Irritable Bowel Syndrome Clinical Presentation

  • Author: Jenifer K Lehrer, MD; Chief Editor: Julian Katz, MD   more...
 
Updated: May 4, 2012
 

History

A meticulous history is the key to establish a diagnosis of irritable bowel syndrome. The Rome criteria provide the construct upon which questions are based (see Diagnostic Considerations).

Altered bowel habits

Constipation variably results in complaints of hard stools of narrow caliber, painful or infrequent defecation, and intractability to laxatives. Diarrhea usually is described as small volumes of loose stool, with evacuation preceded by urgency or frequent defecation. Postprandial urgency is common, as is alternation between constipation and diarrhea. Characteristically, one feature predominates in a single patient, but significant variability exists among patients.

Abdominal pain

Descriptions are protean. Pain frequently is diffuse without radiation. Common sites of pain include the lower abdomen, specifically the left lower quadrant. Acute episodes of sharp pain are often superimposed on a more constant dull ache. Meals may precipitate pain, and defecation commonly improves pain. Defecation may not fully relieve pain, however.

Pain from presumed gas pockets in the splenic flexure may masquerade as anterior chest pain or left upper quadrant abdominal pain. This splenic flexure syndrome is demonstrable by balloon inflation in the splenic flexure and should be considered in the differential of chest or left upper quadrant abdominal pain.

Abdominal distention

Patients frequently report increased amounts of bloating and gas. Quantitative measurements fail to support this claim. People with irritable bowel syndrome may manifest increasing abdominal circumference throughout the day, as assessed by CT scan. They may also demonstrate intolerance to otherwise normal amounts of abdominal distention.

Additional symptoms consistent with irritable bowel syndrome

Clear or white mucorrhea of a noninflammatory etiology is commonly reported. Epidemiologic associations with dyspepsia, heartburn, nausea, vomiting, sexual dysfunction (including dyspareunia and poor libido), and urinary frequency and urgency have been noted. Symptoms may worsen in the perimenstrual period, and fibromyalgia is a common comorbidity. Stressor-related symptoms may be revealed with careful questioning (emphasize avoidance of stressors).

Symptoms inconsistent with irritable bowel syndrome

Symptoms not consistent with irritable bowel syndrome should alert the clinician to the possibility of an organic pathology. Inconsistent symptoms include the following:

  • Onset in middle age or older
  • Acute symptoms (irritable bowel syndrome is defined by chronicity)
  • Progressive symptoms
  • Nocturnal symptoms
  • Anorexia or weight loss
  • Fever
  • Rectal bleeding
  • Painless diarrhea
  • Steatorrhea
  • Lactose and/or fructose intolerance
  • Gluten intolerance
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Physical Examination

The patient with irritable bowel syndrome has an overall healthy appearance but may be tense or anxious. The patient may present with sigmoid tenderness or a palpable sigmoid cord.

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Criteria for Diagnosis

A consensus panel created and then updated the Rome criteria to provide a standardized diagnosis for research and clinical practice. The Rome III criteria for the diagnosis of irritable bowel syndrome[12] require that patients have had recurrent abdominal pain or discomfort at least 3 days per month during the previous 3 months that is associated with 2 or more of the following:

  • Relieved by defecation
  • Onset associated with a change in stool frequency
  • Onset associated with a change in stool form or appearance

Supporting symptoms include the following:

  • Altered stool frequency
  • Altered stool form
  • Altered stool passage (straining and/or urgency)
  • Mucorrhea
  • Abdominal bloating or subjective distention

Four bowel patterns may be seen with irritable bowel syndrome. These patterns include the following:

  • IBS-D (diarrhea predominant)
  • IBS-C (constipation predominant)
  • IBS-M (mixed diarrhea and constipation)
  • IBS-A (alternating diarrhea and constipation)

The usefulness of these subtypes is debatable. Notably, within 1 year, 75% of patients change subtypes, and 29% switch between constipation-predominant IBS and diarrhea-predominant IBS.

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Contributor Information and Disclosures
Author

Jenifer K Lehrer, MD  Attending Physician, Department of Gastroenterology and Hepatology, Aria Health System, Philadelphia

Jenifer K Lehrer, MD, is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, and American Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Gary R Lichtenstein, MD  Director of Inflammatory Bowel Disease Center, Professor, Department of Internal Medicine, University of Pennsylvania

Gary R Lichtenstein, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Specialty Editor Board

Rajeev Vasudeva, MD, FACG  Clinical Professor of Medicine, Consultants in Gastroenterology, University of South Carolina School of Medicine

Rajeev Vasudeva, MD, FACG is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, Columbia Medical Society, South Carolina Gastroenterology Association, and South Carolina Medical Association

Disclosure: Pricara Honoraria Speaking and teaching; UCB Consulting fee Consulting

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Douglas M Heuman, MD, FACP, FACG, AGAF  Chief of GI, Hepatology, and Nutrition at North Shore University Hospital/Long Island Jewish Medical Center; Professor, Department of Medicine, Hofstra North Shore-LIJ School of Medicine

Douglas M Heuman, MD, FACP, FACG, AGAF is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Physicians, and American Gastroenterological Association

Disclosure: Novartis Grant/research funds Other; Bayer Grant/research funds Other; Otsuka Grant/research funds None; Bristol Myers Squibb Grant/research funds Other; Scynexis None None; Salix Grant/research funds Other; MannKind Other

Chief Editor

Julian Katz, MD  Clinical Professor of Medicine, Drexel University College of Medicine

Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law, Medicine & Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility

Disclosure: Nothing to disclose.

References

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  6. Kassinen A, Krogius-Kurikka L, Mäkivuokko H, Rinttilä T, Paulin L, Corander J, et al. The fecal microbiota of irritable bowel syndrome patients differs significantly from that of healthy subjects. Gastroenterology. Jul 2007;133(1):24-33. [Medline].

  7. Camilleri M. Functional Gastrointestinal Disorders: Novel Insights and Treatments. Medscape General Medicine. 1999. Medscape. Available at http://www.medscape.com/viewarticle/717346. Accessed September 20, 2010.

  8. Wensaas KA, Langeland N, Hanevik K, et al. Irritable bowel syndrome and chronic fatigue 3 years after acute giardiasis: historic cohort study. Gut. Sep 12 2011;[Medline].

  9. Pimentel M, Chow EJ, Lin HC. Normalization of lactulose breath testing correlates with symptom improvement in irritable bowel syndrome. a double-blind, randomized, placebo-controlled study. Am J Gastroenterol. Feb 2003;98(2):412-9. [Medline].

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  15. Ruepert L, Quartero AO, de Wit NJ, et al. Bulking agents, antispasmodics and antidepressants for the treatment of irritable bowel syndrome. Cochrane Database Syst Rev. Aug 10 2011;CD003460. [Medline].

  16. Biesiekierski JR, Newnham ED, Irving PM, Barrett JS, Haines M, Doecke JD, et al. Gluten causes gastrointestinal symptoms in subjects without celiac disease: a double-blind randomized placebo-controlled trial. Am J Gastroenterol. Mar 2011;106(3):508-14. [Medline].

  17. [Best Evidence] Zijdenbos IL, de Wit NJ, van der Heijden GJ, Rubin G, Quartero AO. Psychological treatments for the management of irritable bowel syndrome. Cochrane Database Syst Rev. Jan 21 2009;CD006442. [Medline].

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  19. Menees SB, Maneerattannaporn M, Kim HM, Chey WD. The efficacy and safety of rifaximin for the irritable bowel syndrome: a systematic review and meta-analysis. Am J Gastroenterol. Jan 2012;107(1):28-35. [Medline].

  20. Pimentel M, Lembo A, Chey WD, et al. Rifaximin therapy for patients with irritable bowel syndrome without constipation. N Engl J Med. Jan 6 2011;364(1):22-32. [Medline].

  21. Chang L, Tong K, Ameen V. Ischemic colitis and complications of constipation associated with the use of alosetron under a risk management plan: clinical characteristics, outcomes, and incidences. Am J Gastroenterol. Apr 2010;105(4):866-75. [Medline].

  22. Psychosocial Alarm Questionnaire for the Functional GI disorders. Am J Gastro. 2010;105(4): 795-7. Appendix A.

 
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