the enigma of
irritable bowel
IBS shows a widely variable presentation, has no
definitive cause, and can be tough to diagnose. But
symptoms are manageable with an integrated approach.
By Patti Radovich, MSN, RN, CNS, FCCM
IMAGINE being afraid to leave the
house for fear you’ll lose bowel control. That’s what some people with
irritable bowel syndrome (IBS) go
through on a monthly, weekly, or
even daily basis. Obviously, IBS can
significantly reduce the quality of life
and work productivity. In some cases, quality of life declines enough to
increase suicidal behavior.
Chronic but benign, IBS is considered a functional disorder because
symptoms persist despite a negative
examination for GI abnormalities. It
accounts for approximately 25% to
50% of gastroenterologist referrals
and is one of the most common
complaints among patients seeing
primary care physicians.
Predominant manifestations of
IBS (also called spastic or irritable
colon) are abdominal pain and altered bowel habits. IBS pathophysiology remains unclear, but the condition doesn’t lead to development
of cancer. (Take care not to confuse
IBS with inflammatory bowel disease, such as Crohn’s disease or
membranous ulcerative colitis.)
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In 2009, the American College of
Gastroenterology (ACG) updated its
guidelines for IBS diagnosis and
treatment. This article reflects the
revised ACG guidelines.
Who gets it
IBS affects the young and the old,
males and females (although it’s
twice as common in women). Many
sufferers are younger than age 50.
One study found that while IBS
prevalence is similar across all
racial and ethnic groups, it’s higher
in persons with annual incomes
below $20,000 and in unemployed
and unmarried persons. It has been
recognized as a key component of
Gulf War syndrome, a multisymptom disorder affecting soldiers deployed in the 1991 Gulf War.
rhea alternates with constipation.
IBS-D and IBS-M are more prevalent than IBS-C. Some evidence suggests that in some persons who initially have one subtype, symptoms
eventually switch to those of another subtype. (See Classifying IBS.)
Studies have identified potential risk
factors, such as heredity, environment, visceral hypersensitivity, food
hypersensitivities, abnormal GI motility, previous GI infections, emotional
stress, and a history of physical or
sexual abuse. (See IBS risk factors.)
About 50% of persons with IBS also
have signs and symptoms of depression, anxiety, somatization, or personality disorders.
IBS subtypes
IBS occurs in three subtypes, identified by their predominant symptoms:
• diarrhea-predominant IBS (IBS-D)
• constipation-predominant IBS
• mixed IBS (IBS-M), in which diar-
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The primary complaint among IBS
patients is abdominal pain with altered bowel habits for a period of at
least 3 months. The pain, typically felt
in the left lower abdomen, is crampy
with variable duration and intensity.
It varies with each individual, may
Classifying IBS
Irritable bowel syndrome (IBS) occurs in three general subtypes.
• In IBS with diarrhea (IBS-D), bowel movements consist of stools that are watery
more than 25% of the time and hard less than 5% of the time.
• In IBS with constipation (IBS-C), bowel movements consist of stools that are watery less than 25% of the time and hard more than 25% of the time.
• In mixed IBS (IBS-M), bowel movements alternate between hard and watery
stools more than 25% of the time.
worsen with eating or emotional
stress, and may ease with defecation.
Certain types of abdominal pain
are not characteristic of IBS and
should be investigated further.
These include pain associated with
anorexia, malnutrition, or weight
loss and progressive pain that awakens the person or prevents sleep.
Altered bowel habits
In IBS patients, the range of bowel
habits is broad and can vary from
diarrhea to constipation, diarrhea alternating with constipation, and normal bowel habits alternating with
either diarrhea or constipation.
Diarrhea. In IBS, diarrhea typically is marked by frequent loose
stools of small to moderate volume,
occurring during waking hours and
linked to awakening or eating a
meal. Some patients complain of
cramping and urgency, fecal incontinence, a feeling of incomplete
evacuation, and mucus discharge.
Up to 17% of IBS occurrences seem
to follow acute viral or bacterial
gastroenteritis caused by Campylobacter, Salmonella, or Shigella infections. Large-volume or nighttime
diarrhea, bloody stools, and greasy
stools are not typical of IBS and
should be investigated.
Constipation. This may last from
days to months, with remissions of
normal stools or diarrhea. Patients
may report a feeling of incomplete
evacuation without producing stool,
straining at stool, and prolonged
bathroom times. Some may report
using enemas or laxatives for relief.
Other GI complaints. Other complaints may include gastroesophageal reflux, dysphagia, early satiety,
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intermittent dyspepsia, nausea, noncardiac chest pain, bloating, or increased gas production. Some patients are sensitive to dairy foods,
fried foods, fats, caffeine, carbonated beverages, and red meat.
Extraintestinal conditions
Extraintestinal conditions possibly
associated with IBS include dysmenorrhea, dyspareunia, increased urinary frequency and urgency, hypertension, reactive airway disease, and
rheumatologic syndromes.
No symptom-based diagnostic criteria
can identify IBS syndrome accurately.
Evaluation of patients with abdominal pain and altered bowel habits
must exclude colitis, inflammatory
bowel disease, celiac disease, lactose
intolerance, infection, diverticula,
pancreatic insufficiency, thyroid malfunction, cancer, pelvic-floor dyssynergia, and psychiatric disorders.
For patients who present with abdominal pain and altered bowel
habits, ACG advises clinicians to
evaluate the history for hematochezia, weight loss greater than 10 lb
(4.5 kg), recurring fever, anemia,
chronic severe diarrhea, and a family
history of colorectal cancer. These
IBS risk factors
Risk factors for IBS include adverse
life events, recent GI infection, chronic pain, family history of celiac disease or sprue, hypochondria, postoperative conditions such as ileus,
excessive alcohol consumption, and
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“alarm” factors should be investigated for a potential organic cause.
No specific laboratory tests diagnose IBS. In patients without alarm
factors, obtain a detailed history of
nutritional intake and signs and
symptoms. ACG guidelines don’t
recommend laboratory testing, such
as a chemistry panel, complete
blood count, thyroid function studies, inflammatory markers, stool
studies for ova and parasites and fecal fat, or testing for celiac disease
or lactose malabsorption. Unless the
patient has alarm features, such tests
aren’t likely to identify an organic
condition. Patients older than age 50
should have routine colon-cancer
screenings, but in younger patients,
a sigmoidoscopy or colonoscopy
isn’t necessary and adds little to IBS
diagnosis or treatment.
Current treatment focuses on symptom management. An effective management plan takes an integrated
gradual approach. It includes individualized patient education and dietary
modification with a holistic focus
that addresses the physical, psychological, and emotional dimensions of
the disorder. Caregivers should strive
to develop a trusting, therapeutic relationship with the patient, starting
with simple reassurance.
For some patients with severe
symptoms, lifestyle modification,
medications, and treatment of psychological factors (such as depression, anxiety, or other psychiatric
conditions) are indicated. Little evidence supports the efficacy of specific treatments for all IBS patients.
Dietary changes
Current evidence indicates foodallergy testing and exclusion diets
aren’t effective in managing IBS.
Psyllium hydrophilic mucilloid (ispaghula husk) is moderately effective. For some patients, increasing
soluble fiber intake provides relief.
Teach patients to eat regularly
and slowly. Advise them to avoid
drinking liquids with meals, dietary
excesses, gas-producing or spicy
foods, and chewing gum. Some patients find probiotic foods and supplements (containing so-called
“good” bacteria) effective, although
studies don’t show consistent results
when compared to placebo. In some
patients, probiotic-containing yogurt
may improve the balance of normal
intestinal flora and ease symptoms.
Chinese herbal mixtures have
been studied in randomized clinical
trials and appear to have some benefit. But they may contain various
components, and their purity varies.
They aren’t recommended as some
have been linked to liver failure.
Pharmacologic therapy
For abdominal pain and discomfort,
certain antispasmodics (such as hyoscine, peppermint oil, cimetropium,
and pinaverium) may provide shortterm relief. In addition, anticholinergics, calcium channel blockers, combination sedative-anticholinergics,
and antidepressants may be prescribed for pain relief.
Nonabsorbable antibiotics such as
rifaximin have been effective in 8%
to 23% of IBS patients with diarrhea,
reducing both global IBS symptoms
and bloating. While not FDAapproved for IBS, rifaximin is approved for traveler’s diarrhea. In IBS
trials, the rifaximin dosage was higher
and therapy duration was longer than
when used for traveler’s diarrhea.
Diarrhea may improve with loperamide (Imodium). Although this
drug may not effectively reduce pain
or bloating, it does help reduce the
number of stools and improve stool
consistency. Alosetron hydrochloride
(Lotronex), introduced to treat diarrhea-predominant IBS in women,
was removed from the market due
to the risk of ischemic colitis and severe constipation. Later it was reintroduced only for select patients under close supervision.
Constipation may improve with
prescribed osmotic laxatives or bulking agents. Tegaserod (Zelnorm),
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ou’ll likely
encounter IBS
patients in various
clinical settings.
prescribed for certain women with
IBS-C, has been taken off the market
due to the risk of myocardial infarction, stroke, and unstable angina.
Lubiprostone (Amitiza), which improved global IBS-C symptoms in
randomized clinical trials, is FDAapproved for women with IBS-C. It’s
also approved for chronic idiopathic
constipation, and so far it appears to
be safe and effective for that purpose. But more research on the
drug’s effectiveness and safety is
needed. The most common side effects are mild to moderate nausea
and diarrhea. Lubiprostone enhances
fluid secretion and softens bowel
movements; for IBS-C, it’s given at
one-third the dosage used in treating
chronic constipation. The drug
shouldn’t be taken by patients with
mechanical bowel obstruction or
preexisting diarrhea. Women of
childbearing age should have a documented negative pregnancy test
before starting ther-apy and must
use contraception during therapy.
Stress reduction
Patients should be screened to assess their anxiety level, coping ability, emotional support system, and
commitment to adhering to treatment. Alternative and complementary therapies, such as acupuncture,
hypnosis, fish oils, and peppermint
oil, have been effective for some patients. Performing breathing and relaxation exercises, getting regular
exercise, and maintaining rest patterns also can be effective. For some
patients, psychological counseling,
support groups, cognitive therapy,
dynamic psychotherapy, and hyp-
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notherapy can help reduce global
IBS symptoms by reducing stress.
Partner with patients
You’re likely to encounter IBS patients in various clinical settings. To
ensure their accurate diagnosis and
management, inform yourself about
the condition and use an integrated
management approach. Help your
patients understand this complex
condition and work with them to
improve their quality of life.
Selected references
American College of Gastroenterology Task
Force on IBS. An evidence-based systematic
review on the management of irritable bowel syndrome. Am J Gastroenterol. 2009;104
(suppl 1):S1-S34.
Andrews EB, Eaton SC, Hollis KA, et al.
Prevalence and demographics of irritable
bowel syndrome: results from a large webbased survey. Aliment Pharmacol Ther.
Jamieson AE, Fletcher PC, Schneider MA.
Seeking control through the determination of
diet: a qualitative investigation of women
with irritable bowel syndrome and inflammatory bowel disease. Clin Nurse Spec. 2007;
Moore J. Uncovering the link between irritable bowel syndrome and abuse. Nurs N Z.
O'Mahony L, McCarthy J, Kelly P, et al. Lactobacillus and bifidobacterium in irritable
bowel syndrome: symptom responses and
relationship to cytokine profiles. Gastroenterology. 2005;128(3):541-551.
Spiegel BM, Farid M, Esrailian E, Talley J,
Chang L. Is irritable bowel syndrome a diagnosis of exclusion?: a survey of primary care
providers, gastroenterologists, and IBS experts.
Am J Gastroenterol. 2010;105(4):848-858.
Wald A. Pathophysiology of irritable bowel
syndrome. UpToDate. www.uptodate.com/
contents/pathophysiology-of-irritable-bowelsyndrome. Accessed July 14, 2011.
Zijdenbos IL, de Wit NJ, van der Heijden GJ,
Rubin G, Quartero, AO. Psychological treatments for the management of irritable bowel
syndrome. Cochrane Database Syst Rev.
2009;Jan 21(1):CD006442.
Visit www.AmericanNurseToday.com/Archives
.aspx for a complete list of selected references
and a list of dietary do’s and don’ts.
Patti Radovich is a clinical nurse specialist and
manager of nursing research at Loma Linda
University Medical Center in Loma Linda, California.
ONLINE Sidebar
Dietary do’s and don’ts
Inform patients with irritable bowel syndrome (IBS) that soluble fiber may ease
symptoms and that certain foods can trigger an IBS attack or exacerbate the condition. The table below shows good soluble fiber sources, along with foods that can
trigger an IBS attack or increase intestinal gas production.
Good sources of
soluble fiber
Foods that can
trigger an IBS attack
Corn meal
Flour tortillas
Fresh white breads, such as
French or sourdough
Pasta and noodles
Rice cereals
Squash and pumpkin
Sweet potatoes
Battered or deep-fried foods
Biscuits, croissants,
doughnuts, scones, or
other pastries
Coconut milk or shredded
Dairy products
Nuts, nut butters
Oils, fats, and spreads
Pie crust
Potato chips
Salad dressings
Solid chocolate
Tartar sauce
Whipped cream
Foods that can
increase intestinal
gas production
Apple peels
Brussels sprouts
Eating fruits and
vegetables at same
Red meat
September 2011
American Nurse Today