Irritable Bowel Syndrome: A Quality of Life Concern

Patients experiencing IBS need counseling on the pharmacologic and lifestyle medications that will help them manage their condition.

Irritable bowel syndrome (IBS) is a chronic disorder characterized by 4 core symptoms: abdominal pain, changes in bowel habits (diarrhea or constipation), bloating, and incomplete defecation. Many patients also report nausea and vomiting concurrent with abdominal cramping.¹

IBS is further subclassified as diarrhea- predominant, constipation-dominant, or alternating. Symptoms are recurrent, varying in severity. Bloating and diarrhea have the greatest negative impact on quality of life, with up to 50% of patients indicating they are forced to stay close to a toilet. Many patients develop symptom-related fears such as that of having an “accident,” leading to social isolation.

Prevalence ranges from 5% to 15% of the population, affecting twice as many women as men.^1,2 Prevalence declines with advanced age.³ Following the common cold, IBS is the second-most frequent reason for individuals needing time off from their jobs.¹

Because IBS’s symptoms mimic those of other gastrointestinal disorders, such as bile acid diarrhea, celiac disease, and pancreatic insufficiency, delayed diagnosis or misdiagnosis is common. One study, for example, reported that up to one-third of IBS patients may actually be suffering from bile acid diarrhea.² It is estimated that approximately 75% of patients are undiagnosed. Among those who are correctly diagnosed, 75% had IBS for 2 years and 33% had IBS for more than 10 years before receiving an accurate diagnosis.³

Pathophysiology

IBS is a functional disorder of the gastrointestinal tract and is not attributed to morphologic abnormalities. Exact causes are unknown, but research suggests that IBS patients have heightened sensitivity in their intestines. IBS’s etiology is multi-factoral, involving interference of neurotransmissions between the central nervous system

and the intestines.

Other proposed causes include muscle and nerve dysfunction, increased or reduced gastrointestinal transit, reduced tolerance to painful stimuli, alterations in gut bacteria, and intestinal inflammation.^2-4 Although genetics play a role in etiology, a definitive disease-causing gene or set of genes has yet to be identified.^4,5

Stress, anxiety, depression, and poor coping skills exacerbate symptoms.³ Numerous environmental and social stresses are also linked to IBS, including childhood trauma, dysfunctional family dynamics, abuse history either as an adult or child, and major life stressors (eg, divorce, death of a loved one, or unemployment).⁴ Many IBS patients also have mental health problems. Approximately 30% suffer from clinical depression and the presence of generalized anxiety in patients with IBS exceeds that observed in the general population.⁴

Treatment

There is no effective treatment that alters IBS’s disease course. Managing symptoms and improving quality of life are treatment’s main objectives. A combination of pharmacotherapy and dietary and stress-reducing interventions is used for symptom management. The Table outlines the pharmacologic options for managing symptoms of IBS.

Counseling

When patients present with IBS symptoms, the pharmacist should probe for symptom duration. If symptoms have persisted more than 6 months (a diagnostic criterion for IBS), encourage patients to see a physician. In making the referral, note that IBS is not a life-threatening condition and does not lead to other serious conditions. Interestingly, some studies suggest IBS patients tend to live longer than those without the disease.¹ Inform patients that although antidiarrheal agents reduce the frequency of watery stools and laxatives may ease constipation, these agents have no effect on painful cramping and bloating.¹

Dietary changes are beneficial for symptom management (see sidebar for IBS dietary guidelines). Patients should introduce dietary changes gradually. Query for lactose intolerance, because up to 40% of IBS patients are lactose intolerant. Recommend a food diary; it helps to identify foods linked to symptom worsening. Ask about eating habits; many IBS patients change eating habits in an attempt to control symptoms, increasing risk for eating disorders (especially women) and malnutrition.⁶

Query for depression and/or anxiety; these are common comorbid conditions. When present, encourage patients to discuss their feelings with their physician. Reducing stress and developing effective coping mechanisms have positive benefits. Cognitive-behavioral therapy, dynamic psychology, and hypnosis have been used successfully to reduce IBSrelated stress.⁶

Up to 50% of patients turn to complementary and alternative medicine (CAM) to seek relief³; however, the American College of Gastroenterology Task Force on IBS reports that evidence-based support for CAM is lacking. Although evidence is limited, many patients report positive outcomes for acupuncture, yoga, peppermint oil (which has antispasmodic properties), turmeric, and artichoke leaf extract.³

For patients receiving treatment for IBS, as for all conditions, patient counseling should include a review of their side effect profile.

Final Thought

Knowing that many people are embarrassed to talk about gas, diarrhea, or constipation, health care providers should routinely initiate questions and discussions. Emphasizing that IBS is a valid medical condition facilitates a useful and responsive counseling session.

Dr. Zanni is a psychologist and health-systems consultant based in Alexandria, Virginia.

References

1. American College of Gastroenterology. Irritable bowel syndrome. Available at http://patients.gi.org/topics/irritable-bowel-syndrome/#tabs2. Accessed April 25, 2012.

2. Suares NC, Ford AC. Diagnosis and treatment of irritable bowel syndrome. Discov Med. 2011;11:425-33.

3. Yoon SL, Grundmann O, Koepp L, Farrell L. Management of irritable bowel syndrome (IBS) in adults: conventional and complementary/alternative approaches. Altern Med Rev. 2011;16:134-51.

4. Surdea-Blaga T, Băban A, Dumitrascu DL. Psychosocial determinants of irritable bowel syndrome. World J Gastroenterol. 2012;18:616-26.

5. Saito YA. The role of genetics in IBS. Gastroenterol Clin North Am. 2011;40:45-67.

6. World Gastroenterology Organisation (WGO). World Gastroenterology Organization Global Guideline: irritable bowel syndrome: a global perspective. Munich (Germany): World Gastroenterology Organization (WGO); 2009. Available at http://guideline.gov/content.aspx?id=15232&search=irritable+bowel+syndrome. Accessed April 28, 2012.

7. WebMD. Irritable bowel syndrome (IBS) health center. Available at http://www.webmd.com/ibs/guide/irritable-bowel-syndrome-ibs-treatment-overview. Accessed May 1, 2012.