Signs and Symptoms
- Abdominal pain:
- Triggered by meals
- Relief with defecation
- Altered stool frequency
- Altered stool consistency
- Bloating or distention
- Passage of clear or white mucus
- Feeling of incomplete emptying
ALERT |
- Consider further diagnostic workup if any of the following “alarm” features are present:
- Onset >50
- Acute or progressive symptoms
- Nocturnal symptoms
- Unintentional weight loss
- Iron-deficiency anemia
- Hematochezia
- Fever
|
History
- Rome IV diagnostic criteria: Recurrent abdominal pain at least 1 d per wk in the last 3 mo associated with ≥2 of:
- Related to defecation (increased or improved pain)
- A change in frequency of stool
- A change in form (appearance) of stool
- Other symptoms consistent with IBS:
- Abdominal distention or bloating
- Passage of mucus in stools
- Altered stool passage (straining, urgency, or feeling of incomplete evacuation)
- Female > male, higher in those who seek care
Physical Exam
- Usually well appearing with normal physical
- May be anxious
- May have tender sigmoid or palpable sigmoid cord
Essential Workup
Clinical diagnosis: Careful history crucial
Diagnostic Tests & Interpretation
Lab
- Typically no abnormalities found
- Labs to be considered (to exclude other pathology):
- CBC CRP to screen for IBD
- Outpatient celiac serologic testing
- Outpatient fecal calprotectin level
Imaging
Only necessary if excluding emergent pathology
Diagnostic Procedures/Surgery
Colonoscopy/flexible sigmoidoscopy for select patients (outpatient)
Differential Diagnosis
- Celiac disease
- Inflammatory bowel disease:
- Infectious enteritis
- Small-intestinal bacterial overgrowth
- Lactose intolerance
- Colorectal cancer
- Diverticular disease
- Biliary disease
- Diabetic gastroparesis
- Pancreatitis
- Thyroid malfunction
- Obstruction
- Peptic ulcer disease
- Acute intermittent porphyria
Prehospital
No specific treatment required
Initial Stabilization/Therapy
- Symptomatic treatment
- Pain control
- Administer fluids if dehydrated
ED Treatment/Procedures
- Empathetic approach and therapeutic physician-patient relationship is most important
- Exercise:
- Diet:
- Increase soluble fiber (psyllium husk)
- Exclusion diets starting with gluten or lactose can be empirically considered
- Exclude gas-producing foods
- Low-FODMAP (fermentable sugar present in stone fruits, legumes, lactose, etc.)
- Constipation symptoms:
- High-fiber diet, fiber supplements
- Osmotic laxatives
- Lubiprostone, linaclotide, and plecanatide increase intestinal secretion, decreasing transit time
- Diarrhea symptoms:
- Antidiarrheal agents (data showing efficacy limited)
- Eluxadoline work on mu receptors
- Alosetron (severe IBS-D not responsive to initial therapy). It can induce constipation and ischemic colitis. Need special prescribing authority
- Abdominal pain and bloating:
- Antispasmodics like hyoscyamine and dicyclomine and even peppermint oil may be helpful short term
- Rifaximin, a minimally absorbed antibiotic, has shown some benefit for IBS without constipation
- Probiotics bifidobacteria and lactobacilli may have benefit
- Antidepressants may be helpful. TCAs have anticholinergic properties and slow intestinal transit. They have shown some benefit. Benefit from other antidepressants including SSRIs is unclear
- Psychological therapies appear effective
Medication
First Line
- Dicyclomine: 10-20 mg PO q6h
- Hyoscyamine: 0.125-0.25 mg PO q4h p.r.n
- Osmotic laxatives
- Antidiarrheals
Second Line
- Amitriptyline: 25 mg PO at bedtime
- Rifaximin 550 mg PO t.i.d × 14 d
- Lubiprostone 8 mcg PO b.i.d
- Linaclotide 290 mcg PO per day
- Eluxadoline 100 mg PO b.i.d
- Bifidobacteria or Lactobacillus probiotic
Disposition
Admission Criteria
Uncertain diagnosis with suspicion of an emergent abdominal condition
Discharge Criteria
Almost all patients can be managed as outpatients
Issues for Referral
Some may benefit from GI or psychiatric referral
Follow-up Recommendations
Most important is follow-up with primary care physician to foster a therapeutic physician-patient relationship
- CheyWD, Kurland erJ, EswaranS. Irritable bowel syndrome: A clinical review . JAMA. 2015;313(9):949-958.
- FordAC, LaceBE, TalleyNJ. Irritable bowel syndrome . N Engl J Med. 2017;376:2566-2578.
- LacyBE, PatelNK. Rome criteria and a diagnostic approach to irritable bowel syndrome . J Clin Med. 2017;6(11):99.
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