Irritable bowel syndrome: Minimize testing, let symptoms guide treatment

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Applied Evidence

Irritable bowel syndrome: Minimize testing, let symptoms guide treatment

J Fam Pract. 2003 December;52(12):942-950

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References

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Test results yield little. Most research in this area has compared the prevalence of specific illnesses in the general population with the yield of positive test results for these illnesses among persons meeting the symptom-based diagnostic criteria for IBS.

Two studies^15,16 determined the incidence of abnormal test results in patients who met the Manning or Rome I criteria for IBS. In these studies, most diagnostic tests yielded positive results in 2% (range, 0%-8.2%) of patients or less, except for thyroid and lactose intolerance testing. That is equivalent to the incidence in the general population. The prevalence of thyroid disorders and lactose malabsorption was higher in IBS patients (6% and 22%-26%, respectively), but prevalence in the general population is similarly higher (5%-9% and 25%). Based on these results, testing for thyroid disease or lactose malabsorption is indicated only for patients exhibiting symptoms of these disorders (fatigue/weight change or diarrhea related to diertary intake of dairy products, respectively).

An exception. Some clinicians propose that diagnostic testing for patients with IBS symptoms should be driven by the pretest probability of organic disease (prevalence) compared with the general population. Cash²¹ found the pretest probability of inflammatory bowel disease, colorectal cancer, and infectious diarrhea is less than 1% among IBS patients without alarm symptoms ( Table 2 ). He demonstrated that patients with IBS had a 5% pretest probability of celiac sprue compared with healthy patients (<1% prevalence). Therefore, testing for celiac sprue (eg, complete blood count, antiendomysial antibody, and antigliadin antibody) may be considered for patients with diarrhea.^6,21,22 Sigmoidoscopy,^15,17 rectal biopsy,¹⁷ and abdominal ultrasound¹⁸ have low positive yield in patients meeting the diagnostic criteria for IBS.

TABLE 2
Probability of organic disease in irritable bowel syndrome patients

Disease	Pretest probability-IBS patients (%)	Prevalence-general population (%)	Comments
Colitis/inflammatory inflammatory bowel disease	0.51-0.98	0.3-1.2	Structural colon lesions were detected with barium enema, colonscopy, sigmoidoscopy
Colon cancer	0-0.51	4-6	Structural colon lesions were detected with barium enema, colonoscopy, sigmoidoscopy
Celiac disease	4.67	0.25-0.5	Note: celiac disease prevalence higher than in general population.
Gastrointestinal infection	0-1.7	N/A
Thyroid dysfunction	6	5-9	Prevalence high in both groups
Lactose malabsorption	22-26	25	Prevalence high in both groups
Adapted from: Cash BD, Schonfeld P, Chey WD. The utility of diagnostic tests in irritable bowel syndrome patients: a systematic review. Am J Gastroenterol 2002; 97:2812-2819.
Results are from multiple studies: n=125-306.

How to proceed

Those under 50 years of age who have no alarm symptoms can forgo further testing. Testing for celiac sprue and lactose malabsorption might be considered for patients with diarrhea that improves or worsens with change in diet (strength of recommendation [SOR]: C).

Threshold for treatment

Treatment for IBS is indicated when both patient and physician believe global symptoms (abdominal discomfort, bloating, altered bowel habits) have diminished the quality of life (SOR: C). The goal of treatment is to alleviate all IBS symptoms (SOR: C). Treating altered bowel habits (constipation, diarrhea, and fecal urgency) without addressing other IBS symptoms (eg, abdominal pain) is inferior treatment.^23,24

Treatment options for IBS

Treatments for IBS include medications, behavior therapy, and complimentary and alternative therapies. Medications traditionally prescribed include bulking agents, anticholinergics/antispasmodics, antidiarrheals, and antidepressants. A 5HT₃ receptor antagonist and a 5HT₄ receptor partial agonist are now available. Table 3 summarizes the traditional treatments in terms of efficacy, strength of recommendations, and outcomes measured. Alternative and complimentary therapies appear in Table 4 .

As Brandt²⁴ has noted, the evidence for treatment effectiveness is difficult to review and summarize, because the quality of studies has been poor. Most studies did not use healthy control groups, and the numbers of participants were small. Many studies did not use blinded placebo groups. Outcomes measured varied among the studies, with most of them measuring reductions of individual bowel symptoms (eg, diarrhea or constipation). Quality-of-life tools were used in other studies to measure reduction in global IBS symptoms (eg, IBS Quality of Life ²⁵). Because of these discrepancies, there is no sound evidence for traditional therapies.

TABLE 3
Treatments for irritable bowel syndrome

Treatment	Efficacy (NNT)	SOR (studies)	Outcomes measured	Comments
5HT₄receptor agonist (tegaserod)^23,24,26-30	More effective than placebo at relieving global IBS symptoms in women with constipation (3.9-17)	A (4)	Global IBS symptoms, individual IBS symptoms	83%-100% of study participants were women with IBS and constipation. Rome I and II criteria for entry. May cause diarrhea
5HT₄receptor agonist(alosetron)^{23,24,26- 35}	More effective than placebo at relieving global IBS symptoms in women with diarrhea (2.5-8.3)	A (4)	Global IBS symptoms, individual IBS symptoms, adverse events	82%-93% of study participants were women. Rome I and II criteria for entry. May cause severe constipation; restricted use
Tricylic antidepressants (trimipramine, desipramine)^{23,24,36- 39}	Reduces abdominal pain. No more effective than placebo at relieving gloal IBS symptoms (3.2-5)	B (6)	GI symptoms	May cause constipation; no studies done with SSRIs
Loperamide^23,24,36-39	Relieves diarrhea. No more effective than placebo at relieving global IBS symptoms (3.2-5)	B (3)	Global IBS symptoms, diarrhea	Constipation or paralytic ileus can occur
Bulking agents (corn fiber, wheat bran, psyllium, ispaghula husks, calcium polycabophil)^{23,24,31,40-42}	Improves constipation. No more effective than placebo in studies considering global symptom improvement (2.2-8.6)	B (13)	GI symptoms, global IBS symptoms	May increase bloating. All studiessmall numbers of patients
Anti-spasmodics (hyoscyamine dicyclomine)^23,24,26-30	No evidence on improvement of global IBS symptoms (5.9)	B (3)	Individual IBS and global symptoms	Studies were short, small numbers, inconsistent effectiveness. Could worsen constipation; 15 additional studies done on drugs not available in the US
Behavioral therapies (hypnotherapy, relaxation therapy, psychotherapy, biofeedback)^{23,24,44, 52-57}	More effective than placebo at relieving individuals IBS symptoms (1.4-1.9)	B (16)	GI symptoms, psychological sypmtoms	None measures global IBS symptom improvement. Small numbers of patients
SSRI antidepressants (paroxtetine, fluoxetine)^{23,24, 50-51}	Improved quality of life, decreased abdominal pain	B (16)	Abdominal	One study severe IBS, other study only 10 participants quality of life
SOR, strength of recommendation; IBS, irritable bowel syndrome; GI, gastrointestinal; SSRI, selective serotonin reuptake inhibitor. For an explanation of SORs.