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How to Approach a Patient with Difficult-to-Treat IBS

  • Lin Chang
    Correspondence
    Correspondence Address correspondence to: Lin Chang, MD, G Oppenheimer Family Center for Neurobiology of Stress and Resilience, 10833 Le Conte Ave, CHS 42-210, Los Angeles, CA 90095-7378.
    Affiliations
    Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
    Search for articles by this author
      Irritable bowel syndrome (IBS) is a common gastrointestinal (GI) disorder characterized by recurrent or chronic abdominal pain associated with diarrhea and/or constipation.
      • Mearin F.
      • Lacy B.E.
      • Chang L.
      • et al.
      Bowel disorders.
      IBS has been redefined as a disorder of gut–brain interaction, which is classified by GI symptoms related to any combination of the following: motility disturbance, visceral hypersensitivity, altered mucosal and immune function, altered gut microbiota, and altered central nervous system processing.
      • Drossman D.A.
      Functional gastrointestinal disorders: history, pathophysiology, clinical features and Rome IV.
      The severity of IBS is determined by the individual’s symptom experience and behaviors rather than by objective tests or histopathological markers in the bowel.
      • Drossman D.A.
      • Chang L.
      • Bellamy N.
      • et al.
      Severity in irritable bowel syndrome: a Rome Foundation Working Team report.
      Recognizing the severity level can influence diagnostic and treatment decisions. A greater severity of IBS has been associated with more intense and bothersome abdominal pain, bloating, and bowel difficulties, increased psychological and extraintestinal symptoms, dietary restriction, medication use, and health care utilization, and poorer health-related quality of life (HRQOL).
      • Drossman D.A.
      • Morris C.B.
      • Schneck S.
      • et al.
      International survey of patients with IBS: symptom features and their severity, health status, treatments, and risk taking to achieve clinical benefit.
      • Spiegel B.
      • Strickland A.
      • Naliboff B.D.
      • et al.
      Predictors of patient-assessed illness severity in irritable bowel syndrome.
      • Lenhart A.
      • Dong T.
      • Joshi S.
      • et al.
      Effect of exclusion diets on symptom severity and the gut microbiota in patients with irritable bowel syndrome.
      Although patients with mild to moderate IBS most likely have symptoms related to gut-related factors, patients with severe IBS have unpredictable and/or refractory symptoms in which there is a relatively greater contribution of centrally driven factors. They tend to have more psychosocial distress (eg, adverse or stressful life events, psychiatric comorbidities, poor coping), GI symptom-related anxiety, hyperattentiveness and hypervigilance toward symptoms resulting in central amplification of symptoms.
      • Drossman D.A.
      • Chang L.
      • Bellamy N.
      • et al.
      Severity in irritable bowel syndrome: a Rome Foundation Working Team report.
      Understanding the basis for more difficult to treat IBS will provide the foundation to identify the clinically meaningful factors driving symptoms and guide patient-centered care. This review addresses the management approaches, including practical tips, that can be used to treat more severe IBS.
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      References

        • Mearin F.
        • Lacy B.E.
        • Chang L.
        • et al.
        Bowel disorders.
        Gastroenterology. 2016; 150: 1393-1407
        • Drossman D.A.
        Functional gastrointestinal disorders: history, pathophysiology, clinical features and Rome IV.
        Gastroenterology. 2016 Feb 19; S0016-5085 (Epub ahead of print): 00223-00227https://doi.org/10.1053/j.gastro.2016.02.032
        • Drossman D.A.
        • Chang L.
        • Bellamy N.
        • et al.
        Severity in irritable bowel syndrome: a Rome Foundation Working Team report.
        Am J Gastroenterol. 2011; 106 (quiz 1760): 1749-1759
        • Drossman D.A.
        • Morris C.B.
        • Schneck S.
        • et al.
        International survey of patients with IBS: symptom features and their severity, health status, treatments, and risk taking to achieve clinical benefit.
        J Clin Gastroenterol. 2009; 43: 541-550
        • Spiegel B.
        • Strickland A.
        • Naliboff B.D.
        • et al.
        Predictors of patient-assessed illness severity in irritable bowel syndrome.
        Am J Gastroenterol. 2008; 103: 2536-2543
        • Lenhart A.
        • Dong T.
        • Joshi S.
        • et al.
        Effect of exclusion diets on symptom severity and the gut microbiota in patients with irritable bowel syndrome.
        Clin Gastroenterol Hepatol. 2021;
        • Kellow J.E.
        Rome IV Diagnostic algorithms for common GI symptoms.
        Rome Foundation, Raleigh, NC2016
        • Chey W.D.
        • Kurlander J.
        • Eswaran S.
        Irritable bowel syndrome: a clinical review.
        JAMA. 2015; 313: 949-958
        • Smalley W.
        • Falck-Ytter C.
        • Carrasco-Labra A.
        • et al.
        AGA Clinical Practice Guidelines on the laboratory evaluation of functional diarrhea and diarrhea-predominant irritable bowel syndrome in adults (IBS-D).
        Gastroenterology. 2019; 157: 851-854
        • Lacy B.E.
        • Pimentel M.
        • Brenner D.M.
        • et al.
        ACG Clinical Guideline: management of irritable bowel syndrome.
        Am J Gastroenterol. 2021; 116: 17-44
        • Moayyedi P.
        • Andrews C.N.
        • MacQueen G.
        • et al.
        Canadian Association of Gastroenterology Clinical Practice Guideline for the management of irritable bowel syndrome (IBS).
        J Can Assoc Gastroenterol. 2019; 2: 6-29
        • Vasant D.H.
        • Paine P.A.
        • Black C.J.
        • et al.
        British Society of Gastroenterology guidelines on the management of irritable bowel syndrome.
        Gut. 2021; 70: 1214-1240
        • Palsson O.S.
        • Whitehead W.E.
        • van Tilburg M.A.
        • et al.
        Rome IV diagnostic questionnaires and tables for investigators and clinicians.
        Gastroenterology. 2016; 150: 1481-1491
        • Black C.J.
        • Craig O.
        • Gracie D.J.
        • et al.
        Comparison of the Rome IV criteria with the Rome III criteria for the diagnosis of irritable bowel syndrome in secondary care.
        Gut. 2021; 70: 1110-1116
        • Posserud I.
        • Syrous A.
        • Lindstrom L.
        • et al.
        Altered rectal perception in irritable bowel syndrome is associated with symptom severity.
        Gastroenterology. 2007; 133: 1113-1123
        • Chey W.Y.
        • Jin H.O.
        • Lee M.H.
        • et al.
        Colonic motility abnormality in patients with irritable bowel syndrome exhibiting abdominal pain and diarrhea.
        Am J Gastroenterol. 2001; 96: 1499-1506
        • Chey W.D.
        • Keefer L.
        • Whelan K.
        • et al.
        Behavioral and diet therapies in integrated care for patients with irritable bowel syndrome.
        Gastroenterology. 2021; 160: 47-62
        • Drossman D.A.
        • Ruddy J.
        Improving patient-provider relationships to improve health care.
        Clin Gastroenterol Hepatol. 2020; 18: 1417-1426
        • Drossman D.A.
        • Tack J.
        • Chang L.
        • et al.
        Multidimensional clinical profile for disorders of gut-brain interaction.
        Rome Foundation, Raleigh, NC2021
        • Lin L.D.
        • Chang L.
        Using the Rome IV Criteria to help manage the complex IBS patient.
        Am J Gastroenterol. 2018; 113: 453-456
        • Tu Q.
        • Heitkemper M.M.
        • Jarrett M.E.
        • et al.
        Sleep disturbances in irritable bowel syndrome: a systematic review.
        Neurogastroenterol Motil. 2017; 29
        • Drossman D.A.
        • Tack J.
        • Ford A.C.
        • et al.
        Neuromodulators for functional gastrointestinal disorders (disorders of gut-brain interaction): a Rome Foundation Working Team Report.
        Gastroenterology. 2018; 154: 1140-1171 e1
        • Weinberg D.S.
        • Smalley W.
        • Heidelbaugh J.J.
        • et al.
        American Gastroenterological Association Institute Guideline on the pharmacological management of irritable bowel syndrome.
        Gastroenterology. 2014; 147: 1146-1148
        • Camilleri M.
        Diagnosis and treatment of irritable bowel syndrome: a review.
        JAMA. 2021; 325: 865-877