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Irritable Bowel Syndrome
Diagnosis/Definition
Continuous or recurrent symptoms for at least 3 months of:
- Abdominal pain or discomfort relieved with defecation, or associated with a change in the frequency or consistency of stool, and an irregular pattern of defecation at least 25% of the time and consisting of two or more of the following:
- Altered stool frequency.
- Altered stool form (hard or loose, watery stool).
- Altered stool passage (straining or urgency, feeling of incomplete evacuation).
- Passage of mucus.
- Bloating or feeling of abdominal distention.
Initial Diagnosis and Management
- Evaluation: only a history, physical exam, hemoccult, sigmoidoscopy, and CBC with ESR and stool examination for O & P times three are needed if a positive diagnosis had been made by above criteria. Lactose intolerance should be sought in the history, but an exclusion diet may be needed to rule this out.
- Extra evaluations should be reserved for a history suggestive of specific problems (e.g., U/S for gallstones, UGI for PUD, ACBE (air contrast barium enema) for severe constipation).
- Emphasize it is a “real” disease, but not associated with serious morbidity.
- Explain it is a motility disorder, “spasm” may cause the pain and stress may make it worse. Educational handouts are recommended.
- A high fiber diet, usually including psyllium (e.g., Metamucil) should be used first. Gradually increase psyllium to as much as 1 tsp. tid, advising that excess gas is usually transitory.
- If psyllium alone doesn’t help, anticholinergic (e.g., dicyclomine) for pain and loperamide for intermittent bouts of diarrhea can be used.
- When patient’s fail to respond to the above; the provider should consider psychiatric screening for depression.
Ongoing Management and Objectives
- Major objective should be symptom alleviation, as this is a chronic disorder with intermittent exacerbations, and a cure is not possible.
- Needed diagnostic tests should be done early and not repeated, and the patient should be reassured that serious pathology has been excluded.
Indications for Specialty Care Referral
When the diagnosis is uncertain.
When specific organic pathology is suspected. Examples: occult or gross blood in stool, diarrhea waking the patient from sleep or associated with weight loss, iron deficiency anemia, or significantly elevated ESR.
Referral should not be given to merely confirm the diagnosis if a positive diagnosis has been made.
Criteria for Return to Primary Care
Completed GI evaluation that rules out or resolves other potential causes of symptoms.
