This document provides a summary of the American College of Gastroenterology's position statement and evidence-based systematic review on the management of irritable bowel syndrome (IBS). It finds that:
1. IBS is a common functional gastrointestinal disorder characterized by abdominal pain and altered bowel habits. Diagnostic criteria should be used to identify patients and rule out other organic diseases.
2. Common treatments for IBS symptoms include fiber, antispasmodics, peppermint oil, probiotics, antidepressants, and certain newer drugs. However, evidence for many treatments is limited.
3. Psychological therapies may benefit IBS patients, though evidence is poor. Managing comorbid conditions, quality of life,
Dr.NAGARJUNA JOURNAL - GUM CHEWING REDUCES POST OPERATIVE ILEUS?Butkuri Nagarjuna
This document summarizes a systematic review and meta-analysis on the effect of gum chewing in reducing postoperative ileus. The review included 9 randomized controlled trials with a total of 437 patients who underwent elective intestinal surgery. The meta-analysis found that gum chewing was associated with a shorter time to passing flatus (reduced by 14 hours) and stool (reduced by 23 hours), as well as a shorter hospital stay (reduced by 1.1 days). However, the evidence was limited by the small sample sizes of the included studies and lack of details on randomization and blinding methods. While gum chewing appears to be a low-cost intervention, more rigorous studies are still needed to confirm its benefits.
This document discusses guidelines for managing Crohn's disease in adults. It provides background on Crohn's disease and summarizes the process used to develop the guidelines. Literature on Crohn's disease was reviewed from 1946 to 2018 using several medical databases. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was used to evaluate evidence and assign strengths to recommendations. Key clinical features of Crohn's disease are summarized, including common symptoms, diagnosis, and extraintestinal manifestations. The natural history of Crohn's disease is described as typically chronic and progressive, with potential for intestinal complications over time.
The guidelines provide new diagnostic criteria for coeliac disease (CD) based on recent scientific and technical developments. Two groups of patients are defined with different diagnostic approaches: 1) children with symptoms suggestive of CD and 2) asymptomatic children at increased risk.
For group 1, the diagnosis is based on symptoms, positive serology, and compatible histology. If anti-tissue transglutaminase antibody titers are >10 times the upper limit of normal, CD can be diagnosed without biopsies by applying further testing.
For group 2, the diagnosis is based on positive serology and histology. HLA testing for HLA-DQ2 and HLA-DQ8 is valuable to exclude CD if both haplotypes
This document discusses Helicobacter pylori (H. pylori), including its epidemiology, complications, diagnosis, and treatment. Some key points:
- H. pylori was first discovered in 1982 and linked to peptic ulcer disease and gastric cancer. It is acquired primarily in childhood and transmitted within families.
- Asia has a high prevalence of around 58%. Risk factors include poor hygiene and high population density.
- Complications include gastric cancer, ulcers, gastric MALT lymphoma, and intestinal metaplasia.
- Diagnosis involves tests like the urea breath test, stool antigen test, and endoscopy. Treatment guidelines recommend testing dyspepsia, ulcer,
This study compared the effects of epidural analgesia and patient-controlled analgesia on patients undergoing laparoscopic right colectomy or low anterior resection. The study found that:
1) Epidural analgesia was associated with faster return of bowel function by 1 day in patients undergoing low anterior resection, but not in patients undergoing right colectomy.
2) Epidural analgesia provided significantly better pain control compared to patient-controlled analgesia for both right colectomy and low anterior resection patients.
3) However, epidural analgesia alone was inadequate for pain control in 28% of patients, who required the addition of patient-controlled analgesia.
Bone marrow transplant (BMT) recipients often require parenteral nutrition (PN) to meet their nutrient needs. While general guidelines for the provision of PN support by nutrition support teams (NSTs) have been shown to decrease inappropriate PN use, recommendations for nutrition in BMT recipients are lacking. We reviewed the charts of patients status post BMT on PN to determine whether institutional guidelines for PN initiation and continuous supervision of NSTs could be applied in this population. With the Institutional Review Board (IRB) approval, charts of adult BMT recipients on PN between June 14, 2006 and June 30, 2007 were examined. Sixty-nine charts were reviewed. Indications for initiation of PN included severe mucositis, graft versus host disease (GVHD), and other transplant related side effects resulting in poor oral intake. Among 69 patients, 37 (54%) had severe mucositis, 12 (17%) had GVHD, 2 (3%) had both mucositis and GVHD, and 18 (26%) had other side effects. It was determined that all patients met the criteria for initiation of PN support, as outlined in the guidelines form. Comprehensive guidelines for initiating PN support, developed by NSTs can also be used for BMT recipients in order to optimize their nutritional status.
The document reviews evidence on the use of immunonutrition for patients undergoing major upper gastrointestinal cancer surgeries. It summarizes 7 randomized control trials that found immunonutrition containing arginine, omega-3 fatty acids, and nucleotides reduced postoperative infections compared to control solutions. However, studies had flaws like low feeding volumes. More recent research has found benefits of immunonutrition are greater when aggressive enteral feeding protocols are used to provide over 800mL per day. Overall, evidence suggests immunonutrition may decrease infection risk for patients with gastrointestinal cancer undergoing surgery.
Dr.NAGARJUNA JOURNAL - GUM CHEWING REDUCES POST OPERATIVE ILEUS?Butkuri Nagarjuna
This document summarizes a systematic review and meta-analysis on the effect of gum chewing in reducing postoperative ileus. The review included 9 randomized controlled trials with a total of 437 patients who underwent elective intestinal surgery. The meta-analysis found that gum chewing was associated with a shorter time to passing flatus (reduced by 14 hours) and stool (reduced by 23 hours), as well as a shorter hospital stay (reduced by 1.1 days). However, the evidence was limited by the small sample sizes of the included studies and lack of details on randomization and blinding methods. While gum chewing appears to be a low-cost intervention, more rigorous studies are still needed to confirm its benefits.
This document discusses guidelines for managing Crohn's disease in adults. It provides background on Crohn's disease and summarizes the process used to develop the guidelines. Literature on Crohn's disease was reviewed from 1946 to 2018 using several medical databases. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was used to evaluate evidence and assign strengths to recommendations. Key clinical features of Crohn's disease are summarized, including common symptoms, diagnosis, and extraintestinal manifestations. The natural history of Crohn's disease is described as typically chronic and progressive, with potential for intestinal complications over time.
The guidelines provide new diagnostic criteria for coeliac disease (CD) based on recent scientific and technical developments. Two groups of patients are defined with different diagnostic approaches: 1) children with symptoms suggestive of CD and 2) asymptomatic children at increased risk.
For group 1, the diagnosis is based on symptoms, positive serology, and compatible histology. If anti-tissue transglutaminase antibody titers are >10 times the upper limit of normal, CD can be diagnosed without biopsies by applying further testing.
For group 2, the diagnosis is based on positive serology and histology. HLA testing for HLA-DQ2 and HLA-DQ8 is valuable to exclude CD if both haplotypes
This document discusses Helicobacter pylori (H. pylori), including its epidemiology, complications, diagnosis, and treatment. Some key points:
- H. pylori was first discovered in 1982 and linked to peptic ulcer disease and gastric cancer. It is acquired primarily in childhood and transmitted within families.
- Asia has a high prevalence of around 58%. Risk factors include poor hygiene and high population density.
- Complications include gastric cancer, ulcers, gastric MALT lymphoma, and intestinal metaplasia.
- Diagnosis involves tests like the urea breath test, stool antigen test, and endoscopy. Treatment guidelines recommend testing dyspepsia, ulcer,
This study compared the effects of epidural analgesia and patient-controlled analgesia on patients undergoing laparoscopic right colectomy or low anterior resection. The study found that:
1) Epidural analgesia was associated with faster return of bowel function by 1 day in patients undergoing low anterior resection, but not in patients undergoing right colectomy.
2) Epidural analgesia provided significantly better pain control compared to patient-controlled analgesia for both right colectomy and low anterior resection patients.
3) However, epidural analgesia alone was inadequate for pain control in 28% of patients, who required the addition of patient-controlled analgesia.
Bone marrow transplant (BMT) recipients often require parenteral nutrition (PN) to meet their nutrient needs. While general guidelines for the provision of PN support by nutrition support teams (NSTs) have been shown to decrease inappropriate PN use, recommendations for nutrition in BMT recipients are lacking. We reviewed the charts of patients status post BMT on PN to determine whether institutional guidelines for PN initiation and continuous supervision of NSTs could be applied in this population. With the Institutional Review Board (IRB) approval, charts of adult BMT recipients on PN between June 14, 2006 and June 30, 2007 were examined. Sixty-nine charts were reviewed. Indications for initiation of PN included severe mucositis, graft versus host disease (GVHD), and other transplant related side effects resulting in poor oral intake. Among 69 patients, 37 (54%) had severe mucositis, 12 (17%) had GVHD, 2 (3%) had both mucositis and GVHD, and 18 (26%) had other side effects. It was determined that all patients met the criteria for initiation of PN support, as outlined in the guidelines form. Comprehensive guidelines for initiating PN support, developed by NSTs can also be used for BMT recipients in order to optimize their nutritional status.
The document reviews evidence on the use of immunonutrition for patients undergoing major upper gastrointestinal cancer surgeries. It summarizes 7 randomized control trials that found immunonutrition containing arginine, omega-3 fatty acids, and nucleotides reduced postoperative infections compared to control solutions. However, studies had flaws like low feeding volumes. More recent research has found benefits of immunonutrition are greater when aggressive enteral feeding protocols are used to provide over 800mL per day. Overall, evidence suggests immunonutrition may decrease infection risk for patients with gastrointestinal cancer undergoing surgery.
This document discusses irritable bowel syndrome (IBS) and summarizes a case study of a 32-year-old female patient, Ms. Lee, experiencing IBS symptoms. It covers the evolving diagnostic criteria for IBS, potential treatments including lifestyle modifications, medications, probiotics, and the relationship between small intestinal bacterial overgrowth (SIBO) and IBS. Hydrogen breath testing is presented as a non-invasive way to diagnose SIBO, though it has limitations. The antibiotic rifaximin is introduced as a treatment option for patients who test positive for SIBO.
Helicobacter Pylori Infection: Management in 2020ChernHaoChong
1) Helicobacter pylori infection is common and testing should be done for patients with dyspepsia, peptic ulcer history, or family history of gastric cancer.
2) The urea breath test is the best tool to detect active H. pylori infection.
3) Patients who test positive for H. pylori antibodies should undergo a urea breath test to confirm active infection before treatment.
Gastroenterology for the internist. The Clinics 2019Manuel Chumacero
This document summarizes key points about proton pump inhibitors (PPIs):
1) PPIs are among the most commonly prescribed medications but have been associated with potential adverse effects in observational studies.
2) While evidence for adverse effects is weak, there is also insufficient evidence to dismiss the risks.
3) PPIs are often prescribed inappropriately or at higher than recommended doses.
4) Physicians should carefully consider the indication for PPIs and ensure appropriate dosing before prescribing, and regularly review whether continued PPI therapy is needed.
This document summarizes a study of 233 cases of abdominal tuberculosis treated at a hospital in Pakistan from 2003-2008. Some key findings include:
- The average age was 28 years and most patients were from poor families.
- The most common presentation was acute abdomen (67%), requiring emergency surgery. Common surgical findings included intestinal strictures (69%).
- Most cases involved the ileocecal region and presented as intestinal obstructions.
- The majority of cases were considered primary abdominal tuberculosis, though some had a history of pulmonary TB.
- Most patients required hospitalization, with an average stay of 19.5 days. The in-hospital mortality rate was 2.1%.
Ulcerative Colitis: Applying Guidelines in PracticeDevi Seal
This presentation developed was by David Rubin, MD, Millie Long, MD, MPH, and Anita Afzali, MD, MPH, for a CME activity titled, Ulcerative Colitis: Applying Guidelines in Practice
This document provides guidelines for the diagnosis, treatment and prevention of Clostridium difficile infections (CDI). It summarizes key recommendations with evidence grading. For diagnosis, it recommends nucleic acid amplification tests over toxin enzyme immunoassays, and only testing diarrheal stool samples. It stratifies treatment based on disease severity into mild-moderate (treat with metronidazole), severe (vancomycin with/without metronidazole), and complicated (vancomycin orally and rectally with intravenous metronidazole). It also covers recurrent CDI treatment, managing CDI in patients with comorbidities, and infection control practices like contact precautions and environmental disinfection. The guidelines
1) Pancreatic cancer is a lethal malignancy with increasing incidence rates and poor survival outcomes.
2) EUS-guided celiac plexus neurolysis (EUS-CPN) and celiac ganglia neurolysis (EUS-CGN) provide effective pain relief for pancreatic cancer patients, with EUS-CGN showing potential for longer pain relief.
3) Randomized studies have shown EUS-CPN provides significantly better pain relief than sham treatment or percutaneous CPN. Bilateral neurolysis may offer longer pain relief than central injection.
Initial human experience with restrictive duodenal jejunal bypass liner for t...Ricardo Yanez
This study evaluated the use of a duodenal-jejunal bypass liner (DJBL) with a restrictor orifice for weight loss in 10 obese patients over 12 weeks. Key results:
1) Patients experienced a mean excess weight loss of 40% and total weight loss of 16.7 kg by the end of the study.
2) Gastric emptying was delayed with the DJBL in place, returning to normal levels after its removal in most patients.
3) Episodes of nausea and abdominal pain required dilation of the restrictor orifice in most patients, but there were no clinically significant adverse events.
4) The DJBL with restrictor orifice promoted substantial weight loss
Gemcitabine and Cisplatin In Metastatic Carcinoma Gallbladder. A Single Insti...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
Metabolic effects of bariatric surgery in patients with moderate obesity and ...Apollo Hospitals
Metabolic effects of bariatric surgery in patients with moderate obesity and type 2 diabetes: Analysis of a randomized control trial comparing surgery with intensive medical treatment
Sleeve vs Mini-Gastric Bypass
IN EVERY STUDY, by every measure, the Mini-Gastric Bypass is equal to or better than every other form of bariatric surgery
This document provides an overview and learning objectives for the 15th Annual Gastroenterology/Hepatology Update meeting. Key presentations will cover new clinical information and treatment updates in gastrointestinal and liver diseases. Recent breakthrough research will be discussed, including updates on colorectal cancer screening guidelines, management of gastroesophageal reflux disease, evaluation and treatment of abnormal liver tests and viral hepatitis, and implications for clinical practice in lower GI diseases and pancreatic disorders.
This study evaluated the long-term safety of tegaserod, a 5-hydroxytryptamine-4 receptor partial agonist used to treat constipation-predominant irritable bowel syndrome, in 579 patients over 12 months. The most common adverse events related to tegaserod were mild and transient diarrhea, headache, abdominal pain, and flatulence. The study found that tegaserod appeared to be well tolerated for long-term use with no unexpected safety issues identified.
This document summarizes trends in gastrointestinal diseases at a single institution in Korea over the past two decades from 1990 to 2006. Some key findings include:
1) Admission rates for GI diseases increased between 1990 and 2006, with gastric cancer, colon cancer, and colon adenomas/polyps becoming the most prevalent.
2) While gastric cancer rates decreased, colon cancer rates doubled over the two decades.
3) Detection and treatment of early gastric cancer and colon adenomas increased noticeably.
4) New emerging diseases included inflammatory bowel disease and gastroesophageal reflux.
This document provides biographical and professional information about Dr. Anastasios Manessis, including his education, training, licensure, certifications, appointments, clinical responsibilities, research experience, publications, presentations, and honors. It details his medical career path from obtaining his MD and completing residency in internal medicine and pediatrics, to becoming board certified in endocrinology and holding various teaching and clinical roles in New York.
This guideline presents recommendations for the management of acute pancreatitis (AP). Key recommendations include: assessing hemodynamic status upon presentation and providing resuscitation as needed; admitting patients with organ failure to intensive care; providing aggressive intravenous hydration within the first 12-24 hours; using ERCP within 24 hours for patients with AP and cholangitis; not routinely using prophylactic antibiotics for severe AP or sterile necrosis; considering infected necrosis in patients not improving after 7-10 days and using antibiotics known to penetrate pancreatic necrosis; and providing enteral nutrition for severe AP to prevent infectious complications while avoiding parenteral nutrition.
This document provides an overview of endoscopic eradication therapy for Barrett's esophagus. It begins with definitions of Barrett's esophagus and risk factors. It then discusses the progression of Barrett's to malignancy and guidelines for screening and diagnosis. Treatment options including endoscopic mucosal resection (EMR) and radiofrequency ablation (RFA) are reviewed. The document presents data on the efficacy, safety, and durability of EMR and RFA. It concludes with an overview of the author's experience treating Barrett's esophagus at Northwestern University.
This guideline discusses the appropriate use of endoscopy in evaluating patients with dyspepsia. It recommends that patients over 50 years old or those with alarm features should undergo endoscopy due to their higher risk of structural diseases like cancer or peptic ulcers. Younger patients without alarm features may initially receive noninvasive testing for H. pylori infection and be treated if positive, or try acid suppression therapy. If these approaches do not resolve symptoms, endoscopy is recommended to check for structural causes. The guideline aims to help clinicians determine which dyspepsia patients most need endoscopy versus other initial treatment strategies.
Factors associated with developing esophageal adenocarcinoma in Barett's esop...Dr Sayan Das
Based on the study “Rates and predictors of progression to esophageal carcinoma in a large population-based Barrett’s esophagus cohort” by Krishnamoorthi R et al published in “HHS Public Access” on 2016 July
TheList is an application that is downloaded directly into the user's smartphone and features a complete catalog of nightlife/entertainment venues and a "Live Feed" (patent pending)of all current events that are occurring instantly updated by the venues themselves. By covering everything from events, promotions, celebrity sightings and last minute deals in real-time updates, TheList seeks to become THE source for entertainment information in the U.S. All of the information will be available in the palm of your hand displayed in an innovative design that is both convenient and user-friendly.
This document discusses irritable bowel syndrome (IBS) and summarizes a case study of a 32-year-old female patient, Ms. Lee, experiencing IBS symptoms. It covers the evolving diagnostic criteria for IBS, potential treatments including lifestyle modifications, medications, probiotics, and the relationship between small intestinal bacterial overgrowth (SIBO) and IBS. Hydrogen breath testing is presented as a non-invasive way to diagnose SIBO, though it has limitations. The antibiotic rifaximin is introduced as a treatment option for patients who test positive for SIBO.
Helicobacter Pylori Infection: Management in 2020ChernHaoChong
1) Helicobacter pylori infection is common and testing should be done for patients with dyspepsia, peptic ulcer history, or family history of gastric cancer.
2) The urea breath test is the best tool to detect active H. pylori infection.
3) Patients who test positive for H. pylori antibodies should undergo a urea breath test to confirm active infection before treatment.
Gastroenterology for the internist. The Clinics 2019Manuel Chumacero
This document summarizes key points about proton pump inhibitors (PPIs):
1) PPIs are among the most commonly prescribed medications but have been associated with potential adverse effects in observational studies.
2) While evidence for adverse effects is weak, there is also insufficient evidence to dismiss the risks.
3) PPIs are often prescribed inappropriately or at higher than recommended doses.
4) Physicians should carefully consider the indication for PPIs and ensure appropriate dosing before prescribing, and regularly review whether continued PPI therapy is needed.
This document summarizes a study of 233 cases of abdominal tuberculosis treated at a hospital in Pakistan from 2003-2008. Some key findings include:
- The average age was 28 years and most patients were from poor families.
- The most common presentation was acute abdomen (67%), requiring emergency surgery. Common surgical findings included intestinal strictures (69%).
- Most cases involved the ileocecal region and presented as intestinal obstructions.
- The majority of cases were considered primary abdominal tuberculosis, though some had a history of pulmonary TB.
- Most patients required hospitalization, with an average stay of 19.5 days. The in-hospital mortality rate was 2.1%.
Ulcerative Colitis: Applying Guidelines in PracticeDevi Seal
This presentation developed was by David Rubin, MD, Millie Long, MD, MPH, and Anita Afzali, MD, MPH, for a CME activity titled, Ulcerative Colitis: Applying Guidelines in Practice
This document provides guidelines for the diagnosis, treatment and prevention of Clostridium difficile infections (CDI). It summarizes key recommendations with evidence grading. For diagnosis, it recommends nucleic acid amplification tests over toxin enzyme immunoassays, and only testing diarrheal stool samples. It stratifies treatment based on disease severity into mild-moderate (treat with metronidazole), severe (vancomycin with/without metronidazole), and complicated (vancomycin orally and rectally with intravenous metronidazole). It also covers recurrent CDI treatment, managing CDI in patients with comorbidities, and infection control practices like contact precautions and environmental disinfection. The guidelines
1) Pancreatic cancer is a lethal malignancy with increasing incidence rates and poor survival outcomes.
2) EUS-guided celiac plexus neurolysis (EUS-CPN) and celiac ganglia neurolysis (EUS-CGN) provide effective pain relief for pancreatic cancer patients, with EUS-CGN showing potential for longer pain relief.
3) Randomized studies have shown EUS-CPN provides significantly better pain relief than sham treatment or percutaneous CPN. Bilateral neurolysis may offer longer pain relief than central injection.
Initial human experience with restrictive duodenal jejunal bypass liner for t...Ricardo Yanez
This study evaluated the use of a duodenal-jejunal bypass liner (DJBL) with a restrictor orifice for weight loss in 10 obese patients over 12 weeks. Key results:
1) Patients experienced a mean excess weight loss of 40% and total weight loss of 16.7 kg by the end of the study.
2) Gastric emptying was delayed with the DJBL in place, returning to normal levels after its removal in most patients.
3) Episodes of nausea and abdominal pain required dilation of the restrictor orifice in most patients, but there were no clinically significant adverse events.
4) The DJBL with restrictor orifice promoted substantial weight loss
Gemcitabine and Cisplatin In Metastatic Carcinoma Gallbladder. A Single Insti...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
Metabolic effects of bariatric surgery in patients with moderate obesity and ...Apollo Hospitals
Metabolic effects of bariatric surgery in patients with moderate obesity and type 2 diabetes: Analysis of a randomized control trial comparing surgery with intensive medical treatment
Sleeve vs Mini-Gastric Bypass
IN EVERY STUDY, by every measure, the Mini-Gastric Bypass is equal to or better than every other form of bariatric surgery
This document provides an overview and learning objectives for the 15th Annual Gastroenterology/Hepatology Update meeting. Key presentations will cover new clinical information and treatment updates in gastrointestinal and liver diseases. Recent breakthrough research will be discussed, including updates on colorectal cancer screening guidelines, management of gastroesophageal reflux disease, evaluation and treatment of abnormal liver tests and viral hepatitis, and implications for clinical practice in lower GI diseases and pancreatic disorders.
This study evaluated the long-term safety of tegaserod, a 5-hydroxytryptamine-4 receptor partial agonist used to treat constipation-predominant irritable bowel syndrome, in 579 patients over 12 months. The most common adverse events related to tegaserod were mild and transient diarrhea, headache, abdominal pain, and flatulence. The study found that tegaserod appeared to be well tolerated for long-term use with no unexpected safety issues identified.
This document summarizes trends in gastrointestinal diseases at a single institution in Korea over the past two decades from 1990 to 2006. Some key findings include:
1) Admission rates for GI diseases increased between 1990 and 2006, with gastric cancer, colon cancer, and colon adenomas/polyps becoming the most prevalent.
2) While gastric cancer rates decreased, colon cancer rates doubled over the two decades.
3) Detection and treatment of early gastric cancer and colon adenomas increased noticeably.
4) New emerging diseases included inflammatory bowel disease and gastroesophageal reflux.
This document provides biographical and professional information about Dr. Anastasios Manessis, including his education, training, licensure, certifications, appointments, clinical responsibilities, research experience, publications, presentations, and honors. It details his medical career path from obtaining his MD and completing residency in internal medicine and pediatrics, to becoming board certified in endocrinology and holding various teaching and clinical roles in New York.
This guideline presents recommendations for the management of acute pancreatitis (AP). Key recommendations include: assessing hemodynamic status upon presentation and providing resuscitation as needed; admitting patients with organ failure to intensive care; providing aggressive intravenous hydration within the first 12-24 hours; using ERCP within 24 hours for patients with AP and cholangitis; not routinely using prophylactic antibiotics for severe AP or sterile necrosis; considering infected necrosis in patients not improving after 7-10 days and using antibiotics known to penetrate pancreatic necrosis; and providing enteral nutrition for severe AP to prevent infectious complications while avoiding parenteral nutrition.
This document provides an overview of endoscopic eradication therapy for Barrett's esophagus. It begins with definitions of Barrett's esophagus and risk factors. It then discusses the progression of Barrett's to malignancy and guidelines for screening and diagnosis. Treatment options including endoscopic mucosal resection (EMR) and radiofrequency ablation (RFA) are reviewed. The document presents data on the efficacy, safety, and durability of EMR and RFA. It concludes with an overview of the author's experience treating Barrett's esophagus at Northwestern University.
This guideline discusses the appropriate use of endoscopy in evaluating patients with dyspepsia. It recommends that patients over 50 years old or those with alarm features should undergo endoscopy due to their higher risk of structural diseases like cancer or peptic ulcers. Younger patients without alarm features may initially receive noninvasive testing for H. pylori infection and be treated if positive, or try acid suppression therapy. If these approaches do not resolve symptoms, endoscopy is recommended to check for structural causes. The guideline aims to help clinicians determine which dyspepsia patients most need endoscopy versus other initial treatment strategies.
Factors associated with developing esophageal adenocarcinoma in Barett's esop...Dr Sayan Das
Based on the study “Rates and predictors of progression to esophageal carcinoma in a large population-based Barrett’s esophagus cohort” by Krishnamoorthi R et al published in “HHS Public Access” on 2016 July
TheList is an application that is downloaded directly into the user's smartphone and features a complete catalog of nightlife/entertainment venues and a "Live Feed" (patent pending)of all current events that are occurring instantly updated by the venues themselves. By covering everything from events, promotions, celebrity sightings and last minute deals in real-time updates, TheList seeks to become THE source for entertainment information in the U.S. All of the information will be available in the palm of your hand displayed in an innovative design that is both convenient and user-friendly.
The document summarizes key information about functional gastrointestinal disorders (FGIDs):
- FGIDs affect 40% of patients seen in GI settings and are a leading cause of emergency referrals. They are defined by symptoms in the absence of structural abnormalities and involve motility, sensitivity, immune, and central nervous system abnormalities.
- Food can trigger FGID symptoms in many patients. Dietary triggers may involve immune activation, direct effects of food chemicals, or carbohydrate malabsorption. Low FODMAP and gluten-free diets can provide relief.
- A multidisciplinary approach including a gastroenterologist, psychologist, dietician, and others results in significantly reduced anxiety and depression in FGID patients
Effect of Antibiotics on The Gut Microbiota in Children with Chronic Pancreat...JohnJulie1
Little is known about the effect of antibiotic treatment on the gut microbiota in children with chronic pancreatitis (CCP). Our objective was to identify the effect of antibiotic treatment on the gut microbiota in children with chronic pancreatitis (CCP), the main gut microbiota genera and characterize the patients’ functional mutations after using antibiotics.
WEEK 6 ASSIGNMENT 1 LAB ASSESSING THE ABDOMEN2WEEK 6 ASSIGNMEN.docxhelzerpatrina
WEEK 6 ASSIGNMENT 1: LAB ASSESSING THE ABDOMEN 2
WEEK 6 ASSIGNMENT 1: LAB ASSESSING THE ABDOMEN 2
Week 6 Assignment 1: Lab Assessing the Abdomen
Walden University
NURS 6512 N
Silifat Jones-Ibrahim
Running head: WEEK 6 ASSIGNMENT 1: LAB ASSESSING THE ABDOMEN 2
Week 6 Assignment 1: Lab Assessing the Abdomen
Abdominal Assessment Case Study SOAP Note
Subjective:
•CC: “My stomach hurts, I have diarrhea, and nothing seems to help.”
•HPI: JR, 47-year-old WM, complains of having generalized abdominal pain that started 3 days ago. He has not taken any medications because he did not know what to take. He states the pain is a 5/10 today but has been as much as 9/10 when it first started. He has been able to eat, with some nausea afterwards.
•PMH: HTN, Diabetes, hx of GI bleed 4 years ago
•Medications: Lisinopril 10mg, Amlodipine 5 mg, Metformin 1000mg, Lantus 10 units qhs
•Allergies: NKDA
•FH: No hx of colon cancer, Father hx DMT2, HTN, Mother hx HTN, Hyperlipidemia, GERD
•Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)
Objective:
•VS: Temp 99.8; BP 160/86; RR 16; P 92; HT 5’10”; WT 248lbs
•Heart: RRR, no murmurs
•Lungs: CTA, chest wall symmetrical
•Skin: Intact without lesions, no urticaria
•Abd: soft, hyperactive bowel sounds, pos pain in the LLQ
•Diagnostics: None
Assessment:
•Left lower quadrant pain
•Gastroenteritis
PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
Analyze the subjective portion of the note. List additional information that should be included in the documentation.
Subjective Analysis
According to Ball et al, (2015) when treating a patient with generalized abdominal pain, it is important to collect a detailed subjective history of the pain in order to better narrow down possible differential diagnoses. Chief complaint needs to be “stomach hurts.” The HPI needs to include the timing and characteristics of abdominal pain, more information is needed about the history of the patient concerning the present condition (HPI) and the general health from the past, this could be achieved by asking more focused questions. More investigation into the diet of the patient and history before the condition should be inquired. In the scenario, in the subjective part of the SOAP note, more information is needed about the history of the patient concerning the present condition (HPI) and the general health from the past, this could be achieved by asking more focused questions. More investigation into the diet of the patient and history before the condition should be inquired. Also, additional information about any changes in appetite and bowel movements is also needed. The history of present illness should incorporate data like onset, duration, characteristics, exacerbating, and alleviating symptoms as it relates to abdominal pain. Location is one of the most critical questi ...
This document provides an overview of acute pancreatitis (AP), including its epidemiology, etiology, classification, clinical presentation, investigations, and management. Some key points:
- AP is responsible for over 300,000 admissions per year in the US and its incidence has increased in recent decades. Gallstones and alcohol are the most common causes.
- The revised Atlanta classification categorizes AP based on morphological features and presence of organ failure. Severity is classified as mild, moderate, or severe.
- Common symptoms include severe epigastric pain, nausea, vomiting, and abdominal tenderness. Systemic complications can include shock, respiratory failure, and renal failure.
- Investigations include serum amyl
This document discusses Gastro Esophageal Reflux Disease (GERD) in infants. It provides definitions of key terms like GER and GERD. It reviews the epidemiology and natural history of GER in infants, noting that the prevalence of daily regurgitation peaks between 1-6 months of age in around 70% of infants. It discusses the anatomy and physiology involved in GER and reviews approaches to diagnosing GERD in infants, including history, physical exam, upper GI imaging, endoscopy, and pH monitoring. Non-pharmacological and pharmacological treatment options are also covered.
This document discusses Gastro Esophageal Reflux Disease (GERD) in infants. It provides definitions of key terms like GER and GERD. It reviews the epidemiology and natural history of GER in infants, noting that the prevalence of daily regurgitation peaks between 1-6 months of age in around 70% of infants. It also discusses the evaluation and diagnosis of GERD in infants, noting that diagnostic tests like upper GI radiography are not recommended, while tests like pH probes can help assess acid reflux. The document provides an overview of treatment options for GER including non-pharmacological and medication approaches.
1. The document discusses a case study of a 47-year-old male patient presenting with abdominal pain, diarrhea, and fever.
2. It analyzes the subjective and objective portions of the patient's SOAP note, finding several important omitted details.
3. It identifies diagnostic tests that should have been performed to confirm or rule out potential diagnoses like gastroenteritis, Crohn's disease, ulcerative colitis, and kidney stones.
- Irritable bowel syndrome (IBS) affects 7-21% of the general population and is the most commonly diagnosed gastrointestinal condition. It is defined by abdominal pain or discomfort with altered bowel habits in the absence of underlying disease.
- Factors that contribute to IBS include alterations in the gut microbiome, intestinal permeability, immune function, motility, sensation, brain-gut interactions, and psychosocial status. Dietary triggers and a history of infection or antibiotics can also play a role.
- IBS substantially reduces quality of life and productivity. While some patients improve over time, it is generally a chronic relapsing condition. Diagnosis involves symptom evaluation and exclusion of other diseases through selected testing. Management
The document discusses pediatric pancreatitis. It begins by noting the increasing incidence of acute pancreatitis in pediatric patients, which now approaches rates in adults. The main types of pancreatitis - acute and chronic - are described. Acute pancreatitis is reversible while chronic pancreatitis is irreversible. For causes of acute pancreatitis in children, the document lists common causes as biliary disorders, systemic conditions, medications, trauma and idiopathic cases. Less common causes include infection, metabolic diseases and genetic/hereditary disorders. The document provides details on the pathophysiology of acute pancreatitis and the various etiologies.
Usefulness of Bifidobacterium longum BB536.pdfNgnH133
This randomized controlled trial investigated the effects of the probiotic Bifidobacterium longum BB536 in treating chronic constipation in elderly individuals. 80 elderly adults with chronic constipation were randomly assigned to receive either B. longum BB536 or a placebo daily for 4 weeks. While the primary endpoint of differences in constipation scoring between groups was not significant, within the BB536 group constipation scores significantly improved from baseline to week 4. Additionally, stool frequency significantly increased and difficulty with evacuation tended to decrease more in the BB536 group compared to placebo. The probiotic was found to be safe with few reported adverse effects.
Postpartum Meningitis by Enterococcus Faecalis Secondary to Neuraxial AnesthesiaAnonIshanvi
This study evaluated the efficacy and safety of fecal microbiota transplantation (FMT) for 12 patients with diarrhea-predominant irritable bowel syndrome (IBS-D). Baseline symptoms and scores were assessed using IBS severity scores, Birmingham IBS symptom scores, and quality of life questionnaires. Patients underwent FMT and were followed up at 1, 3, and 6 months. Scores showed significant improvement from baseline to 3 months after FMT, including reduced IBS severity scores and Birmingham scores. FMT was found to provide significant symptom relief for IBS-D over 6 months with no serious adverse events reported.
Evidence Based Practice_lecture 5_slidesZakCooper1
This document provides an overview of evidence-based practice as it relates to assessing questions about harm or etiology. It discusses how these types of questions are best assessed through randomized controlled trials or observational studies like cohort and case-control studies. Examples are provided of questions about harm that have been studied, like whether silicone breast implants or weight-loss drugs cause certain health issues. The limitations of different study types are also outlined. Finally, the document discusses how prognosis questions are typically assessed through survival curve analysis and provides some examples of prognosis studies.
This document discusses approaches to drug discovery for irritable bowel syndrome (IBS). IBS is defined by abdominal pain and altered bowel habits without detectable organic disease. Current treatments have safety issues. The review discusses targeting pathways locally in the gut from an "outside-in" perspective to identify therapeutic targets related to bile acid malabsorption, microbial dysbiosis, intestinal barrier function, immune dysregulation, motility and visceral hypersensitivity. Challenges to new drug discovery are the unknown mechanisms underlying IBS and limited options for translational research and disease biomarkers. Drugs acting locally via multiple targets that are proven to modulate secretory and motility effects, like eluxadoline and crofelemer, are proving successful
This document discusses the role of probiotics in adult gastroenterology. It provides a brief history of probiotics dating back to Elie Metchnikof in 1908. Probiotics are defined as live microorganisms that provide health benefits when consumed. The gut microbiota plays an important role in health, and probiotics may help treat or prevent conditions caused by microbial imbalances like infectious diarrhea, irritable bowel syndrome, inflammatory bowel disease, obesity, and liver diseases. Probiotics have demonstrated benefits, but their effects tend to be strain-specific and more research is still needed, especially for conditions like Crohn's disease. Safety concerns also exist for certain at-risk populations.
This study evaluated the effects of probiotic therapy in patients with mild to moderate ulcerative colitis. 70 male patients were randomly assigned to receive either mesalamine or probiotic treatment for 3 months. Both treatments showed statistically significant improvements in disease parameters and inflammation markers. Clinical remission occurred within 1-2 months for most patients in both groups. Probiotic therapy was also effective at maintaining remission in 85.7% of patients for over 6 months. The study concluded that probiotics can effectively treat and maintain remission of mildly to moderately severe ulcerative colitis.
We Are More Than What We Eat Dietary Interventions Depend on Sex and Genetic ...InsideScientific
To learn more visit: https://insidescientific.com/webinar/we-are-more-than-what-we-eat-dietary-interventions-depend-on-sex-and-genetic-background/
Despite evidence that sex and genetic background are key factors in the response to diet, most studies of how diet regulates metabolic health and even longevity in mice examine only a single strain and sex.
Using multiple strains and both male and female mice, Dr Lamming's team has found that improvements in metabolic health and in longevity in response to reduced levels of protein or specific amino acids strongly depend on sex and strain. While some phenotypes were conserved across strains and sexes, including increased glucose tolerance and energy expenditure, they observed high variability in adiposity, insulin sensitivity, and circulating hormones. Using a multi-omics approach, they identified mega-clusters of differentially expressed hepatic genes, metabolites, and lipids associated with each phenotype, gaining new insight into role of the energy balance hormone FG21 in the response to protein restriction.
Running Head GASTROINTESTINAL TRACT1GASTROINTESTINAL TRACT3.docxjeanettehully
Running Head: GASTROINTESTINAL TRACT 1
GASTROINTESTINAL TRACT 3
GastroIntestinal Tract
Name
Institution
Course
Date
GastroIntestinal Disorders
Introduction
Normally, gastric acids are produced and stimulated so that the body can break down consumed foods and digest them easily. The major component of gastric juice is hydrochloric acid, which is produced by oxyntic cells. The secretion of these acids takes place in three phases namely: the cephalic phase, the gastric phase and the intestinal phase. The cephalic phase starts when someone has an urge to eat or smells food. The brain signals the parietal cells to secrete gastric acids and the ECL to secrete histamine. The gastric phase is when someone has eaten and the amino acids present in the food stimulates the production of these acids. The last phase is stimulated by the distention in the small intestines and the amino acids too and the secretion takes place when chime enters the small intestines (Testani et al., 1996).
Gastroesophageal Reflex Disease (GERD)
There are gastrointestinal orders that exist, such as Gastroesophageal Reflex Disease (GERD), Peptic Ulcer Disease (PUD) and Gastritis disorders. Patients suffering from GERD have a complex gastric acid secretion caused by frequent acid reflux. There are cases where HCL frequently flows back to the esophagus and when this happens, the lining of the esophagus becomes irritated. The age factor is visible in this disorder. Older people are more likely to experience this disease than young. However, symptoms are less visible in the elderly. The fact that there is no serious warning symptom of GERD among the elderly makes the disorder more complicated in them. GERD can be diagnosed by a probe test, upper endoscopy or x-ray of the upper digestive system. For the elderly, adequate doses of medication that do not harm the digestive system are effective. Medical therapeautic agents, including PPIs such as pantoprazole and Omeprazole, can also cure GERD.
Peptic Ulcer Disease (PUD)
PUD is caused by an imbalance between the secretion of gastric acid and duodenal mucous defence. When the balance between the two is disrupted, there is a consequence of mucousal injury and hence peptic ulcers. PUD among the elderly is associated by complications and when administering medication, special attention should be given to the elderly since they respond negatively to medications and surgery. PUD can be diagnosed by carrying out both physical and diagnostic tests (Okello, et. al, 2016) . Once it has been diagnosed, laboratory tests can then be undertaken such as breath tests, stool and blood tests. There are two main factors that contribute to the high rate of PUD among the elderly are the high rates of H. Pylori and prescription of drugs that increase damage in the gastroduodenal drugs. Elderly patients receive medical treatment of PUD
Gastritis Disorders
Gastritis disorders basically results from mucous injury that may have been caused by ...
1) A 32-year-old woman presented with a 10-year history of severe recurrent abdominal pain.
2) Extensive prior testing and evaluations did not identify a cause, though she was diagnosed with conversion disorder during one hospitalization.
3) During her most recent hospitalization for abdominal pain, she developed hyponatremia that was initially thought to be due to poor oral intake but worsened despite IV fluids.
4) Further testing revealed findings consistent with SIADH and elevated urine porphyrin levels, leading to a diagnosis of acute intermittent porphyria, a rare genetic disorder causing episodic severe abdominal pain and other symptoms.
This document provides recommendations from Cynthia Belew, CNM, WHNP-C on strategies to support the microbiome in women's healthcare. Key recommendations include educating patients on fiber and fermented foods, using probiotics judiciously based on evidence, decreasing antibiotic use by only prescribing when clinically indicated, and engaging in shared decision-making for GBS prophylaxis. The document emphasizes viewing the gut microbiome as integral to human health and considers ways to minimize disruptions during pregnancy and childbirth.
1. Volume 104 supplement 1 January 2009
www.amjgastro.com
supplement to
official publication of the american college of gastroenterology
official publication of the american college of gastroenterology
supplement
An Evidence-Based Systematic Review on the Management of Irritable Bowel Syndrome
American College of Gastroenterology Task Force on IBS
2. American College of Gastroenterology
Task Force on Irritable Bowel Syndrome
Lawrence J. Brandt, MD, MACG, Chair
Department of Medicine
Montefiore Medical Center
Albert Einstein School of Medicine
William D. Chey, MD, FACG
Department of Gastroenterology
University of Michigan Medical Center
Amy E. Foxx-Orenstein, DO, FACG
Division of Gastroenterology and Hepatology
Department of Internal Medicine
Mayo Clinic
Lawrence R. Schiller, MD, FACG
Division of Gastroenterology
Baylor University Medical Center
Philip S. Schoenfeld, MD, FACG
Division of Gastroenterology
Veterans Affairs Ann Arbor Healthcare System
Brennan M. Spiegel, MD, FACG
VA Greater Los Angeles Healthcare System
David Geffen School of Medicine at UCLA
UCLA/VA Center for Outcomes Research and Education (CORE)
Nicholas J. Talley, MD, PhD, FACG
Department of Internal Medicine
Mayo Clinic Jacksonville
Eamonn M.M. Quigley, MD, FACG
Department of Medicine
Cork University Hospital
National University of Ireland at Cork
Paul Moayyedi, BSc, MB ChB, PhD, MPH, FRCP (London), FRCPC, FACG, Statistician-Epidemiologist
Department of Medicine, Division of Gastroenterology
McMaster University Medical Centre
Unrestricted grants have been provided to the American College of Gastroenterology from Takeda Pharmaceuticals North America, Inc. and
Sucampo Pharmaceuticals, Inc. and Salix Pharmaceuticals in support of the work of the ACG IBS Task Force. This monograph was developed on
behalf of the American College of Gastroenterology and the ACG Institute for Clinical Research & Education by the ACG IBS Task Force which
had complete scientific and editorial control of its content.
3. contentS
Volume 104 Supplement 1 january 2009
official publication of the american college of gastroenterology
Supplement
An Evidence-Based Systematic Review on the
Management of Irritable Bowel Syndrome
Section 1
S1 An Evidence-Based Position Statement on the Management of Irritable Bowel Syndrome
Section 2
An EvIdEncE-BASEd SyStEMAtIc REvIEw on thE MAnAgEMEnt of IRRItABlE BowEl SyndRoME
S8 2.1 Methodology for systematic reviews of irritable bowel syndrome therapy, levels of evidence,
and grading recommendations
S9 2.2 the burden of illness of irritable bowel syndrome
S12 2.3 the utility of diagnostic criteria in IBS
S12 2.4 the role of alarm features in the diagnosis of IBS
S14 2.5 the role of diagnostic testing in patients with IBS symptoms
S17 2.6 diet and irritable bowel syndrome
S17 2.7 Effectiveness of dietary fiber, bulking agents, and laxatives in the management of irritable bowel
syndrome
S18 2.8 Effectiveness of antispasmodic agents, including peppermint oil, in the management of irritable bowel
syndrome
S19 2.9 Effectiveness of antidiarrheals in the management of irritable bowel syndrome
S19 2.10 Effectiveness of antibiotics in the management of irritable bowel syndrome
S20 2.11 Effectiveness of probiotics in the management of irritable bowel syndrome
S21 2.12 Effectiveness of the 5ht 3 receptor antagonists in the management of irritable bowel syndrome
S22 2.13 Effectiveness of 5ht 4 (serotonin) receptor agonists in the management of irritable bowel syndrome
S23 2.14 Effectiveness of the selective c-2 chloride channel activators in the management of irritable bowel
syndrome
S24 2.15 Effectiveness of antidepressants in the management of irritable bowel syndrome
S25 2.16 Effectiveness of psychological therapies in the management of irritable bowel syndrome
S25 2.17 Effectiveness of herbal therapies and acupuncture in the management of irritable bowel syndrome
S26 2.18 Emerging therapies for the irritable bowel syndrome
www.amjgastro.com
5. American College of Gastroenterology IBS Task Force
of people have IBS worldwide. Community-based data indicate providers should remain alert for signs of somatization in IBS,
that diarrhea-predominant IBS (IBS-D) and mixed IBS (IBS-M) and aggressively treat or refer somatization patients to an expe-
subtypes are more prevalent than constipation-predominant IBS rienced specialist rather than performing potentially unneces-
(IBS-C), and that switching among subtype groups may occur. sary diagnostic tests.
IBS is 1.5 times more common in women than in men, is more In addition to direct costs of care, IBS patients engender
common in lower socioeconomic groups, and is more commonly signi cant indirect costs of care as a consequence of both
diagnosed in patients younger than 50 years of age. Patients missing work and su ering impaired work performance while
with IBS visit the doctor more frequently, use more diagnostic on the job. Compared with IBS patients who exhibit normal
tests, consume more medications, miss more workdays, have work productivity, patients with impaired productivity have
lower work productivity, are hospitalized more frequently, and more extraintestinal comorbidities and more disease-speci c
consume more overall direct costs than patients without IBS. fears and concerns. In contrast, the speci c pro le of individual
Resource utilization is highest in patients with severe symptoms, bowel symptoms does not undermine work productivity, sug-
and poor HRQOL. Treatment decisions should be tailored to gesting that enhancing work productivity in IBS may require
the severity of each patient’s symptoms and HRQOL decrement. treatments that improve both gastrointestinal (GI) and non-
GI symptom intensity, while also modifying the cognitive and
Prevalence estimates of IBS range from 1% to more than 20%. behavioral responses to bowel symptoms and the contexts in
When limited to unselected population-based studies, the which they occur.
pooled prevalence of IBS in North America is 7%. Community-
based data indicate that IBS-D and IBS-M subtypes are more The utility of diagnostic criteria in irritable bowel syndrome
prevalent than IBS-C, and that switching may occur among (see Section 2.3)
subtype groups. IBS is 1.5 times more common in women IBS is de ned by abdominal pain or discomfort that occurs in
than in men, although IBS is not simply a disorder of women. association with altered bowel habits over a period of at least
In fact, IBS is now recognized to be a key component of the three months. Individual symptoms have limited accuracy for
Gulf War Syndrome, a multi-symptom complex a ecting diagnosing IBS and, therefore, the disorder should be considered
soldiers (a predominantly male population) deployed in the as a symptom complex. Although no symptom-based diagnos-
1991 Gulf War. IBS is diagnosed more commonly in patients tic criteria have ideal accuracy for diagnosing IBS, traditional
under the age of 50 years than in patients older than 50 years. criteria, such as Kruis and Manning, perform at least as well as
ere is a graded decrease in IBS prevalence with increasing Rome I criteria; the accuracy of Rome II and Rome III criteria
income. has not been evaluated.
Patients with IBS have a lower HRQOL compared with
non-IBS cohorts. It is possible that patients with IBS develop IBS is a chronic illness of disordered bowel function and abdo-
HRQOL decrements due to their disease, and also possible that minal pain or discomfort that is distinguished by the absence of
some patients with diminished HRQOL subsequently develop biochemical markers or structural abnormalities. As individual
IBS. Although the precise directionality of this relationship symptoms have imperfect accuracy in diagnosing IBS, crite-
may vary from patient to patient, it is clear that IBS is strongly ria have been developed to identify a combination of symp-
related to low HRQOL, and vice versa. e HRQOL decre- toms to diagnose the condition. Manning et al. promulgated
ment can, in some cases, be so severe as to increase the risk of the original account of this approach. Two of four studies that
suicidal behavior. Because HRQOL decrements are common in have evaluated the accuracy of the Manning criteria suggested
IBS, we recommend that clinicians perform routine screening they perform well, with a sensitivity of 78% and speci city of
for diminished HRQOL in their IBS patients. Treatment should 72%. Kruis et al developed another set of criteria; three of four
be initiated when the symptoms of IBS are found to reduce studies that examined the accuracy of the Kruis symptom score
functional status and diminish overall HRQOL. Furthermore, suggested it provides an excellent positive predictive value
clinicians should remain wary of potential suicidal behavior in with a high sensitivity (77%) and speci city (89%). e Rome
patients with severe IBS symptoms, and should initiate timely criteria subsequently were developed and have undergone three
interventions if suicide indicators are identi ed. iterations. One study has evaluated the accuracy of Rome I
Patients with IBS consume a disproportionate amount of criteria, and determined it had a sensitivity of 71% and spe-
resources. IBS care consumes over $20 billion in both direct ci city of 85%; Rome II and Rome III have not yet been evalu-
and indirect expenditures. Moreover, patients with IBS ated. None of the symptom-based diagnostic criteria have an
consume over 50% more health care resources than matched ideal accuracy, and the Rome criteria, in particular, have been
controls without IBS. Resource utilization in IBS is driven partly inadequately evaluated. e ACG Task Force believes that a
by the presence of comorbid somatization—a trait found in up practical de nition, i.e., one that is simple to use and incor-
to one-third of IBS patients that is characterized by the propen- porates key features of previous diagnostic criteria would be
sity to overinterpret normal physiologic processes. ere is a clinically useful. erefore, we have de ned IBS as abdominal
highly signi cant relationship between levels of somatization pain or discomfort that occurs in association with altered bowel
and the amount of diagnostic testing in IBS, suggesting that habits over a period of at least 3 months.
S2 VOLUME 104 | SUPPLEMENT 1 | JANUARY 2009 www.amjgastro.com
7. American College of Gastroenterology IBS Task Force
colonic imaging to exclude organic disease. ere is emerging No placebo-controlled, randomized study of laxatives in
evidence to suggest that microscopic colitis can masquerade IBS has been published. Laxatives have been studied mostly
as IBS-D, and therefore, when patients with IBS-D undergo in patients with chronic constipation. A single small sequen-
colonoscopy, performance of random mucosal biopsies should tial study compared symptoms before and with PEG laxative
be considered. In patients whose symptoms are consistent with treatment in adolescents with IBS-C. Stool frequency improved
IBS and who also have alarm features, the nature and severity of from an average of 2.07 ± 0.62 bowel movements per week to
the symptoms as well as the patient’s expectations and concerns 5.04 ± 1.51 bowel movements per week (P < 0.05), but there was
in uence the choice of diagnostic testing. no e ect on pain intensity.
Diet and irritable bowel syndrome (see Section 2.6) Effectiveness of antispasmodic agents, Including peppermint
Patients o en believe that certain foods exacerbate their IBS symp- oil, in the management of irritable bowel syndrome (see
toms. ere is, however, insu cient evidence that food allergy Section 2.8)
testing or exclusion diets are e cacious in IBS and their routine Certain antispasmodics (hyoscine, cimetropium, pinaverium,
use outside of a clinical trial is not recommended (Grade 2C). and peppermint oil) may provide short-term relief of abdomi-
nal pain/discomfort in IBS (Grade 2C). Evidence for long-term
Approximately 60% of IBS patients believe that food exacer- e cacy is not available. Evidence for safety and tolerability is
bates their symptoms, and research has suggested that allergy to limited (Grade 2C).
certain foods could trigger IBS symptoms. A systematic review
identi ed eight studies that assessed a symptomatic response to ere is evidence for the e cacy of antispasmodics as a class
exclusion diets in 540 IBS subjects. Studies reported a positive and some peppermint oil preparations (which also may act as
response in 12.5–67% of patients, but the absence of control antispasmodics) in IBS. ere are, however, signi cant varia-
groups makes it is unclear whether these rates simply re ect a tions in the availability of these agents in di erent countries;
placebo response. ere is no correlation between foods that little of the data is recent; early trials vary considerably in terms
patients identify as a cause of their IBS symptoms and the results of inclusion criteria, dosing schedule, duration of therapy, and
of food allergy testing. One randomized trial suggested that study endpoints; and many are of poor quality and frequently
patients with IBS can identify foods that cause symptoms, but fail to di erentiate between the e ects of these agents on global
two subsequent trials have not con rmed this. symptoms and individual symptoms, such as pain. Further-
more, the adverse event pro le of these agents has not been
Effectiveness of dietary fiber, bulking agents, and laxatives in de ned adequately.
the management of irritable bowel syndrome (see Section 2.7)
Psyllium hydrophilic mucilloid (ispaghula husk) is moderately Effectiveness of antidiarrheals in the management of irritable
e ective and can be given a conditional recommendation (Grade bowel syndrome (see Section 2.9)
2C). A single study reported improvement with calcium poly- e antidiarrheal agent loperamide is not more e ective than
carbophil. Wheat bran or corn bran is no more e ective than placebo at reducing pain, bloating, or global symptoms of IBS,
placebo in the relief of global symptoms of IBS and cannot be but it is an e ective agent for the treatment of diarrhea, reduc-
recommended for routine use (Grade 2C). Polyethylene glycol ing stool frequency, and improving stool consistency (Grade 2C).
(PEG) laxative was shown to improve stool frequency—but not Randomized controlled trials comparing loperamide with other
abdominal pain—in one small sequential study in adolescents antidiarrheal agents have not been performed. Safety and toler-
with IBS-C (Grade 2C). ability data on loperamide are lacking.
Dietary ber supplements studied in patients with IBS Patients with IBS-D display faster intestinal transit compared
include wheat and corn bran. Bulking agents include psyllium with healthy subjects and, therefore, agents that delay intestinal
hydrophilic mucilloid (ispaghula husk) and calcium polycar- transit may be bene cial in reducing symptoms. Loperamide is
bophil. Most trials of these agents are suboptimal and had small the only antidiarrheal agent su ciently evaluated in randomized
sample sizes, short duration of follow-up, and were conducted controlled trials (RCTs) for the treatment of IBS-D. Of the
before modern standards for study design were established. two RCTs evaluating the e ectiveness of loperamide in the
Neither wheat bran nor corn bran reduced global IBS symp- treatment of IBS with diarrhea-predominant symptoms, there
toms. Psyllium hydrophilic mucilloid improved global IBS were no signi cant e ects in favor of loperamide compared with
symptoms in four of the six studies reviewed. Meta-analysis placebo. e trials were both double-blinded, but the propor-
showed that the relative risk of IBS symptoms not improving tion of women in each trial was unclear and neither reported
with psyllium was 0.78 (95% CI = 0.63–0.96) and the number adequate methods of randomization or adequate concealment
needed to treat (NNT) was six (95% CI = 3–50). A single study of allocation. Each trial used a clinical diagnosis of IBS sup-
of calcium polycarbophil showed bene t. Adverse events in plemented by negative investigations to de ne the condition.
these studies were not reported systematically. Bloating may be Loperamide had no e ect on symptoms of bloating, abdomi-
a risk with these agents. nal discomfort or global IBS symptoms. ere was a bene cial
S4 VOLUME 104 | SUPPLEMENT 1 | JANUARY 2009 www.amjgastro.com
9. American College of Gastroenterology IBS Task Force
IBS-D patients for up to 48 weeks, with a safety pro le compa- likely to experience satisfactory improvement of global IBS
rable to that of placebo. Another recent randomized, placebo- symptoms than were placebo-treated patients. Tegaserod is also
controlled trial found alosetron to be more e ective for the only 5-HT4 agonist that has been evaluated in an IBS-M
abdominal pain and discomfort than placebo in men with population. In a well-designed RCT, tegasarod-treated patients
IBS-D (53 vs. 40%, P < 0.001). with the IBS-M were 15% more likely to demonstrate improve-
In a recent systematic review which included data from seven ment in global IBS symptoms compared with placebo-treated
studies, patients randomized to alosetron were statistically patients. In most RCTs, tegaserod-treated patients were signi -
signi cantly more likely to report an adverse event than those cantly more likely to experience improvement in abdominal
randomized to placebo (relative risk (RR) of adverse event = 1.18; discomfort, satisfaction with bowel habits, and bloating than
95% CI = 1.08–1.29). e number needed to harm (NNH) with placebo-treated patients. Diarrhea occurred signi cantly more
alosetron was 10 (95% CI = 7–16). Dose-dependent constipa- o en in tegaserod-treated patients compared with placebo-
tion was the most commonly reported adverse event with treated patients, most trials reporting diarrhea in approximately
alosetron (1 mg twice daily = 29%; 0.5 mg twice daily = 11%). 10% of tegaserod-treated patients and in approximately 5% of
Another systematic review of the clinical and postmarketing placebo-treated patients. Approximately 1–2% of tegaserod-
surveillance data from IBS patients and the general population treated patients discontinued tegaserod because of diarrhea.
con rmed a greater incidence of severe complicated constipa- Tegaserod was removed from the market in March of 2007
tion and ischemic colitis in patients taking alosetron, however, a er examination of the total clinical trial database revealed
the incidence of these events was low, with a rate of 1.1 cases of that cardiovascular events were more frequent in tegaserod-
ischemic colitis and 0.66 cases of complicated constipation per treated patients (n = 11,614) compared with placebo-treated
1,000 patients-years of alosetron use. patients (n = 7,031; 0.11% vs. 0.01%). irteen tegaserod-treated
Current use of alosetron is regulated by a prescribing patients had cardiovascular events including myocardial infarc-
program set forth by the FDA and administered by the tion (n = 4), unstable angina (n = 6), and cerebral vascular acci-
manufacturer (Prometheus Laboratories, San Diego, CA). e dent (n = 3) whereas one placebo-treated patient had a transient
recommended starting dose of alosetron is 0.5 mg twice daily. ischemic attack. Currently, tegaserod is not available under any
If a er four weeks, the drug is well tolerated but the patient’s treatment investigational new drug protocol, but it is available
IBS-D symptoms are not adequately controlled, the dose can from the FDA through an emergency investigational new drug
be escalated to 1 mg twice daily. Alosetron should be discon- protocol.
tinued if the patient develops symptoms or signs suggestive of Renzapride and cisapride did not produce any statistically
severe constipation or ischemic colitis or if there is no clinical signi cant improvement in global IBS symptoms compared
response to the 1 mg twice daily dose a er four weeks. with placebo.
Effectiveness of 5HT4 (serotonin) receptor agonists in the Effectiveness of the selective C-2 chloride channel activators in
management of irritable bowel syndrome (see Section 2.13) the management of irritable bowel syndrome (see Section 2.14)
e 5-HT4 receptor agonist tegaserod is more e ective than Lubiprostone in a dose of 8 g twice daily is more e ective than
placebo at relieving global IBS symptoms in female IBS-C placebo in relieving global IBS symptoms in women with IBS-C
patients (Grade 1A) and IBS-M patients (Grade 1B). e most (Grade 1B).
common side e ect of tegaserod is diarrhea (Grade 1A). A small
number (0.11%) of cardiovascular events (myocardial infarc- Lubiprostone (8 g twice daily) is approved by the FDA for
tion, unstable angina, or stroke) were reported among patients the treatment of IBS-C in women on the basis of two well-
who had received tegaserod in clinical trials. designed, large clinical trials. Based on a conservative endpoint
designed to minimize placebo response, lubiprostone improved
Currently, there are no 5-HT4 receptor agonists available for global IBS-C symptoms in nearly twice as many subjects as did
use in North America. Tegaserod (6 mg twice daily) has been placebo (18 vs. 10%, P < 0.001). Lubiprostone also improved
approved by the FDA for the treatment of IBS with constipa- individual symptoms of IBS including abdominal discomfort/
tion in women. Tegaserod was evaluated in multiple RCTs that pain, stool constancy, straining, and constipation severity. No
were very well designed, meeting all criteria for appropriately one symptom appeared to drive the global improvement. E ects
designed RCTs (i.e., truly randomized studies with concealment were well maintained for up to 48 weeks in open-label continu-
of treatment allocation, implementation of masking, complete- ation studies. Side e ects included nausea (8%), diarrhea (6%)
ness of follow-up and intention-to-treat analysis) and meeting and abdominal pain (5%), but were less frequent in these IBS-C
almost all criteria of the Rome committee for design of treat- studies than in previous studies of patients with chronic consti-
ment trials of functional GI disorders. Each of the RCTs assess- pation in which a larger dose (24 g twice daily) of lubiprostone
ing the e cacy of tegaserod 6 mg twice daily demonstrated that was used. Lubiprostone should not be used in patients with
it was superior to placebo for global IBS symptom improve- mechanical bowel obstruction or preexisting diarrhea. Women
ment. Based on the de ned end point of global IBS symptom capable of bearing children should have a documented negative
improvement, tegaserod-treated patients were 5–19% more pregnancy test before starting therapy and should be advised to
S6 VOLUME 104 | SUPPLEMENT 1 | JANUARY 2009 www.amjgastro.com
11. VOLUME
Brandt et al. 104 SUPPLEMENT 1 JANUARY 2009 nature publishing group
An Evidence-Based Systematic Review on the
Management of Irritable Bowel Syndrome
American College of Gastroenterology IBS Task Force:
Lawrence J. Brandt, MD, MACG, Chair1, William D. Chey, MD, FACG2, Amy E. Foxx-Orenstein, DO, FACG3, Eamonn M.M. Quigley, MD,
FACG4, Lawrence R. Schiller, MD, FACG5, Philip S. Schoenfeld, MD, FACG6, Brennan M. Spiegel, MD, FACG7, Nicholas J. Talley, MD, PhD,
FACG8 with Paul Moayyedi, Epidemiologist-Statistician, BSc, MB ChB, PhD, MPH, FRCP (London), FRCPC, FACG9
Section 2.1 Methodology for systematic reviews of irritable (xi) Psychological therapies
bowel syndrome therapy, levels of evidence, and grading of (xii) Herbal therapies and acupuncture
recommendations (xiii) Emerging therapies
We have conducted a series of systematic reviews on the diag-
nostic criteria, the value of diagnostic tests, and the e cacy Subjects needed to be followed up for at least one week. e
of therapy in IBS. We also performed a narrative review of trial needed to include one or more of the following outcome
the epidemiology of IBS. ere have been several systematic measures:
reviews of therapy for IBS (1–5), but these either have not (i) Global assessment of IBS cure or improvement
quantitatively combined the data into meta-analyses (1–3) (ii) Abdominal pain cure or improvement
or have inaccuracies in applying eligibility criteria and data (iii) Global IBS symptom or abdominal pain scores
extraction (4,5). We have, therefore, repeated all systematic
reviews of IBS and synthesized the data where appropriate. Search strategy for identi cation of studies
Medline (1966–June 2008), Embase (1988–June 2008), and the
Systematic review methodology Cochrane Controlled Trials Register (Issue 2, 2008) electronic
For all reviews, we evaluated manuscripts that studied adults databases were searched. An example of the Medline search is
using any de nition of IBS. is included a clinician-de ned given below.
diagnosis, Manning criteria (6), the Kruis score (7), or Rome I IBS patients were identi ed with the terms irritable bowel
(8), II (9), or III (10) criteria. syndrome and functional diseases, colon (both as medical sub-
For reviews of diagnostic tests, we included case series and ject heading (MeSH) and free text terms), and IBS, spastic
case-control studies that evaluated serologic tests for celiac colon, irritable colon, and functional adj5 (adj5 is a term used
sprue (anti-gliadin, anti-endomysial, and tissue transglutami- by Medline for words that appear within 5 adjectives of each
nase antibodies), lactose hydrogen breath tests, and tests for other) bowel (as free text terms).
small bowel bacterial overgrowth (lactulose and glucose hydro- Studies identi ed from this search were combined with
gen breath test or jejunal aspirates). the following terms used to identify therapies for IBS: dietary
For reviews of therapies of IBS, we included only parallel ber, cereals, psyllium, sterculia, karaya gum, parasympatho-
group RCTs comparing active intervention with either placebo lytics, scopolamine, trimebutine, muscarinic antagonists, and the
or no therapy. following free text terms: bulking agent, psyllium ber, ber,
e following treatments were considered: husk, bran, ispaghula, wheat bran, spasmolytics, spasmolytic
(i) Diet agents, antispasmodics, mebeverine, alverine, pinaverium bro-
(ii) Fiber, bulking agents, and laxatives mide, otilonium bromide, cimetropium bromide, hyoscine butyl
(iii) Antispasmodics and Peppermint Oil bromide, butylscopolamine, peppermint oil, loperamide and
(iv) Antidiarrheal agents colpermin, serotonin antagonists, serotonin agonists, cisapride,
(v) Antibiotic therapy receptors (serotonin, 5-HT3), and receptors (serotonin, 5-HT4;
(vi) Probiotic therapy both as MeSH terms and free text terms), and the following
(vii) 5HT3 antagonists
(viii) 5HT4 agonists free text terms: 5-HT3, 5-HT4, alosetron, cilansetron, tegas-
(ix) Selective C-2 chloride channel activators erod, and renzapride, psychotropic drugs, antidepressive agents,
(Lubiprostone) antidepressive agents (tricyclic), desipramine, imipramine,
(x) Antidepressants trimipramine, doxepin, dothiepin, nortriptyline, amitriptyline,
1
Division of Gastroenterology, Montefiore Medical Center, Bronx, New York, USA; 2Division of Gastroenterology, University of Michigan Health System, Ann
Arbor, Michigan, USA; 3Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA; 4Department of
Medicine, Clinical Sciences Building, Cork University Hospital, Cork, Ireland; 5Digestive Health Associates of Texas, Baylor University Medicine Center, Dallas,
Texas, USA; 6Veterans Affairs Ann Arbor Healthcare System, Division of Gastroenterology, Ann Arbor, Michigan, USA; 7VA Greater Los Angeles Healthcare System,
David Geffen School of Medicine at UCLA, Los Angeles, California, USA; 8Department of Medicine, Mayo Clinic, Jacksonville, Florida, USA; 9Department of
Medicine, Division of Gastroenterology, McMaster University Medical Centre, Hamilton, Canada. Correspondence: Lawrence J. Brandt, MD, MACG, Montefiore
Medical Center, 111 East 210 Street, Bronx, New York 10467, USA.
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13. Brandt et al.
Table 1. Grading recommendations
Grade of Recommenda- Benefit vs. risk and burdens Methodological quality of Implications
tion/description supporting evidence
1A. Strong recom- Benefits clearly outweigh risk RCTs without important limitations Strong recommendation, can apply to most pa-
mendation, high-quality and burdens, or vice versa or overwhelming evidence from tients in most circumstances. Further evidence
evidence observational studies is unlikely to change our confidence in the
estimate of effect
1B. Strong recommen- Benefits clearly outweigh risk RCTs with important limitations Strong recommendation, can apply to most
dation, moderate-quality and burdens, or vice versa (inconsistent results, methodologi- patients in most circumstances. Higher quality
evidence cal flaws, indirect, or imprecise) evidence may well change our confidence in
or exceptionally strong evidence the estimate of effect
from observational studies
1C. Strong recommen- Benefits clearly outweigh risk Observational studies or case Strong recommendation can apply to most
dation, low-quality or and burdens, or vice versa series patients in most circumstances. Higher quality
very low-quality evidence evidence is very likely to change our confi-
dence in the estimate of effect
2A. Weak recommen- Benefits closely balanced with RCTs without important limitations Weak recommendation, best action may differ
dation, high-quality risks and burden or overwhelming evidence from depending on circumstances or patients’ or
evidence observational studies societal values. Further evidence is unlikely to
change our confidence in the estimate of effect
2B. Weak recommenda- Benefits closely balanced with RCTs with important limitations Weak recommendation, best action may differ
tion, moderate-quality risks and burden (inconsistent results, methodologi- depending on circumstances or patients’ or
evidence cal flaws, indirect, or imprecise) societal values. Higher quality evidence may
or exceptionally strong evidence well change evidence our confidence in the
from observational studies estimate of effect
2C. Weak recommenda- Uncertainty in the estimates Observational studies or case Very weak recommendations; other alterna-
tion, low-quality or very of benefits, risks, and burden; series tives may be equally reasonable. Higher quality
low-quality evidence benefits, risk, and burden may evidence is likely to change our confidence in
be closely balanced the estimate of effect
RCT, randomized controlled trial.
patients’ well being, and then act on this insight by selecting the studies. To re ne the prevalence estimate, we performed
treatments tailored to each patient’s symptoms and HRQOL an updated systematic review to target studies that only used
decrement. For research funding and drug-approval authori- Rome de nitions, drew upon patients from the general adult
ties, it shows that IBS is far more than a mere nuisance, and is community (i.e., not exclusively from primary or secondary
instead a condition with a prevalence and HRQOL impact that care), and included patients who were not selected speci -
matches other major diagnoses such as diabetes, hypertension, cally (e.g., not evaluating IBS in subjects with re ux symptoms
or kidney disease (16,17). For employers and healthcare insur- or in twins). We identi ed four eligible studies evaluating
ers, it reveals the overwhelming direct and indirect expendi- 32,638 North American subjects and found that IBS prevalence
tures related to IBS, and provides a business rationale to ensure varied between 5 and 10% with a pooled prevalence of 7%
that IBS is treated e ectively. e objective of this section is to (95% CI = 6–8%) (20–23). Although previous reviews indicated
review key data regarding the burden of illness of IBS, includ- that IBS patients are divided evenly among the three major
ing: (1) the prevalence of IBS and its subtypes; (2) the age of subgroups (IBS-D, IBS-C, and IBS-M) (24), the true prevalence
onset and gender distribution of IBS; (3) the e ect of IBS on of IBS subtypes in North America remains unclear; one study
HRQOL; and (4) the economic burden of IBS, including direct suggested that IBS with diarrhea is the most common subtype
and indirect expenditures and their clinical predictors. (21), whereas another indicated that mixed-type IBS is most
Previous systematic reviews have measured the prevalence common (22).
of IBS in both North American and European nations (18,19). ere are several demographic predictors of IBS, including
Prevalence estimates range from 1% to over 20%. is wide gender, age, and socioeconomic status. e odds of having
range indicates that IBS prevalence, like prevalence of all dis- IBS are higher in women than in men (pooled OR = 1.46; 95%
eases, depends on several variables, including the case- nding CI = 1.13–1.88) (20–23), although IBS is not simply a disorder
de nition employed (e.g., Manning criteria vs. Rome criteria), of women. In fact, IBS is now recognized to be a key component
the characteristics of the source population (e.g., primary vs. of the Gulf War Syndrome, a multi-symptom complex a ecting
secondary care), and the methodology and sampling frame of soldiers (a predominantly male population) deployed in the
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15. Brandt et al.
Similarly, nearly 25% of colonoscopies performed in patients e ACG Task Force conducted a systematic review of the
younger than 50 years of age are for IBS symptoms (43), regard- accuracy of symptom-based criteria in the diagnosis of IBS
less of data that indicate colonoscopy has a low diagnostic yield (51). Overall, eight studies (52–59) were identi ed involv-
in IBS, and that “negative” examinations fail to improve intes- ing 2,280 patients. In all studies, IBS was de ned as a clinical
tinal symptoms, do not augment HRQOL, and are unlikely to diagnosis a er investigations that included either a colono-
provide additional reassurance when compared with not per- scopy or a barium enema. e accuracy of individual symp-
forming colonoscopy (44). Resource utilization in IBS also is toms was described in six studies (52–57) evaluating 1,077
driven partly by the presence of comorbid somatization—a trait patients. Symptoms such as abdominal pain, loose or frequent
found in up to one-third of IBS patients that is characterized by stools associated with pain, incomplete evacuation, mucus per
the propensity to overinterpret normal physiologic processes rectum, and abdominal distention all had limited accuracy in
(45,46). Patients with somatization typically report a barrage of diagnosing IBS. Lower abdominal pain had the highest sensi-
seemingly unrelated physical complaints (e.g., back pain, tin- tivity (90%) but very poor speci city (32%), whereas patient-
gling, headaches, temporomandibular joint pain, muscle aches) reported visible abdominal distention had the highest speci city
that may, in fact, be linked to underlying psychosocial distress (77%) but low sensitivity (39%). A variety of criteria therefore
(45,46). ese patients are sometimes misclassi ed as hav- have been developed to identify a combination of symptoms
ing several underlying organic conditions, and subsequently to diagnose IBS (see Table 2).
undergo sequential diagnostic tests in chase of the disparate e rst description of this approach was by Manning et al.
symptoms (47). ere is a linear and highly signi cant relation- (52) and there have been four studies evaluating the accuracy
ship between levels of somatization and the amount of diag- of Manning’s criteria in 574 patients. Two studies (52,58) sug-
nostic testing in IBS, suggesting that providers should remain gested these criteria performed well, whereas accuracy was poor
alert for somatization in IBS, and aggressively treat or refer in the other two studies (56,57). Overall, Manning’s criteria had
somatization patients to an experienced specialist rather than a pooled sensitivity of 78% and pooled speci city of 72% (51).
performing potentially unnecessary diagnostic tests (47). e next description of symptom criteria was by Kruis et al.,
In addition to direct costs of care, IBS patients engender and four studies (53–55) have described the accuracy of this
signi cant indirect costs of care as a consequence of both approach in 1,166 patients. ree studies (53,54,58) suggested
missing work and su ering impaired work performance the Kruis symptoms score had an excellent positive predictive
while on the job. Employees with IBS are absent 3–5% of the value with a pooled sensitivity of 77% and pooled speci city
workweek, and report impaired productivity 26–31% of the of 89%. Subsequently, an international working group deve-
week (48–50)—rates that exceed those of non-IBS con- loped the Rome criteria, which have undergone three itera-
trol employees by 20% (49); this is equivalent to 14 hours of tions over 15 years. ese criteria have been heavily promoted,
lost productivity per 40-hour workweek. Compared with IBS although there has been only one study in which the accuracy
patients who exhibit normal work productivity, patients with of Rome I criteria has been evaluated and none describing
impaired productivity have more extraintestinal comorbidi- the accuracy of Rome II or III (50). In the 602 patients studied,
ties (e.g., chronic fatigue syndrome, bromyalgia, interstitial the Rome I criteria had a sensitivity of 71% and speci city of
cystitis), and more disease-speci c fears and concerns (50). In 85% (59).
contrast, the speci c pro le of individual bowel symptoms does All studies evaluating the accuracy of diagnostic criteria
not undermine work productivity (50), suggesting that enhanc- in patients with IBS face the problem of lack of a reference
ing work productivity in patients with IBS may require treat- standard test for this condition. Notwithstanding, none of
ments that improve both GI and non-GI symptom intensity, the symptom-based diagnostic criteria have an ideal accuracy
while also modifying the cognitive and behavioral responses to and the Rome criteria, in particular, have been inadequately
bowel symptoms and the contexts in which they occur. In other evaluated, despite their extensive use in the research setting.
words, it may be inadequate to treat bowel symptoms alone e ACG Task Force felt that a pragmatic de nition that was
without simultaneously addressing the emotional context in simple to use and that incorporated key features of previous
which the symptoms occur. diagnostic criteria would be clinically useful. We, therefore,
de ned IBS as abdominal pain or discomfort that occurs in
Section 2.3 The utility of diagnostic criteria in IBS association with altered bowel habits over a period of at least
IBS is de ned by abdominal pain or discomfort that occurs in three months.
association with altered bowel habits over a period of at least
three months. Individual symptoms have limited accuracy for Section 2.4 The role of alarm features in the diagnosis of IBS
diagnosing IBS and, therefore, the disorder should be considered Overall, the diagnostic accuracy of alarm features is disappoint-
as a symptom complex. Although no symptom-based diagnos- ing. Rectal bleeding and nocturnal pain o er little discriminative
tic criteria have ideal accuracy for diagnosing IBS, traditional value in separating patients with IBS from those with organic
criteria, such as Kruis and Manning, perform at least as well as diseases. Whereas anemia and weight loss have poor sensitivity
Rome I criteria; the accuracy of Rome II and Rome III criteria for organic diseases, they o er very good speci city. As such, in
has not been evaluated. patients who ful ll symptom-based criteria of IBS, the absence
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17. Brandt et al.
of selected organic diseases including colorectal cancer, IBD, family history of colorectal cancer, IBD or celiac sprue, should
and celiac sprue. Usually, it is recommended that patients who reassure the clinician that the diagnosis of IBS is correct.
exhibit alarm features undergo further investigation, particu-
larly with colonoscopy to rule out organic disease, e.g., color- Section 2.5 The role of diagnostic testing in patients with IBS
ectal cancer. e utility of this approach has been addressed in symptoms
a systematic review of the literature (60). is review evaluated Routine diagnostic testing with complete blood count, serum
all patients presenting with lower gastrointestinal symptoms, as chemistries, thyroid function studies, stool for ova and para-
there was no study that speci cally addressed IBS patients as a sites, and abdominal imaging is not recommended in patients
group. Nevertheless, the results of this review are likely to be with typical IBS symptoms and no alarm features because of
applicable to IBS patients or may even overestimate the utility a low likelihood of uncovering organic disease (Grade 1C).
of alarm symptoms because abdominal pain (a de ning Routine serologic screening for celiac sprue should be pursued in
symptom of IBS) is a negative predictor of serious underlying patients with IBS-D and IBS-M (Grade 1B). Lactose breath testing
pathology (60). In 13 studies evaluating the diagnostic utility can be considered when lactose maldigestion remains a concern
of abdominal pain in 19,238 patients, the pooled positive despite dietary modi cation (Grade 2B). Currently, there are
likelihood ratio was 0.72 (95% CI = 0.60–0.88), and the pooled insu cient data to recommend breath testing for small intestinal
negative likelihood ratio was 1.21 (95% CI = 1.11-1.32) for bacterial overgrowth in IBS patients (Grade 2C). Because of the
colorectal cancer, i.e., the presence of abdominal pain reduces low pretest probability of Crohn’s disease, ulcerative colitis, and
the likelihood and the absence of pain increases the likelihood colonic neoplasia, routine colonic imaging is not recommended in
of colorectal cancer. patients younger than 50 years of age with typical IBS symptoms
Our review on the utility of alarm features to diagnose color- and no alarm features (Grade 1B). Colonoscopic imaging should
ectal cancer (1) identi ed 14 studies evaluating 19,189 patients be performed in IBS patients with alarm features to rule out or-
with lower GI symptoms and reported on the accuracy of rectal ganic diseases and in those over the age of 50 years for the pur-
bleeding in this regard. Rectal bleeding had a pooled sensitivity pose of colorectal cancer screening (Grade 1C). When colonoscopy
of 64% (95% CI = 55–73%) and pooled speci city of 52% (95% is performed in patients with IBS-D, obtaining random biopsies
CI = 42–63%) for diagnosing colorectal cancer. Seven studies should be considered to rule out microscopic colitis (Grade 2C).
involving 4,404 patients evaluated the diagnostic utility of ane-
mia and found a pooled sensitivity of 19% (95% CI = 5.5–33%) IBS is a disorder of heterogeneous pathophysiology for which
and pooled speci city of 90% (95% CI = 87–92%) for diag- speci c biomarkers are not yet available. Diagnostic tests are
nosing colorectal cancer in patients with lower GI symptoms. therefore performed to exclude organic diseases that may mas-
ere were ve studies that assessed the accuracy of weight querade as IBS and, in so doing, reassure both the clinician and
loss in 7,418 patients with lower GI symptoms. Weight loss had the patient that the diagnosis of IBS is correct. Historically, IBD,
a pooled sensitivity of 22% (95% CI = 14–31%) and pooled colorectal cancer, diseases associated with malabsorption, sys-
speci city of 89% (95% CI = 81–95%). temic hormonal disturbances, and enteric infections are of the
It also has been suggested that the presence of nocturnal greatest concern to clinicians caring for patients with IBS symp-
symptoms may identify a group of patients more likely to har- toms. e broad di erential diagnosis of IBS symptoms as well
bor organic disease. Studies suggest, however, that nocturnal as medicolegal concerns related to making an incorrect diagno-
abdominal pain is no more likely in patients with organic sis of IBS drives most clinicians to view IBS as a “diagnosis of
diseases than it is in in patients with IBS (61,62). exclusion”. is practice has tangible consequences for patients,
ere is evidence to suggest that individuals with a family payors, and society at large. Physicians who feel that IBS is a
history of colorectal cancer, IBD, and celiac sprue are at higher diagnosis of exclusion order more diagnostic tests and spend
risk of having these organic diseases. e increased risk of more money to evaluate their patients than do experts who feel
colorectal cancer among individuals with an a ected rst- more con dent about diagnosing IBS (66). Given this informa-
degree relative under 60 years of age is well documented (63). tion, it is important to review the value of commonly ordered
ere is epidemiologic evidence of a 4- to 20-fold increased diagnostic tests in patients with suspected IBS, including com-
risk of IBD disease in rst-degree relatives of an a ected patient plete blood count, serum chemistries, thyroid function studies,
(64). Recent evidence also has shown that between 4 and 5% of markers of in ammation, testing for celiac sprue, breath testing
individuals with an a ected rst-degree relative will have celiac for lactose maldigestion and bacterial overgrowth, and colonic
sprue (65). imaging.
Overall, the accuracy of alarm features is disappointing. When deciding on the necessity of a diagnostic test in a
Rectal bleeding and nocturnal pain o er little discriminative patient with IBS symptoms, one should consider rst the pretest
value in separating patients with IBS from those with organic probability of the disease in question. If the pretest probability
diseases. Whereas anemia and weight loss have poor sensitivity of a particular disease is su ciently small, diagnostic testing
for organic diseases, they o er very good speci city. As such, directed at uncovering that improbable disease is unlikely to
in patients who ful ll symptom-based criteria, the absence of be either clinically useful or cost e ective. Clinicians also
selected alarm features, including anemia, weight loss, and a should consider the performance characteristics (e.g., sensitivity,
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