Clinical manifestations and diagnosis of irritable bowel syndrome in adults
- Arnold Wald, MD
Arnold Wald, MD
- Professor of Medicine
- University of Wisconsin School of Medicine and Public Health, Madison
Irritable bowel syndrome (IBS) is a functional disorder of the gastrointestinal tract characterized by chronic abdominal pain and altered bowel habits. However, only a small percentage of those affected seek medical attention [1-5]. Approximately 40 percent of individuals who meet diagnostic criteria for IBS do not have a formal diagnosis . IBS is associated with increased health care costs and is the second highest cause of work absenteeism [7,8]. In the United States, IBS accounts for 25 to 50 percent of all referrals to gastroenterologists . This topic will review the clinical manifestations and diagnosis of IBS. The pathophysiology and management of IBS are discussed in detail separately. (See "Pathophysiology of irritable bowel syndrome" and "Treatment of irritable bowel syndrome in adults".)
Prevalence — The prevalence of irritable bowel syndrome (IBS) in North America estimated from population-based studies is approximately 10 to 15 percent [1,2,10-14]. In a meta-analysis that included eight international studies, the pooled prevalence of IBS was estimated to be 11 percent, with wide variation by geographic region . The prevalence of IBS was 25 percent lower in those aged over 50 years as compared with those who were younger (OR, 0.75; 95% CI, 0.62-0.92) . The overall prevalence of IBS in women was higher as compared with men (odds ratio 1.67 [95% CI 1.53–1.82]) . This relative difference reflects an absolute difference in prevalence of approximately 5 percent between the sexes, with a prevalence in women and men of 14 and 9 percent, respectively. Women may be more likely to have constipation-predominant IBS as compared with men .
Associated conditions — IBS is associated with other conditions including fibromyalgia, chronic fatigue syndrome (also known as systemic exertion intolerance disease), gastroesophageal reflux disease, functional dyspepsia, non-cardiac chest pain, and psychiatric disorders including major depression, anxiety, and somatization [17-21]. (See "Pathophysiology of irritable bowel syndrome", section on 'Psychosocial dysfunction'.)
Irritable bowel syndrome (IBS) is characterized by chronic abdominal pain and altered bowel habits .
Chronic abdominal pain — Abdominal pain in IBS is usually described as a cramping sensation with variable intensity and periodic exacerbations. The location and character of the pain can vary widely [17,22]. The severity of the pain may range from mild to severe. The pain is frequently related to defecation. While in some patients abdominal pain is relieved with defecation, some patients report worsening of pain with defecation . Emotional stress and meals may exacerbate the pain. Patients with IBS also frequently report abdominal bloating and increased gas production in the form of flatulence or belching.
- Talley NJ, Zinsmeister AR, Van Dyke C, Melton LJ 3rd. Epidemiology of colonic symptoms and the irritable bowel syndrome. Gastroenterology 1991; 101:927.
- Drossman DA, Li Z, Andruzzi E, et al. U.S. householder survey of functional gastrointestinal disorders. Prevalence, sociodemography, and health impact. Dig Dis Sci 1993; 38:1569.
- Jones R, Lydeard S. Irritable bowel syndrome in the general population. BMJ 1992; 304:87.
- Heaton KW, O'Donnell LJ, Braddon FE, et al. Symptoms of irritable bowel syndrome in a British urban community: consulters and nonconsulters. Gastroenterology 1992; 102:1962.
- Ford AC, Forman D, Bailey AG, et al. Irritable bowel syndrome: a 10-yr natural history of symptoms and factors that influence consultation behavior. Am J Gastroenterol 2008; 103:1229.
- Sayuk GS, Wolf R, Chang L. Comparison of Symptoms, Healthcare Utilization, and Treatment in Diagnosed and Undiagnosed Individuals With Diarrhea-Predominant Irritable Bowel Syndrome. Am J Gastroenterol 2017; 112:892.
- Schuster MM. Diagnostic evaluation of the irritable bowel syndrome. Gastroenterol Clin North Am 1991; 20:269.
- Sandler RS, Everhart JE, Donowitz M, et al. The burden of selected digestive diseases in the United States. Gastroenterology 2002; 122:1500.
- Everhart JE, Renault PF. Irritable bowel syndrome in office-based practice in the United States. Gastroenterology 1991; 100:998.
- American College of Gastroenterology Task Force on Irritable Bowel Syndrome, Brandt LJ, Chey WD, et al. An evidence-based position statement on the management of irritable bowel syndrome. Am J Gastroenterol 2009; 104 Suppl 1:S1.
- Hahn BA, Saunders WB, Maier WC. Differences between individuals with self-reported irritable bowel syndrome (IBS) and IBS-like symptoms. Dig Dis Sci 1997; 42:2585.
- Saito YA, Locke GR, Talley NJ, et al. A comparison of the Rome and Manning criteria for case identification in epidemiological investigations of irritable bowel syndrome. Am J Gastroenterol 2000; 95:2816.
- Thompson WG, Irvine EJ, Pare P, et al. Functional gastrointestinal disorders in Canada: first population-based survey using Rome II criteria with suggestions for improving the questionnaire. Dig Dis Sci 2002; 47:225.
- Lovell RM, Ford AC. Global prevalence of and risk factors for irritable bowel syndrome: a meta-analysis. Clin Gastroenterol Hepatol 2012; 10:712.
- Hungin AP, Whorwell PJ, Tack J, Mearin F. The prevalence, patterns and impact of irritable bowel syndrome: an international survey of 40,000 subjects. Aliment Pharmacol Ther 2003; 17:643.
- Lovell RM, Ford AC. Effect of gender on prevalence of irritable bowel syndrome in the community: systematic review and meta-analysis. Am J Gastroenterol 2012; 107:991.
- Longstreth GF, Thompson WG, Chey WD, et al. Functional bowel disorders. Gastroenterology 2006; 130:1480.
- Lovell RM, Ford AC. Prevalence of gastro-esophageal reflux-type symptoms in individuals with irritable bowel syndrome in the community: a meta-analysis. Am J Gastroenterol 2012; 107:1793.
- Whorwell PJ, McCallum M, Creed FH, Roberts CT. Non-colonic features of irritable bowel syndrome. Gut 1986; 27:37.
- Hershfield NB. Nongastrointestinal symptoms of irritable bowel syndrome: an office-based clinical survey. Can J Gastroenterol 2005; 19:231.
- Chey WD, Kurlander J, Eswaran S. Irritable bowel syndrome: a clinical review. JAMA 2015; 313:949.
- Swarbrick ET, Hegarty JE, Bat L, et al. Site of pain from the irritable bowel. Lancet 1980; 2:443.
- Simren M, Palsson OS, Whitehead WE. Update on Rome IV Criteria for Colorectal Disorders: Implications for Clinical Practice. Curr Gastroenterol Rep 2017; 19:15.
- Manning AP, Thompson WG, Heaton KW, Morris AF. Towards positive diagnosis of the irritable bowel. Br Med J 1978; 2:653.
- American Gastroenterology Association. American Gastroenterological Association medical position statement: irritable bowel syndrome. Gastroenterology 2002; 123:2105.
- Mearin F, Lacy BE, Chang L, et al. Bowel Disorders. Gastroenterology 2016.
- Talley NJ, Phillips SF, Melton LJ, et al. Diagnostic value of the Manning criteria in irritable bowel syndrome. Gut 1990; 31:77.
- Smith RC, Greenbaum DS, Vancouver JB, et al. Gender differences in Manning criteria in the irritable bowel syndrome. Gastroenterology 1991; 100:591.
- Taub E, Cuevas JL, Cook EW 3rd, et al. Irritable bowel syndrome defined by factor analysis. Gender and race comparisons. Dig Dis Sci 1995; 40:2647.
- Kruis W, Thieme C, Weinzierl M, et al. A diagnostic score for the irritable bowel syndrome. Its value in the exclusion of organic disease. Gastroenterology 1984; 87:1.
- Frigerio G, Beretta A, Orsenigo G, et al. Irritable bowel syndrome. Still far from a positive diagnosis. Dig Dis Sci 1992; 37:164.
- Hammer J, Talley NJ. Diagnostic criteria for the irritable bowel syndrome. Am J Med 1999; 107:5S.
- Fass R, Longstreth GF, Pimentel M, et al. Evidence- and consensus-based practice guidelines for the diagnosis of irritable bowel syndrome. Arch Intern Med 2001; 161:2081.
- Vanner SJ, Depew WT, Paterson WG, et al. Predictive value of the Rome criteria for diagnosing the irritable bowel syndrome. Am J Gastroenterol 1999; 94:2912.
- Ford AC, Bercik P, Morgan DG, et al. Validation of the Rome III criteria for the diagnosis of irritable bowel syndrome in secondary care. Gastroenterology 2013; 145:1262.
- Talley NJ. How to do and interpret a rectal examination in gastroenterology. Am J Gastroenterol 2008; 103:820.
- Waugh N, Cummins E, Royle P, et al. Faecal calprotectin testing for differentiating amongst inflammatory and non-inflammatory bowel diseases: systematic review and economic evaluation. Health Technol Assess 2013; 17:xv.
- Menees SB, Powell C, Kurlander J, et al. A meta-analysis of the utility of C-reactive protein, erythrocyte sedimentation rate, fecal calprotectin, and fecal lactoferrin to exclude inflammatory bowel disease in adults with IBS. Am J Gastroenterol 2015; 110:444.
- Ford AC, Chey WD, Talley NJ, et al. Yield of diagnostic tests for celiac disease in individuals with symptoms suggestive of irritable bowel syndrome: systematic review and meta-analysis. Arch Intern Med 2009; 169:651.
- Cash BD, Rubenstein JH, Young PE, et al. The prevalence of celiac disease among patients with nonconstipated irritable bowel syndrome is similar to controls. Gastroenterology 2011; 141:1187.
- Rezaie A, Park SC, Morales W, et al. Assessment of Anti-vinculin and Anti-cytolethal Distending Toxin B Antibodies in Subtypes of Irritable Bowel Syndrome. Dig Dis Sci 2017; 62:1480.
- Pimentel M, Morales W, Rezaie A, et al. Development and validation of a biomarker for diarrhea-predominant irritable bowel syndrome in human subjects. PLoS One 2015; 10:e0126438.
- Schmulson M, Balbuena R, Corona de Law C. Clinical experience with the use of anti-CdtB and anti-vinculin antibodies in patients with diarrhea in Mexico. Rev Gastroenterol Mex 2016; 81:236.
- Schmulson MW, Chang L. Diagnostic approach to the patient with irritable bowel syndrome. Am J Med 1999; 107:20S.
- Svendsen JH, Munck LK, Andersen JR. Irritable bowel syndrome--prognosis and diagnostic safety. A 5-year follow-up study. Scand J Gastroenterol 1985; 20:415.
- O'Connor OJ, McSweeney SE, McWilliams S, et al. Role of radiologic imaging in irritable bowel syndrome: evidence-based review. Radiology 2012; 262:485.
- Guagnozzi D, Arias Á, Lucendo AJ. Systematic review with meta-analysis: diagnostic overlap of microscopic colitis and functional bowel disorders. Aliment Pharmacol Ther 2016; 43:851.
- Kamp EJ, Kane JS, Ford AC. Irritable Bowel Syndrome and Microscopic Colitis: A Systematic Review and Meta-analysis. Clin Gastroenterol Hepatol 2016; 14:659.
- Gudsoorkar VS, Quigley EM. Distinguishing Microscopic Colitis From Irritable Bowel Syndrome. Clin Gastroenterol Hepatol 2016; 14:669.
- Goff B. Symptoms associated with ovarian cancer. Clin Obstet Gynecol 2012; 55:36.
- El-Serag HB, Pilgrim P, Schoenfeld P. Systemic review: Natural history of irritable bowel syndrome. Aliment Pharmacol Ther 2004; 19:861.
- Associated conditions
- CLINICAL MANIFESTATIONS
- Chronic abdominal pain
- Altered bowel habits
- - Diarrhea
- - Constipation
- Overview of diagnostic approach
- Diagnostic criteria
- Initial evaluation
- - History and physical examination
- - Laboratory testing
- - Other tests
- Additional evaluation based on the presence of alarm features
- DIFFERENTIAL DIAGNOSIS
- DISEASE COURSE
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS