1. Irritable bowel syndrome (IBS) is a common chronic condition characterized by abdominal pain and altered bowel habits that affects 10-15% of the population. 2. IBS is diagnosed based on fulfilling the Rome III criteria through symptom assessment alone in the absence of red flags. Testing is generally not required but celiac serology may be considered in some cases. 3. Treatment involves diet modification, medication based on stool pattern (e.g. linaclotide for IBS-C, loperamide for IBS-D), and psychological therapies if needed. Further testing is pursued only if red flags are present.

1. Dr. Mohamed Alshekhani
Professor in Medicine
MBChB-CABM-FRCP-EBGH 2016
1
Irritable bowel syndrome (IBS):

2. IBS:
• A heterogeneous symptom complex characterized by abdominal
pain &altered bowel habits.
• A chronic condition affects 10- 15% of the general population
• Lacks a single unifying pathophysiology & biomarkers.

3. IBS:Diagnosis
• By fulfillment of symptom-based Rome III criteria
• IBS is further subtyped based on the predominant stool pattern as
IBS -constipation (IBS-C), IBS - diarrhea (IBS-D), or mixed (IBS-M).
• Additional symptoms not part of diagnostic criteria but frequently
reported include:
• <3 bowel movements/ week
• >3 bowel movements/day
• Abnormal stool form
• Straining.
• Rectal urgency
• Sensation of incomplete evacuation.
• Passage of mucus
• Bloating.

6. IBS: Differential Diagnosis
• A variety of other functional conditions occur with IBS, as
fibromyalgia, functional heart burn,functional dyspepsia, migraine,
adding to symptoms.
• IBS occurs in all ages & racial/ethnic groups, but >in women (67%
more likely than men) & in younger (25% > ≥50 years).
• Pathological colonic diseases must be sought when there are red
flags or any features of these diseases as infections,
IBD,Cancer,ischemic colitis,etc.

7. Evaluation:
• Accurate diagnosis can be made with fulfillment of the diagnostic
Rome 3 criteria without further testing in the absence of alarm
features (anemia; wt loss& family H/O CRC, IBD, or celiac).
• BPR & nocturnal abd pain are poor predictors of organic disease.
• Routine CBP, serum chemistry, thyroid functions, stool studies for
ova/parasites& abdominal imaging is unnecessary.

8. Evaluation:
• Testing for celiac disease with serum IgA–based tTG should be
considered in patients with IBS-D or IBS-M symptoms.
• Breath testing for lactase deficiency or SIBO can be considered
based on initial treatment response &/or presence of risk factors.
• Colonoscopy should be pursued only in patients who meet criteria
for colon cancer screening based on age, race& family history.
• Random colon biopsies should be obtained at the time of
colonoscopy to screen for microscopic colitis in patients with IBS-D.
• There is no established role for food allergy testing in IBS.

10. Management:
• An essential step is clear diagnosis with explanation& reassurance.
• A strong clinician-patient relationship should be established using a
patient-centered approach focused on effective patient & clinician
communication, using open-ended Qs, actively listening& empathy.
• The growing role of presumed food intolerances (> 50% report
symptom onset following meals), dietary interventions include the
avoidance of trigger foods (caffeine, carbonated beverages, or fatty
foods), increased dietary fiber&various elimination diets to restrict
gluten, lactose, fructose, or FODMAPs (Fermentable
Oligosaccharides, Disaccharides, Monosaccharides& Polyols).
• It is best to involve a dietitian when pursuing elimination diets to
ensure safety & improve efficacy.
• These initial management steps may lead to symptom
improvement in mild symptoms.

12. IBS-C:
• For persistent symptoms, directed pharmacologic therapy should be
pursued based on the predominant stool pattern.
• The soluble fiber supplement psyllium has limited efficacy in IBS.
• Insoluble fiber supplements such as bran appear worsens IBS-C.
• Only the osmotic laxative PEG has been tested in IBS.
• Lubiprostone & linaclotide have demonstrated safety/efficacy in
treating the global symptoms of IBS-C.
• Lubiprostone is FDA approved for women with IBS-C
• Linaclotide is FDA approved for IBS-C in adults
• Both are costy.

14. IBS-D:
• The antispasmodic agents hyoscyamine,Mebeverine,&dicyclomine
are used for the short-term treatment of abdominal pain in IBS-D or
IBS-C, although they can cause constipation.
• The antidiarrheal agent loperamide is safe &is only effective for the
bowel symptoms associated with IBS-D.
• The non-absorbable antimicrobial agent rifaximin can be effective
for global symptoms & bloating associated with IBS-D, by altering
the colonic microbial flora.
• The 5-HT3 antagonist alosetron is available for women with IBS-D
whose symptoms have not responded to conventional therapy; but
can cause severe constipation&ischemic colitis with its use.

17. Other therapies:
• When the previously mentioned therapies are unsuccessful, central-
acting agents such as TADs&SSRIs are effective, primarily for overall
symptoms & abdominal pain.
• TADs is preferred in IBS-D given their constipating side effects.
• SSRIs are preferred in IBS-C.

18. Complementary Therapy
• If pharmacologic therapies are not effective or not desired by the
patient, a variety of complementary interventions considered:
• Prebiotics (nondigestible nutrients intended to encourage desirable
bacterial growth)
• Probiotics
• Herbal medicine
• Cognitive behavioral therapy
• Hypnotherapy
• Acupuncture.

20. BO5:1
• 1. Irritable bowel syndrome is:
• Common.
• Uncommon.
• Not uncommon.
• Rare.
• Very rare.

21. BO5:2
• 2. Irritable bowel syndrome is currently
diagnosed by:
• Rome 1 criteria.
• Rome 2 criteria.
• Rome 3 criteria.
• All of the above.
• None of the above.

22. BO5:3
• 3. Irritable bowel syndrome is usually
diagnosed by:
• Exclusion.
• Symptom – based.
• Immune markers.
• Serum markers.
• All of the above.

23. BO5:4
• 4.The following are subtypes of Irritable bowel
syndrome except:
• IBS-C.
• IBS-D.
• IBS-U.
• IBS-S.
• IBS-M.

24. BO5:5
• 5.The following are parts of Rome 3 criteria for
diagnosis of IBS except:
• Abdominal pain.
• Diarrhea.
• Mucus in stool.
• Improvement with defecation.
• Constipation.

25. BO5:6
• 6.IBS is diagnosed when the symptoms fulfills
Rome 3 criteria in the absence of:
• Depression.
• Anxiety.
• Red flags.
• Family history of the condition.
• Headache.

26. BO5:7
• 7.The only lab test which may be needed for
investigating a case of Rome 3 –diagnosed IBS
is :
• CBP.
• GSE.
• GUE.
• Celiac serology.
• Abdominal utrasound.

27. BO5:8
• 8.The lab test needed for investigating a case
of Rome 3 – diagnosed IBS-D is :
• CBP.
• GSE.
• GUE.
• Celiac serology.
• Abdominal utrasound.

28. BO5:9
• 9.The lab test needed for investigating a case
of Rome 3 – diagnosed IBS-M is :
• CBP.
• GSE.
• GUE.
• Celiac serology.
• Abdominal utrasound.

29. BO5:10
• 10.The cornerstone for effective management
of Rome 3- diagnosed IBS is :
• Exclusion of psychiatric diseases.
• Exclusion of pathological conditions.
• Solid diagnosis & reassurance.
• Exhaustive investigations.
• Drug treatment in all cases.

30. BO5:11
• 11.Treatments of choice for IBS-C include all
except:
• Fiber diet.
• PEG laxative.
• Lactulose.
• Tricyclic antidepressant.
• Linaclotide.

31. BO5:12
• 12.Treatments of choice for IBS-D include all
except:
• Loperamide.
• Diphenoxylate.
• Antispasmotics.
• SSRI.
• Rifaximine.

32. BO5:13
• 13.Treatments for severe refractory IBS
include all except:
• Pain clinic referral.
• Cognitive behavioral therapy.
• Surgery.
• Hypnotherapy.
• Acupuncture.

33. BO5:14
• 14.Red flags that warrants investigations to
exclude an alternative diagnosis for IBS
include all except:
• Anemia.
• Weight loss.
• Age < 50 years.
• Family history of CRC.
• Family history of IBD.