Single Patient Based Medicine: Irritable Bowel Syndrome.                                                         (Sergio S...
Clinical symptomatology of Irritable Bowel Syndrome.        The most common symptoms of IBS include a change in the appear...
Certainly, if alarm symptoms (weight loss, gastrointestinal bleeding, anemia, fever, orfrequent nocturnal symptoms) are pr...
Consequently, from the above remarks, in to-day-practice SPBM and EBM must interacteach other, improving themselves, becau...
20) Stagnaro-Neri M., Stagnaro S., Sindrome di Reaven, classica e variante, in evoluzionediabetica. Il ruolo della Carniti...
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  1. 1. Single Patient Based Medicine: Irritable Bowel Syndrome. (Sergio Stagnaro) Introduction..................................................................................................................................1 Clinical symptomatology of Irritable Bowel Syndrome..............................................................2 Differential Diagnosis..................................................................................................................2 Biophysical Semeiotics of Irritable Bowel Syndrome.................................................................3 Conclusion....................................................................................................................................3 References....................................................................................................................................4Introduction. K.B. Holten and A. Wetherington’s excellent article (1) stimulated me to write this paperaiming to demomstrate the usefulness of Biophysical Semeiotics knowledge of doctors, in general,and particularly general practitioners, all around the world, who first examine patients sufferingfrom abdominal pain and intestinal motility abnormalities, that must be properly and rapidlydiagnosed, particularly in the interest of patient’s life. Diagnosing a patient who presents with abdominal pain and altered bowel habits can bechallenging. As a matter of fact, family physicians frequently see patients who have abdominal painand altered bowel habits. It is, therefore, a challenge to properly evaluate these patients anddifferentiate between irritable bowel syndrome (IBS) and life-threatening illnesses of thegastrointestinal tract. In reality, although serious organic illnesses can cause these symptoms, irritable bowelsyndrome is commonly responsible. The above-cited authors, I sincerely thank once again, state thatit can be difficult to properly evaluate these patients without overusing diagnostic tests andconsultation. A practical approach for diagnosing irritable bowel syndrome is suggested, using theRome II criteria and the presence of alarm symptoms such as weight loss, gastrointestinal bleeding,anemia, fever, or frequent nocturnal symptoms as starting points (1). If there are no alarm symptoms and the Rome II criteria are not met, it is acceptable toreevaluate the patient at a later date. If there are no alarm symptoms and the Rome II criteria aremet, the patient should be categorized on the basis of age: patients 50 years or younger can beevaluated on the basis of predominant symptoms, i.e., constipation, diarrhea, or abdominal pain.Patients older than 50 years should be fully evaluated and considered for gastroenterology referral.If alarm symptoms are present, a full evaluation should be performed (and gastroenterology referralconsidered), regardless of the patients age. From the above remarks, it is easy to understand that IBS is one of the most commonchronic gastrointestinal illnesses. IBS traditionally has been a diagnosis of exclusion, based onhistory, physical examination, and a negative battery of diagnostic studies (2). There are nostructural or chemical markers for IBS (3). Diagnostic tests are frequently overused becausephysicians are concerned about missing a life-threatening illness. In addition, IBS is a real economic problem for every NHS around the world, and absenteismresulting from IBS significantly affects the work force. Studies have shown that IBS affects 3 to 22percent of persons worldwide (4). Symptoms are reported by 12 percent of Americans and are thecause of 20 to 50 percent of referrals to gastroenterology clinics. Most people with IBS do not seekmedical care. Finally, one half of patients develop symptoms before 35 years of age, and 40 percentof patients develop symptoms between 35 and 50 years of age. Onset in elderly persons is rare (1).
  2. 2. Clinical symptomatology of Irritable Bowel Syndrome. The most common symptoms of IBS include a change in the appearance or frequency ofstools, and abdominal pain that is relieved by defecation. Other associated symptoms includebloating, distention, mucus in the stool, urgency, and a feeling of incomplete evacuation. Based on stool-habit alteration, three subgroups of IBS have been described three differentIBS types: constipation-predominant IBS, diarrhea-predominant IBS, and IBS with alternatingbowel habits (also known as pain-predominant) (5). Although these groupings are useful forresearch purposes, in day-to-day practice, symptom patterns may vary. Associated with IBS we canobserve a loth of other disorders, such as anxiety, stress, social phobia, somatization disorders,depression (including dysthymia), panic disorder, fibromyalgia, chronic fatigue syndrome,temporomandibular joint syndrome, intestinal allergy, a.s.o. However, these factors do not enlighten IBS pathogenesis, which is still unknown.Differential Diagnosis. Numerous illnesses, many of them really severe, share some of the same symptoms as IBS..Therefore, a differential diagnosis for patients who present with abdominal pain and altered bowelhabits is important (6, 7). One must consider in particular inflammatory bowel disease, bacterial andviral in origine, Crohns disease or ulcerative colitis, celiac disease, constipating medications,laxatives, malabsorption syndromes, pancreatic insufficiency, endocrine disorders (diabetes, hyper-and hypo-thyroidism, Addison’s disease), psychiatric disorders, anxiety, depression, gastrointestinalcarcinoma. Nowadays, no gold standard or marker for IBS exists and then a cost-effective diagnosticapproach that uses the fewest tests and invasive studies is most desirable. In my opinion, it isdesirable that doctor can clinically utilize very few examinations, which allow to recognize thedisease as well as exclude other severe disorders, causing often mortality. At the present, indiagnosing and differential diagnosing IBS, doctor follows some guide lines and score systems,among them “Rome II criteria”, but no one is 100% of cases sensitive or specific (2). In fact,several scoring systems for diagnosing IBS have been proposed (1). As regards this point, we musttake intoaccount that it is necessary a period of 12 weeks, at least, (not necessarily consecutive), ofthree of following symptoms: abdominal pain or discomfort that is relieved with defecation,associated with a change in frequency of stools, associated with a change in appearance of stools. Inother words, the proper diagnosis is possible after 12 weeks after symptoms begin: really, a time tolong. On the other hand, blood studies are expensive and almost in normal range in case of IBS,ad colon endoscopy. In addition, abdominal ultrasonography is not needed in patients with IBSbecause it can lead to overaggressive diagnosis and treatment of minor findings (8). Thesophysticated semeiotics, referred above, are necessary, because they can point to organic causesfor pain and altered bowel habits (e.g., inflammatory bowel disease, colorectal carcinoma,metabolic causes). Most authors suggest that all symptomatic patients have a complete blood cellcount. Determination of the erythrocyte sedimentation rate, thyroid-stimulating hormone (TSH)level, and electrolyte levels is useful in patients with constipation-predominant and diarrhea-predominant symptoms. Fecal occult blood testing and the testing of stool for ova and parasites areuseful in patients with diarrhea. Lactose-malabsorption studies have limited value except in patientswith diarrhea-predominant symptoms. No psychometric screening tools have high enoughspecificity or sensitivity to warrant their use for diagnostic purposes. In some cases, a psychosocialevaluation is recommended (3).
  3. 3. Certainly, if alarm symptoms (weight loss, gastrointestinal bleeding, anemia, fever, orfrequent nocturnal symptoms) are present, a full evaluation should be performed, regardless of thepatients age. These symproms, however, occur usually to late.Biophysical Semeiotics of Irritable Bowel Syndrome. To understand what follows, reader must obviously have a good knowledge of BiophysicalSemeiotics, illustrated in both this site HONCode 233736, www.semeioticabiofisica, and in its largeBibliography articles. When a patient is suffering from abdominal pain, first of all doctor has to gather accuratelyhis (her) history, which is precious diagnostic tool. The diagnostic iter, starts looking for numerousbiophysical semeiotics signs of inflammation: Rethiculo-Endothelial System HyperfunctionSyndrome, finger-pulp diagram, evaluation of Acute Phase Proteins, a.s.o., as described in PracticalApplications (9, 10). At this points, ascertaining “Oncological Terrain” in a “quantitative” way (11),localizing it precisely, is unavoidable (12). If all these data are absent, doctor is allowed to excludeinflammatory intestinal disorders, and obviously colon cancer. On the contrary, if the patient is involved by oncological terrain, in order to corroborate thepossible intestinal site of malignancy, doctor can perform an useful and easy biophysical-semeioticmanoeuvre, stimulating intestinal trigger-points by means of abdominal wall muscles: the subject,to be examined, must push as during defecation, “simulated defecation test”. In presence of coloncancer, e.g., it appears at first gastric aspecific reflex and, then, tonic gastric contraction. (It isnecessary to exclude both appendicitis and diverticulitis). In case of IBS, wherein inflammation and intestinal malignancy signs are absent(oncological terrain can however be present), doctor has to assess intestinal peristalsis, so-calledcolon “velocimetry”, that sometime results increased or decreased (NN = 30 sec.) in relation to thesubtype of IS (See in this web site: Glossary). As I referred above, patient with IBS present psycho-somatic disorders, anxiety, depression,which can be now-a-days be recongized at the bed side by the aid of Biophysical Semeiotics (13,14, 15). As regards the evaluation of endocrine situation, necessary to exclude some diseases whichcan notoriously bring about intestinal alterations, similar to those of IBS, and, therefore, arechallinging the diagnosing procedure (thyroid dysfunction, diabetes mellitus, Addison’s disease), Iask, in a friendly way, reader to consult my former articles (14, 17, 18, 20, 21).Conclusion. Single patient based medicine, as illustrated in this article, show particularly efficaciouseffects in applying in the singular case general knowledge, obtained by means of meta-analysisresearches on very large populations. Notoriously, the main difficulty of EBM is transfering in one patient all knowledge gatheredin a large number of patients, whose social, ethnic, and racial conditions are not always the same. Statistical data, certainly precious and interesting, can only partially be useful when appliedon a particular subject, suffering from a well-defined disorder. For instance, the fact that coloncancer involves preferentially, i.e., mainly, the ascending tract, is not significant for the doctor whoexamines a patient with oncological terrain, presenting with the complete biophysical-semeioticphenomenology of descending colon cancer, but without any risk of cancer elsewhere in the sameviscera.
  4. 4. Consequently, from the above remarks, in to-day-practice SPBM and EBM must interacteach other, improving themselves, because from such as co-operation the possibility originates toovercome weak points of the medicine based on large number, all authors agree with (22).References.1) Holten K.B., Wetherington A. Diagnosing the Patient with Abdominal Pain and Altered BowelHabits: Is It Irritable Bowel Syndrome? Am Fam Physician 2003; 67:2157-62.2) Longstreth GF. Irritable bowel syndrome: diagnosis in the managed care era. Dig Dis Sci1997;42: 1105-11.3) Fass R, Longstreth GF, Pimentel M, Fullerton S, Russak SM, Chiou CF, et al. Evidence- andconsensus-based practice guidelines for the diagnosis of irritable bowel syndrome. Arch Intern Med2001; 161:2081-8.4) Locke GR 3d, Zinsmeister AR, Talley NJ, Fett SL, Melton LJ. Risk factors for irritable bowelsyndrome: role of analgesics and food sensitivities. Am J Gastroenterol 2000;95:157-65.5) Whitehead WE. Patient subgroups in irritable bowel syndrome that can be defined by symptomevaluation and physical examination. Am J Med 1999;107:33S-40S.6) Dalton CB, Drossman DA. Diagnosis and treatment of irritable bowel syndrome. Am FamPhysician 1997;55:875-80, 883-5.7) Sanders DS, Carter MJ, Hurlstone DP, Pearce A, Ward AM, McAlindon ME, et al. Associationof adult coeliac disease with irritable bowel syndrome: a case-control study in patients fulfillingROME II criteria referred to secondary care. Lancet 2001;358:1504-8.8) Francis CY, Duffy JN, Whorwell PJ, Martin DF. Does routine abdominal ultrasound enhancediagnostic accuracy in irritable bowel syndrome? Am J Gastroenterol 1996;91:1348-50.9) Stagnaro S., Il Ruolo della Percussione Ascoltata nella “difficile Diagnosi” di Appendicite. Biol.Med. 8, 71, 1986.10) Stagnaro-Neri M., Stagnaro S., Appendicite. Min. Med. 87, 183, 1996 (Pub-Med indexed forMedline)11) Stagnaro S. Il Terreno Oncologico. Contributo alla prevenzione primaria di tumori maligni.http://digilander.libero.it/semeioticabiofisica/oncologico.htm.( volume in stampa).12 Stagnaro S. Oncogenesi: il punto di vista semeiotico-biofisico.http://digilander.libero.it/piazzettamedici/professione/professione.htm13) Stagnaro-Neri M, Stagnaro S., Valutazione clinica percusso-ascoltatoria del sistema nervosovegetativo e del sistema renina-angiotensina, circolatorio e tessutale. Arch. Med. Int. XLIV, 3,173-178, 1992. (Infotrieve)14) Stagnaro S., Stagnaro-Neri M. Semeiotica Biofisica: valutazione clinica del picco precoce dellasecrezione insulinica di base e dopo stimolazione tiroidea, surrenalica, con glucagone endogeno edopo attivazione del sistema renina-angiotesina circolante e tessutale – Acta Med. Medit. 13, 99,1997.15) Stagnaro S. Bed-side diagnosing acute appendicitis and gastrointestinal diseases. (17 July 2003) Gut.j.on line: http://gut.bmjjournals.com/cgi/eletters/52/5/770-a#100.16) Stagnaro S. Depression, Anxiety and Psychosis. B C Medical Journal, Volume 43, Number 6,page 321, July-August, 200117) Stagnaro S., Diet and Risk of Type 2 Diabetes. N Engl J Med. 2002 Jan 24;346(4):297-298.letter [PubMed –indexed for MEDLINE].18) Stagnaro S., Stagnaro-Neri M. Valutazione percusso-ascoltatoria del Diabete Mellito. Aspettiteorici e pratici. Epat. 32, 131, 1986.19) Stagnaro-Neri M., Stagnaro S., Il diagramma linfatico dell’arto superiore nella diagnosi clinicapercusso-ascoltatoria del diabete mellito. III Congr. Intern. Di Flebolinfologia. Ferrara-San Marino,18-21 Settembre, 1991. Atti 21-11.
  5. 5. 20) Stagnaro-Neri M., Stagnaro S., Sindrome di Reaven, classica e variante, in evoluzionediabetica. Il ruolo della Carnitina nella prevenzione del diabete mellito. Il Cuore. 6, 617, 1991(Pub-Med indexed for Medline)21) Stagnaro-Neri M., Stagnaro S., Il Segno di Bilancini-Lucchi nella diagnosi clinica del diabetemellito. The Pract. Ed. It. 176, 30.22) Trisha G. Evidence Based Medicine. Le basi. Infomedica S.r.l. Sigma Tau. Pianezza (Torino)1998.

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