Irritable Bowel Syndrome (cont.)
What is a reasonable approach to IBS?
The initial approach to IBS-treatment or testing--depends on the patient's
symptoms and their duration. If the symptoms clearly fit the definition for IBS
and have been present for years without change, then there is less need for
extensive testing to exclude other intestinal and non-intestinal diseases.
Rather, treatment that is directed at specific symptoms, as discussed
previously, can begin. The role of antibiotics and/or probiotics is currently
being studied.
On the other hand, if the symptoms are of recent onset (such as weeks or
months), progressively worsening, severe, or associated with "warning" signs,
then early testing is appropriate. Warning signs include loss of weight,
nighttime awakening, rectal
bleeding, and signs of inflammation, such as fever or abdominal tenderness.
Testing also is appropriate if, in addition to symptoms of IBS, there are other
prominent symptoms that are not part of IBS (for example, abdominal distention,
increased flatus, or vomiting). Finally, testing is warranted if attempts at
treating the symptoms of IBS are unsuccessful.
If there are symptoms that suggest non-IBS diseases, tests that are specific
for these conditions should be done first. The reason is that if these other
tests disclose disease other than IBS, it may not be necessary to do additional
testing. Examples of symptoms and possible testing include:
- Vomiting: upper gastrointestinal endoscopies to diagnose inflammatory or
obstructing diseases; and gastric emptying studies and/or
electrogastrography to diagnose impaired emptying of the stomach.
- Abdominal distention with or without increased flatulence:
upper gastrointestinal and small
intestinal X-rays to diagnose obstructing diseases; and hydrogen breath testing
to diagnose SIBO.
- Constipation without pain:
colonoscopy or barium
enema to exclude colonic cancer; marker studies to diagnose slow colonic
transit; and ano-rectal motility studies to diagnose rectal muscle disorders
For a patient with typical symptoms of IBS who requires testing to exclude
other diseases, the testing might reasonably include a standard screening panel
of blood tests and stool specimens for examination for parasites, pus, and
blood. A plain X-ray of the abdomen might be done during an episode of abdominal
pain (to look for intestinal blockage or obstruction). Testing for lactose
intolerance or a trial of a strict lactose-free diet should be done. Colonoscopy
(and, possibly, esophago-gastro-duodenoscopy, or EGD) would be the next test,
probably with multiple biopsies of the colon (and stomach and duodenum if EGD is
done). Finally, small intestinal X-rays might be done.
If all of the above appropriate testing reveals
no disease that could be causing the symptoms, other tests should
be considered. These tests include hydrogen breath testing to diagnose SIBO
and antro-duodenal and colonic motility studies to diagnose intestinal muscle or
nerve disorders. These studies probably should be done at centers that have
experience and expertise in diagnosing and treating these diseases.
Next: What is in the future for IBS? »
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