, stroke)
Other adverse effects: diarrheaDiarrheaDiarrhea is defined as ≥ 3 watery or loose stools in a 24-hour period. There are a multitude of etiologies, which can be classified based on the underlying mechanism of disease. The duration of symptoms (acute or chronic) and characteristics of the stools (e.g., watery, bloody, steatorrheic, mucoid) can help guide further diagnostic evaluation. Diarrhea, headaches
Tenapanor:
Other therapy options have failed
↓ SodiumSodiumA member of the alkali group of metals. It has the atomic symbol na, atomic number 11, and atomic weight 23.HyponatremiaabsorptionAbsorptionAbsorption involves the uptake of nutrient molecules and their transfer from the lumen of the GI tract across the enterocytes and into the interstitial space, where they can be taken up in the venous or lymphatic circulation.Digestion and Absorption, ↑ water secretionSecretionCoagulation Studies (due to inhibition of the gastrointestinal sodiumSodiumA member of the alkali group of metals. It has the atomic symbol na, atomic number 11, and atomic weight 23.Hyponatremia/hydrogen exchanger isoform 3)
Has antinociceptive effects
Adverse effects: abdominal painAbdominal PainAcute Abdomen, nauseaNauseaAn unpleasant sensation in the stomach usually accompanied by the urge to vomit. Common causes are early pregnancy, sea and motion sickness, emotional stress, intense pain, food poisoning, and various enteroviruses.Antiemetics, diarrheaDiarrheaDiarrhea is defined as ≥ 3 watery or loose stools in a 24-hour period. There are a multitude of etiologies, which can be classified based on the underlying mechanism of disease. The duration of symptoms (acute or chronic) and characteristics of the stools (e.g., watery, bloody, steatorrheic, mucoid) can help guide further diagnostic evaluation. Diarrhea
↑ Smooth muscle relaxation (blocks calciumCalciumA basic element found in nearly all tissues. It is a member of the alkaline earth family of metals with the atomic symbol ca, atomic number 20, and atomic weight 40. Calcium is the most abundant mineral in the body and combines with phosphorus to form calcium phosphate in the bones and teeth. It is essential for the normal functioning of nerves and muscles and plays a role in blood coagulation (as factor IV) and in many enzymatic processes.ElectrolyteschannelsChannelsThe Cell: Cell Membrane)
AntispasmodicAntispasmodicAntispasmodics are a group of medications used to reduce excessive GI smooth muscle contractility and spasm. These medications may be helpful in those with abdominal pain due to conditions such as irritable bowel syndrome, although their efficacy is controversial. Antispasmodics agents:[7,11,12]
DicyclomineDicyclomineA muscarinic antagonist used as an antispasmodic and in urinary incontinence. It has little effect on glandular secretion or the cardiovascular system. It does have some local anesthetic properties and is used in gastrointestinal, biliary, and urinary tract spasms.Anticholinergic Drugs 20 mg up to 4 times a day as needed
↓ Smooth muscle contractionSmooth muscle contractionSmooth muscle is primarily found in the walls of hollow structures and some visceral organs, including the walls of the vasculature, GI, respiratory, and genitourinary tracts. Smooth muscle contracts more slowly and is regulated differently than skeletal muscle. Smooth muscle can be stimulated by nerve impulses, hormones, metabolic factors (like pH, CO2 or O2 levels), its own intrinsic pacemaker ability, or even mechanical stretch.Smooth Muscle Contraction and visceral hypersensitivity
Note: The American College of Gastroenterology (ACG) recommends against using antispasmodics for treatment of IBSIBSIrritable bowel syndrome (IBS) is a functional bowel disease characterized by chronic abdominal pain and altered bowel habits without an identifiable organic cause. The etiology and pathophysiology of this disease are not well understood, and there are many factors that may contribute. Irritable Bowel Syndrome global symptoms.
Tricyclic antidepressantsTricyclic antidepressantsTricyclic antidepressants (TCAs) are a class of medications used in the management of mood disorders, primarily depression. These agents, named after their 3-ring chemical structure, act via reuptake inhibition of neurotransmitters (particularly norepinephrine and serotonin) in the brain.Tricyclic Antidepressants (TCAsTCAsTricyclic antidepressants (TCAs) are a class of medications used in the management of mood disorders, primarily depression. These agents, named after their 3-ring chemical structure, act via reuptake inhibition of neurotransmitters (particularly norepinephrine and serotonin) in the brain.Tricyclic Antidepressants):[7,8,10,11,15]
Options:
AmitriptylineAmitriptylineTricyclic antidepressant with anticholinergic and sedative properties. It appears to prevent the reuptake of norepinephrine and serotonin at nerve terminals, thus potentiating the action of these neurotransmitters. Amitriptyline also appears to antagonize cholinergic and alpha-1 adrenergic responses to bioactive amines.Tricyclic Antidepressants
NortriptylineNortriptylineA metabolite of amitriptyline that is also used as an antidepressant agent. Nortriptyline is used in major depression, dysthymia, and atypical depressions.Tricyclic Antidepressants
Dosing for both:
Start low, at 10 mg/day (at bedtime)
Gradually increase to 50‒100 mg/day (amitriptylineAmitriptylineTricyclic antidepressant with anticholinergic and sedative properties. It appears to prevent the reuptake of norepinephrine and serotonin at nerve terminals, thus potentiating the action of these neurotransmitters. Amitriptyline also appears to antagonize cholinergic and alpha-1 adrenergic responses to bioactive amines.Tricyclic Antidepressants) or 25‒75 mg/day (nortriptylineNortriptylineA metabolite of amitriptyline that is also used as an antidepressant agent. Nortriptyline is used in major depression, dysthymia, and atypical depressions.Tricyclic Antidepressants)
Gut-brain modulators → improve visceral and central painPainAn unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons.Pain: Types and Pathways by acting on norepinephrineNorepinephrinePrecursor of epinephrine that is secreted by the adrenal medulla and is a widespread central and autonomic neurotransmitter. Norepinephrine is the principal transmitter of most postganglionic sympathetic fibers, and of the diffuse projection system in the brain that arises from the locus ceruleus.Receptors and Neurotransmitters of the CNS and dopaminergic receptorsReceptorsReceptors are proteins located either on the surface of or within a cell that can bind to signaling molecules known as ligands (e.g., hormones) and cause some type of response within the cell.Receptors
↓ Intestinal transit (use with caution in constipationConstipationConstipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation)
Adverse effects: dry mouth, constipationConstipationConstipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation, drowsiness
The National Institute for Health and Care Excellence (NICE) and the World Gastroenterology Organisation mention SSRI use only for resistant symptoms (no clear indication or long-term data for use in IBSIBSIrritable bowel syndrome (IBS) is a functional bowel disease characterized by chronic abdominal pain and altered bowel habits without an identifiable organic cause. The etiology and pathophysiology of this disease are not well understood, and there are many factors that may contribute. Irritable Bowel Syndrome).[10,12]
The American Gastroenterology Association (AGA) does NOT recommend SSRIsSSRIsSerotonin Reuptake Inhibitors and Similar Antidepressants for IBSIBSIrritable bowel syndrome (IBS) is a functional bowel disease characterized by chronic abdominal pain and altered bowel habits without an identifiable organic cause. The etiology and pathophysiology of this disease are not well understood, and there are many factors that may contribute. Irritable Bowel Syndrome (no significant improvement in IBSIBSIrritable bowel syndrome (IBS) is a functional bowel disease characterized by chronic abdominal pain and altered bowel habits without an identifiable organic cause. The etiology and pathophysiology of this disease are not well understood, and there are many factors that may contribute. Irritable Bowel Syndrome symptoms).[7,8]
Behavioral therapy:[10,11,15]
Examples: cognitive behavioral therapyCognitive behavioral therapyA directive form of psychotherapy based on the interpretation of situations (cognitive structure of experiences) that determine how an individual feels and behaves. It is based on the premise that cognition, the process of acquiring knowledge and forming beliefs, is a primary determinant of mood and behavior. The therapy uses behavioral and verbal techniques to identify and correct negative thinking that is at the root of the aberrant behavior.Psychotherapy, hypnotherapy
Offer especially if symptoms do not improve after 12 months of treatment
Celiac diseaseCeliac diseaseCeliac disease (also known as celiac sprue or gluten enteropathy) is an autoimmune reaction to gliadin, which is a component of gluten. Celiac disease is closely associated with HLA-DQ2 and HLA-DQ8. The immune response is localized to the proximal small intestine and causes the characteristic histologic findings of villous atrophy, crypt hyperplasia, and intraepithelial lymphocytosis. Celiac Disease: an immunologically mediated disease resulting in mucosal inflammationInflammationInflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body’s defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation and villous atrophyVillous AtrophyGiardia/Giardiasis in the small bowelSmall bowelThe small intestine is the longest part of the GI tract, extending from the pyloric orifice of the stomach to the ileocecal junction. The small intestine is the major organ responsible for chemical digestion and absorption of nutrients. It is divided into 3 segments: the duodenum, the jejunum, and the ileum.Small Intestine: Anatomy due to glutenGlutenProlamins in the endosperm of seeds from the triticeae tribe which includes species of wheat; barley; and rye.Celiac Disease. Symptoms include abdominal bloatingBloatingConstipation and foul-smelling diarrheaDiarrheaDiarrhea is defined as ≥ 3 watery or loose stools in a 24-hour period. There are a multitude of etiologies, which can be classified based on the underlying mechanism of disease. The duration of symptoms (acute or chronic) and characteristics of the stools (e.g., watery, bloody, steatorrheic, mucoid) can help guide further diagnostic evaluation. Diarrhea. PatientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship may also have nutritional deficiencies and weight lossWeight lossDecrease in existing body weight.Bariatric Surgery due to malabsorptionMalabsorptionGeneral term for a group of malnutrition syndromes caused by failure of normal intestinal absorption of nutrients.Malabsorption and Maldigestion, which is not found in IBSIBSIrritable bowel syndrome (IBS) is a functional bowel disease characterized by chronic abdominal pain and altered bowel habits without an identifiable organic cause. The etiology and pathophysiology of this disease are not well understood, and there are many factors that may contribute. Irritable Bowel Syndrome. The diagnosis is established with serologic markers and small bowelSmall bowelThe small intestine is the longest part of the GI tract, extending from the pyloric orifice of the stomach to the ileocecal junction. The small intestine is the major organ responsible for chemical digestion and absorption of nutrients. It is divided into 3 segments: the duodenum, the jejunum, and the ileum.Small Intestine: AnatomybiopsyBiopsyRemoval and pathologic examination of specimens from the living body.Ewing Sarcoma. Treatment requires a strict, gluten-free diet.
Inflammatory bowel disease: includes Crohn’s disease and ulcerative colitisColitisInflammation of the colon section of the large intestine, usually with symptoms such as diarrhea (often with blood and mucus), abdominal pain, and fever.Pseudomembranous Colitis. The disease is characterized by chronic inflammationChronic InflammationInflammation of the GI tract due to a cell-mediated immune response to the GI mucosa. Symptoms include diarrheaDiarrheaDiarrhea is defined as ≥ 3 watery or loose stools in a 24-hour period. There are a multitude of etiologies, which can be classified based on the underlying mechanism of disease. The duration of symptoms (acute or chronic) and characteristics of the stools (e.g., watery, bloody, steatorrheic, mucoid) can help guide further diagnostic evaluation. Diarrhea, abdominal painAbdominal PainAcute Abdomen, weight lossWeight lossDecrease in existing body weight.Bariatric Surgery, and extraintestinal manifestations, which help differentiate IBD from IBSIBSIrritable bowel syndrome (IBS) is a functional bowel disease characterized by chronic abdominal pain and altered bowel habits without an identifiable organic cause. The etiology and pathophysiology of this disease are not well understood, and there are many factors that may contribute. Irritable Bowel Syndrome. Diagnosis includes imaging, endoscopyEndoscopyProcedures of applying endoscopes for disease diagnosis and treatment. Endoscopy involves passing an optical instrument through a small incision in the skin i.e., percutaneous; or through a natural orifice and along natural body pathways such as the digestive tract; and/or through an incision in the wall of a tubular structure or organ, i.e. Transluminal, to examine or perform surgery on the interior parts of the body.Gastroesophageal Reflux Disease (GERD) and biopsyBiopsyRemoval and pathologic examination of specimens from the living body.Ewing Sarcoma. Treatment involves steroidsSteroidsA group of polycyclic compounds closely related biochemically to terpenes. They include cholesterol, numerous hormones, precursors of certain vitamins, bile acids, alcohols (sterols), and certain natural drugs and poisons. Steroids have a common nucleus, a fused, reduced 17-carbon atom ring system, cyclopentanoperhydrophenanthrene. Most steroids also have two methyl groups and an aliphatic side-chain attached to the nucleus.Benign Liver Tumors, aminosalicylates, immunomodulators, and biologic agentsBiologic AgentsImmunosuppressants.
Microscopic colitisColitisInflammation of the colon section of the large intestine, usually with symptoms such as diarrhea (often with blood and mucus), abdominal pain, and fever.Pseudomembranous Colitis: a chronic inflammatory disease of the colonColonThe large intestines constitute the last portion of the digestive system. The large intestine consists of the cecum, appendix, colon (with ascending, transverse, descending, and sigmoid segments), rectum, and anal canal. The primary function of the colon is to remove water and compact the stool prior to expulsion from the body via the rectum and anal canal. Colon, Cecum, and Appendix: Anatomy, which can be categorized as collagenous or lymphocytic colitisColitisInflammation of the colon section of the large intestine, usually with symptoms such as diarrhea (often with blood and mucus), abdominal pain, and fever.Pseudomembranous Colitis. PatientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship tend to be middle-aged. Symptoms include chronic, watery diarrheaWatery diarrheaRotavirus, abdominal painAbdominal PainAcute Abdomen, and bloatingBloatingConstipation. A colonoscopyColonoscopyEndoscopic examination, therapy or surgery of the luminal surface of the colon.Colorectal Cancer Screening will appear normal, but inflammatory cells, cryptitis, or a subepithelialSubepithelialMembranoproliferative GlomerulonephritiscollagenCollagenA polypeptide substance comprising about one third of the total protein in mammalian organisms. It is the main constituent of skin; connective tissue; and the organic substance of bones (bone and bones) and teeth (tooth).Connective Tissue: Histology band will be seen on biopsyBiopsyRemoval and pathologic examination of specimens from the living body.Ewing Sarcoma, differentiating microscopic colitisColitisInflammation of the colon section of the large intestine, usually with symptoms such as diarrhea (often with blood and mucus), abdominal pain, and fever.Pseudomembranous Colitis from IBSIBSIrritable bowel syndrome (IBS) is a functional bowel disease characterized by chronic abdominal pain and altered bowel habits without an identifiable organic cause. The etiology and pathophysiology of this disease are not well understood, and there are many factors that may contribute. Irritable Bowel Syndrome. Treatment includes triggerTriggerThe type of signal that initiates the inspiratory phase by the ventilatorInvasive Mechanical Ventilation avoidance, glucocorticoidsGlucocorticoidsGlucocorticoids are a class within the corticosteroid family. Glucocorticoids are chemically and functionally similar to endogenous cortisol. There are a wide array of indications, which primarily benefit from the antiinflammatory and immunosuppressive effects of this class of drugs.Glucocorticoids, and symptom management.
Small intestinal bacterial overgrowthBacterial overgrowthLactose Intolerance: defined as excessive bacteriaBacteriaBacteria are prokaryotic single-celled microorganisms that are metabolically active and divide by binary fission. Some of these organisms play a significant role in the pathogenesis of diseases. Bacteriology growing in the small intestineSmall intestineThe small intestine is the longest part of the GI tract, extending from the pyloric orifice of the stomach to the ileocecal junction. The small intestine is the major organ responsible for chemical digestion and absorption of nutrients. It is divided into 3 segments: the duodenum, the jejunum, and the ileum. Small Intestine: Anatomy, and can result due to alteration in the intestinal anatomy or motilityMotilityThe motor activity of the gastrointestinal tract.Gastrointestinal Motility. Symptoms can range from mildly symptomatic to chronic diarrheaDiarrheaDiarrhea is defined as ≥ 3 watery or loose stools in a 24-hour period. There are a multitude of etiologies, which can be classified based on the underlying mechanism of disease. The duration of symptoms (acute or chronic) and characteristics of the stools (e.g., watery, bloody, steatorrheic, mucoid) can help guide further diagnostic evaluation. Diarrhea, weight lossWeight lossDecrease in existing body weight.Bariatric Surgery, and malabsorptionMalabsorptionGeneral term for a group of malnutrition syndromes caused by failure of normal intestinal absorption of nutrients.Malabsorption and Maldigestion. Bacterial cultures and breath tests can distinguish this condition from IBSIBSIrritable bowel syndrome (IBS) is a functional bowel disease characterized by chronic abdominal pain and altered bowel habits without an identifiable organic cause. The etiology and pathophysiology of this disease are not well understood, and there are many factors that may contribute. Irritable Bowel Syndrome. Treatment includes antibiotics and correction of nutritional deficiencies.
Lactose intoleranceLactose intoleranceLactose intolerance (LI) describes a constellation of symptoms due to lactase deficiency (LD), the enzyme located in the brush border of the absorptive cells in the small intestine. Lactose is the disaccharide present in milk and requires hydrolysis by lactase to break it down into its 2 absorbable constituents, glucose and galactose. Lactose intolerance typically presents with bloating, abdominal cramping, diarrhea, and flatulence. Lactose Intolerance: an intolerance to lactose-containing foods due to lactase deficiencyLactase deficiencyLactose Intolerance. Symptoms include crampy abdominal painAbdominal PainAcute Abdomen, bloatingBloatingConstipation, nauseaNauseaAn unpleasant sensation in the stomach usually accompanied by the urge to vomit. Common causes are early pregnancy, sea and motion sickness, emotional stress, intense pain, food poisoning, and various enteroviruses.Antiemetics, and diarrheaDiarrheaDiarrhea is defined as ≥ 3 watery or loose stools in a 24-hour period. There are a multitude of etiologies, which can be classified based on the underlying mechanism of disease. The duration of symptoms (acute or chronic) and characteristics of the stools (e.g., watery, bloody, steatorrheic, mucoid) can help guide further diagnostic evaluation. Diarrhea. Diagnosis is based on the association with lactose-containing foods and a lactose hydrogen breath testHydrogen breath testLactose Intolerance, which will differentiate the condition from IBSIBSIrritable bowel syndrome (IBS) is a functional bowel disease characterized by chronic abdominal pain and altered bowel habits without an identifiable organic cause. The etiology and pathophysiology of this disease are not well understood, and there are many factors that may contribute. Irritable Bowel Syndrome. Management includes restriction of dietary lactose and enzyme replacementEnzyme replacementTherapeutic replacement or supplementation of defective or missing enzymes to alleviate the effects of enzyme deficiency (e.g., glucosylceramidase replacement for gaucher disease).Severe Combined Immunodeficiency (SCID).
GiardiasisGiardiasisAn infection of the small intestine caused by the flagellated protozoan giardia. It is spread via contaminated food and water and by direct person-to-person contact.Giardia/Giardiasis: an intestinal infection due to GiardiaGiardiaA genus of flagellate intestinal eukaryotes parasitic in various vertebrates, including humans. Characteristics include the presence of four pairs of flagella arising from a complicated system of axonemes and cysts that are ellipsoidal to ovoidal in shape.Nitroimidazoles duodenalis. PatientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship may be asymptomatic or have watery, foul-smelling diarrheaDiarrheaDiarrhea is defined as ≥ 3 watery or loose stools in a 24-hour period. There are a multitude of etiologies, which can be classified based on the underlying mechanism of disease. The duration of symptoms (acute or chronic) and characteristics of the stools (e.g., watery, bloody, steatorrheic, mucoid) can help guide further diagnostic evaluation. Diarrhea; abdominal crampingAbdominal crampingNorovirus; and distension. Weight lossWeight lossDecrease in existing body weight.Bariatric Surgery and evidence of malabsorptionMalabsorptionGeneral term for a group of malnutrition syndromes caused by failure of normal intestinal absorption of nutrients.Malabsorption and Maldigestion may be present and will differentiate this condition from IBSIBSIrritable bowel syndrome (IBS) is a functional bowel disease characterized by chronic abdominal pain and altered bowel habits without an identifiable organic cause. The etiology and pathophysiology of this disease are not well understood, and there are many factors that may contribute. Irritable Bowel Syndrome. Stool studies for GiardiaGiardiaA genus of flagellate intestinal eukaryotes parasitic in various vertebrates, including humans. Characteristics include the presence of four pairs of flagella arising from a complicated system of axonemes and cysts that are ellipsoidal to ovoidal in shape.Nitroimidazoles will establish the diagnosis, and treatment includes metronidazoleMetronidazoleA nitroimidazole used to treat amebiasis; vaginitis; trichomonas infections; giardiasis; anaerobic bacteria; and treponemal infections.Pyogenic Liver Abscess, tinidazoleTinidazoleA nitroimidazole alkylating agent that is used as an antitrichomonal agent against trichomonas vaginalis; entamoeba histolytica; and giardia lamblia infections. It also acts as an antibacterial agent for the treatment of bacterial vaginosis and anaerobic bacterial infections.Nitroimidazoles, or nitazoxanide.
Billing and Coding
Diagnosis Codes:
Irritable Bowel SyndromeIrritable bowel syndromeIrritable bowel syndrome (IBS) is a functional bowel disease characterized by chronic abdominal pain and altered bowel habits without an identifiable organic cause. The etiology and pathophysiology of this disease are not well understood, and there are many factors that may contribute. Irritable Bowel Syndrome (IBSIBSIrritable bowel syndrome (IBS) is a functional bowel disease characterized by chronic abdominal pain and altered bowel habits without an identifiable organic cause. The etiology and pathophysiology of this disease are not well understood, and there are many factors that may contribute. Irritable Bowel Syndrome) is coded based on the predominant symptom, such as IBSIBSIrritable bowel syndrome (IBS) is a functional bowel disease characterized by chronic abdominal pain and altered bowel habits without an identifiable organic cause. The etiology and pathophysiology of this disease are not well understood, and there are many factors that may contribute. Irritable Bowel Syndrome with diarrheaDiarrheaDiarrhea is defined as ≥ 3 watery or loose stools in a 24-hour period. There are a multitude of etiologies, which can be classified based on the underlying mechanism of disease. The duration of symptoms (acute or chronic) and characteristics of the stools (e.g., watery, bloody, steatorrheic, mucoid) can help guide further diagnostic evaluation. Diarrhea (IBS-D), IBSIBSIrritable bowel syndrome (IBS) is a functional bowel disease characterized by chronic abdominal pain and altered bowel habits without an identifiable organic cause. The etiology and pathophysiology of this disease are not well understood, and there are many factors that may contribute. Irritable Bowel Syndrome with constipationConstipationConstipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation (IBS-C), or mixed-type (IBS-M).
Coding System
Code
Description
ICD-10-CM
K58.0
Irritable bowel syndromeIrritable bowel syndromeIrritable bowel syndrome (IBS) is a functional bowel disease characterized by chronic abdominal pain and altered bowel habits without an identifiable organic cause. The etiology and pathophysiology of this disease are not well understood, and there are many factors that may contribute. Irritable Bowel Syndrome with diarrheaDiarrheaDiarrhea is defined as ≥ 3 watery or loose stools in a 24-hour period. There are a multitude of etiologies, which can be classified based on the underlying mechanism of disease. The duration of symptoms (acute or chronic) and characteristics of the stools (e.g., watery, bloody, steatorrheic, mucoid) can help guide further diagnostic evaluation. Diarrhea
ICD-10-CM
K58.1
Irritable bowel syndromeIrritable bowel syndromeIrritable bowel syndrome (IBS) is a functional bowel disease characterized by chronic abdominal pain and altered bowel habits without an identifiable organic cause. The etiology and pathophysiology of this disease are not well understood, and there are many factors that may contribute. Irritable Bowel Syndrome with constipationConstipationConstipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation
ICD-10-CM
K58.2
Mixed irritable bowel syndromeIrritable bowel syndromeIrritable bowel syndrome (IBS) is a functional bowel disease characterized by chronic abdominal pain and altered bowel habits without an identifiable organic cause. The etiology and pathophysiology of this disease are not well understood, and there are many factors that may contribute. Irritable Bowel Syndrome
Medications:
These codes are for medications used to manage IBSIBSIrritable bowel syndrome (IBS) is a functional bowel disease characterized by chronic abdominal pain and altered bowel habits without an identifiable organic cause. The etiology and pathophysiology of this disease are not well understood, and there are many factors that may contribute. Irritable Bowel Syndrome symptoms. DicyclomineDicyclomineA muscarinic antagonist used as an antispasmodic and in urinary incontinence. It has little effect on glandular secretion or the cardiovascular system. It does have some local anesthetic properties and is used in gastrointestinal, biliary, and urinary tract spasms.Anticholinergic Drugs is an antispasmodicAntispasmodicAntispasmodics are a group of medications used to reduce excessive GI smooth muscle contractility and spasm. These medications may be helpful in those with abdominal pain due to conditions such as irritable bowel syndrome, although their efficacy is controversial. Antispasmodics for abdominal crampingAbdominal crampingNorovirus, loperamideLoperamideOne of the long-acting synthetic antidiarrheals; it is not significantly absorbed from the gut, and has no effect on the adrenergic system or central nervous system, but may antagonize histamine and interfere with acetylcholine release locally.Antidiarrheal Drugs treats diarrheaDiarrheaDiarrhea is defined as ≥ 3 watery or loose stools in a 24-hour period. There are a multitude of etiologies, which can be classified based on the underlying mechanism of disease. The duration of symptoms (acute or chronic) and characteristics of the stools (e.g., watery, bloody, steatorrheic, mucoid) can help guide further diagnostic evaluation. Diarrhea, and lubiprostone is used for constipationConstipationConstipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation.
Coding System
Code
Description
RxNorm
3423
DicyclomineDicyclomineA muscarinic antagonist used as an antispasmodic and in urinary incontinence. It has little effect on glandular secretion or the cardiovascular system. It does have some local anesthetic properties and is used in gastrointestinal, biliary, and urinary tract spasms.Anticholinergic Drugs (ingredient)
RxNorm
6448
LoperamideLoperamideOne of the long-acting synthetic antidiarrheals; it is not significantly absorbed from the gut, and has no effect on the adrenergic system or central nervous system, but may antagonize histamine and interfere with acetylcholine release locally.Antidiarrheal Drugs (ingredient)
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Lembo, A., Sultan, S., Chang, L., Heidelbaugh, J. J., Smalley, W., Verne, G. N. (2022). AGA clinical practice guideline on the pharmacological management of irritable bowel syndrome with diarrhea. Gastroenterology, 163(1), 137–151. https://doi.org/10.1053/j.gastro.2022.04.017
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Lacy, B. E., Pimentel, M., Brenner, D. M., Chey, W. D., Keefer, L. A., Long, M. D., Moshiree, B. (2021). ACG clinical guideline: management of irritable bowel syndrome. American Journal of Gastroenterology, 116(1), 17–44. https://doi.org/10.14309/ajg.0000000000001036
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