eMedicine Specialties > Gastroenterology > Colon

Irritable Bowel Syndrome: Differential Diagnoses & Workup

Author: Jenifer K Lehrer, MD, Attending Physician, Jefferson Health System, Frankford-Torresdale Campus
Coauthor(s): Gary R Lichtenstein, MD, Director of Inflammatory Bowel Disease Center, Professor, Department of Internal Medicine, University of Pennsylvania
Contributor Information and Disclosures

Updated: Aug 9, 2009

Differential Diagnoses

Abdominal Angina
Hypothyroidism
Anxiety Disorders
Inflammatory Bowel Disease
Bacterial Overgrowth Syndrome
Lactose Intolerance
Biliary Colic
Malignant Neoplasms of the Small Intestine
Biliary Disease
Mesenteric Artery Thrombosis
Celiac Sprue
Mesenteric Venous Thrombosis
Chronic Mesenteric Ischemia
Pancreatic Cancer
Collagenous and Lymphocytic Colitis
Pancreatitis, Chronic
Colon Cancer, Adenocarcinoma
Pheochromocytoma
Endometriosis
Porphyria, Acute Intermittent
Food Allergies
Postcholecystectomy Syndrome
Gastroenteritis, Bacterial
Somatostatinomas
Gastroenteritis, Viral
Toxicity, Lead
Giardiasis
Ulcerative Colitis
Hypercalcemia
Hyperthyroidism

Other Problems to Be Considered

Fructose intolerance
Gastrinoma
Infectious colitis
Medication adverse effects
Secretory diarrhea
VIPoma

Workup

Laboratory Studies

  • A comprehensive history, a physical examination, and tailored laboratory and radiographic studies can establish a diagnosis of irritable bowel syndrome in most patients.
  • Lab studies may include the following:
    • CBC count with differential to screen for anemia, inflammation, and infection
    • A comprehensive metabolic panel to evaluate for metabolic disorders and to rule out dehydration/electrolyte abnormalities in patients with diarrhea
  • Gastrointestinal bleeding should be ruled out. A hemoccult test may be useful.
  • Microbiologic studies to consider include the following stool examinations:
    • Ova and parasites: Consider obtaining specimens for Giardia antigen as well.
    • Enteric pathogens
    • Leukocytes
    • Clostridium difficile toxin
  • The following selected studies are directed by history:
    • Breath testing: Screen for lactose and/or fructose intolerance.
    • Thyroid function tests: Screen for hyperthyroidism or hypothyroidism.
    • Serum calcium: Screen for hyperparathyroidism.
    • Erythrocyte sedimentation rate or C-reactive protein: This is a nonspecific screening test for inflammation.
    • Serologies or small bowel biopsy for celiac disease: Consider, especially in diarrhea-predominant IBS.
  • H2 breath test to exclude bacterial overgrowth may be considered in patients with diarrhea.

Imaging Studies

  • The following selected studies are directed by history:
    • Upper GI barium study with small bowel follow-through: Screen for tumor, inflammation, obstruction, and Crohn disease.
    • Double-contrast barium enema: Screen for neoplasm and inflammation.
    • Gallbladder ultrasonography: Consider this test if the patient has recurrent dyspepsia or characteristic postprandial pain.
    • Abdominal CT scan: Screen for tumors, obstruction, and pancreatic disease.

Other Tests

  • Direct a lactose-free diet for 1 week in conjunction with lactase supplements. Improvement incriminates lactose intolerance, although the patient's clinical history and response to a trial may be unreliable. Therefore, some gastroenterologists recommend a formal hydrogen breath test. Fructose intolerance must also be considered.
  • Direct a 48-hour fast. Persistent diarrhea suggests a secretory etiology.
  • Anal manometry may reveal spastic response to rectal distention or other problems.

Procedures

  • Endoscopy directed for many patients with irritable bowel syndrome includes flexible sigmoidoscopy to determine inflammation or distal obstruction.
  • The following selected studies are directed by history:
    • Esophagogastroduodenoscopy with possible biopsy - Indicated for a patient with persistent dyspepsia or if weight loss or symptoms suggest malabsorption or if celiac disease is a concern
    • Colonoscopy - Indicated for patients with warning signs, such as bleeding; anemia; chronic diarrhea; older age; history of colon polyps; cancer in the patient or first-degree relatives; or constitutional symptoms, such as weight loss or anorexia. A screening colonoscopy should be performed according to published guidelines.

Histologic Findings

Research suggests that neuronal degeneration and myenteric plexus lymphocytosis may exist in the proximal jejunum. Additionally, colonic lymphocytosis and enteroendocrine cell hyperplasia have been demonstrated in some patients.

More on Irritable Bowel Syndrome

Overview: Irritable Bowel Syndrome
Differential Diagnoses & Workup: Irritable Bowel Syndrome
Treatment & Medication: Irritable Bowel Syndrome
Follow-up: Irritable Bowel Syndrome
References
Further Reading
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References

  1. Manning AP, Thompson WG, Heaton KW, et al. Towards positive diagnosis of the irritable bowel. Br Med J. Sep 2 1978;2(6138):653-4. [Medline].

  2. Kassinen A, Krogius-Kurikka L, Mäkivuokko H, 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].

  3. Camilleri M. Functional Gastrointestinal Disorders: Novel Insights and Treatments. Available at: http://www.medscape.com/viewarticle/407938. Medscape General Medicine. 1999;[Full Text].

  4. 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].

  5. Shepherd SJ, Parker FC, Muir JG, et al. Dietary triggers of abdominal symptoms in patients with irritable bowel syndrome: randomized placebo-controlled evidence. Clin Gastroenterol Hepatol. Jul 2008;6(7):765-71. [Medline].

  6. Miller V, Hopkins L, Whorwell PJ. Suicidal ideation in patients with irritable bowel syndrome. Clin Gastroenterol Hepatol. Dec 2004;2(12):1064-8. [Medline].

  7. Berstad A. Today's therapy of functional gastrointestinal disorders--does it help?. Eur J Surg Suppl. 1998;92-7. [Medline].

  8. Camilleri M, McKinzie S, Busciglio I, et al. Prospective study of motor, sensory, psychologic, and autonomic functions in patients with irritable bowel syndrome. Clin Gastroenterol Hepatol. Jul 2008;6(7):772-81. [Medline].

  9. Cash BD, Chey WD. Advances in the management of irritable bowel syndrome. Curr Gastroenterol Rep. Dec 2003;5(6):468-75. [Medline].

  10. Corazziari E. Role of opioid ligands in the irritable bowel syndrome. Can J Gastroenterol. Mar 1999;13 Suppl A:71A-75A. [Medline].

  11. Dalton CB, Drossman DA, Hathaway JM, et al. Perceptions of physicians and patients with organic and functional gastrointestinal diagnoses. Clin Gastroenterol Hepatol. Feb 2004;2(2):121-6. [Medline].

  12. Drossman DA, Whitehead WE, Camilleri M. Irritable bowel syndrome: a technical review for practice guideline development. Gastroenterology. Jun 1997;112(6):2120-37. [Medline].

  13. Dunlop SP, Jenkins D, Neal KR, et al. Relative importance of enterochromaffin cell hyperplasia, anxiety, and depression in postinfectious IBS. Gastroenterology. Dec 2003;125(6):1651-9. [Medline].

  14. Evans PR, Bak YT, Kellow JE. Effects of oral cisapride on small bowel motility in irritable bowel syndrome. Aliment Pharmacol Ther. Oct 1997;11(5):837-44. [Medline].

  15. Evans PR, Bak YT, Shuter B, et al. Gastroparesis and small bowel dysmotility in irritable bowel syndrome. Dig Dis Sci. Oct 1997;42(10):2087-93. [Medline].

  16. Evans PR, Bennett EJ, Bak YT, et al. Jejunal sensorimotor dysfunction in irritable bowel syndrome: clinical and psychosocial features. Gastroenterology. Feb 1996;110(2):393-404. [Medline].

  17. Fukudo S, Nomura T, Hongo M. Impact of corticotropin-releasing hormone on gastrointestinal motility and adrenocorticotropic hormone in normal controls and patients with irritable bowel syndrome. Gut. Jun 1998;42(6):845-9. [Medline].

  18. Gui XY. Mast cells: a possible link between psychological stress, enteric infection, food allergy and gut hypersensitivity in the irritable bowel syndrome. J Gastroenterol Hepatol. Oct 1998;13(10):980-9. [Medline].

  19. Heitkemper MM, Jarrett ME, Levy RL, et al. Self-management for women with irritable bowel syndrome. Clin Gastroenterol Hepatol. Jul 2004;2(7):585-96. [Medline].

  20. Jain AP, Gupta OP, Jajoo UN, et al. Clinical profile of irritable bowel syndrome at a rural based teaching hospital in central India. J Assoc Physicians India. May 1991;39(5):385-6. [Medline].

  21. Johanson JF, Panas R, Holland PC. A dose-ranging, double-blind, placebo-controlled study of lubiprostone in subjects with irritable bowel syndrome and constipation (constipation-predominant IBS). Gastroenterology. 2006;130:A-25 [Abstract 131].

  22. Kane SV, Sable K, Hanauer SB. The menstrual cycle and its effect on inflammatory bowel disease and irritable bowel syndrome: a prevalence study. Am J Gastroenterol. Oct 1998;93(10):1867-72. [Medline].

  23. Kapoor KK, Nigam P, Rastogi CK, et al. Clinical profile of irritable bowel syndrome. Indian J Gastroenterol. Jan 1985;4(1):15-6. [Medline].

  24. Kellow JE, Phillips SF, Miller LJ, et al. Dysmotility of the small intestine in irritable bowel syndrome. Gut. Sep 1988;29(9):1236-43. [Medline].

  25. Kennedy TM, Jones RH, Hungin AP, et al. Irritable bowel syndrome, gastro-oesophageal reflux, and bronchial hyper-responsiveness in the general population. Gut. Dec 1998;43(6):770-4. [Medline].

  26. Longstreth GF, Thompson WG, Chey WD, et al. Functional bowel disorders. Gastroenterology. Apr 2006;130(5):1480-91. [Medline].

  27. Longstreth GF, Wolde-Tsadik G. Irritable bowel-type symptoms in HMO examinees. Prevalence, demographics, and clinical correlates. Dig Dis Sci. Sep 1993;38(9):1581-9. [Medline].

  28. Maxwell PR, Mendall MA, Kumar D. Irritable bowel syndrome. Lancet. Dec 6 1997;350(9092):1691-5. [Medline].

  29. Mayer EA, Chang L, Lembo T. Brain-gut interactions: implications for newer therapy. Eur J Surg Suppl. 1998;50-5. [Medline].

  30. Mertz H, Fullerton S, Naliboff B, et al. Symptoms and visceral perception in severe functional and organic dyspepsia. Gut. Jun 1998;42(6):814-22. [Medline].

  31. Mertz HR. New concepts of irritable bowel syndrome. Curr Gastroenterol Rep. Oct 1999;1(5):433-40. [Medline].

  32. [Best Evidence] Pimentel M, Park S, Mirocha J, et al. The effect of a nonabsorbed oral antibiotic (rifaximin) on the symptoms of the irritable bowel syndrome: a randomized trial. Ann Intern Med. Oct 17 2006;145(8):557-63. [Medline].

  33. Rajagopalan M, Kurian G, John J. Symptom relief with amitriptyline in the irritable bowel syndrome. J Gastroenterol Hepatol. Jul 1998;13(7):738-41. [Medline].

  34. Rodríguez LA, Ruigómez A. Increased risk of irritable bowel syndrome after bacterial gastroenteritis: cohort study. BMJ. Feb 27 1999;318(7183):565-6. [Medline].

  35. Salvioli B, Serra J, Azpiroz F, et al. Impaired small bowel gas propulsion in patients with bloating during intestinal lipid infusion. Am J Gastroenterol. Aug 2006;101(8):1853-7. [Medline].

  36. Sharara AI, Aoun E, Abdul-Baki H, et al. A randomized double-blind placebo-controlled trial of rifaximin in patients with abdominal bloating and flatulence. Am J Gastroenterol. Feb 2006;101(2):326-33. [Medline].

  37. Spiller RC. Postinfectious irritable bowel syndrome. Gastroenterology. May 2003;124(6):1662-71. [Medline].

  38. Tolliver BA, Herrera JL, DiPalma JA. Evaluation of patients who meet clinical criteria for irritable bowel syndrome. Am J Gastroenterol. Feb 1994;89(2):176-8. [Medline].

  39. Törnblom H, Lindberg G, Nyberg B, et al. Full-thickness biopsy of the jejunum reveals inflammation and enteric neuropathy in irritable bowel syndrome. Gastroenterology. Dec 2002;123(6):1972-9. [Medline].

  40. Zolotukhina TV. [Determination of the sex and karyotype of the intrauterine fetus]. Akush Ginekol (Mosk). Jan 1972;48(1):38-40. [Medline].

  41. Zuckerman MJ, Guerra LG, Drossman DA, et al. Comparison of bowel patterns in Hispanics and non-Hispanic whites. Dig Dis Sci. Aug 1995;40(8):1763-9. [Medline].

  42. Hunt MG, Moshier S, Milonova M. Brief cognitive-behavioral internet therapy for irritable bowel syndrome. Behav Res Ther. Sep 2009;47(9):797-802. [Medline].

  43. Reitblat T, Zamir D, Polishchuck I, et al. Patients treated by tegaserod for irritable bowel syndrome with constipation showed significant improvement in fibromyalgia symptoms. A pilot study. Clin Rheumatol. Sep 2009;28(9):1079-82. [Medline].

  44. [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].

  45. [Best Evidence] Ford AC, Talley NJ, Schoenfeld PS, Quigley EM, Moayyedi P. Efficacy of antidepressants and psychological therapies in irritable bowel syndrome: systematic review and meta-analysis. Gut. Mar 2009;58(3):367-78. [Medline].

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Further Reading

Additional resources on asthma are available at Medscape’s Irritable Bowel Syndrome and Chronic Constipation Resource Center.

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Keywords

irritable bowel syndrome, IBS, irritable bowel disease, IBD, functional bowel disease, irritable colon, mucous colitis, nervous bowel, spastic bowel, spastic colitis, postprandial abdominal pain, stomach pain, mucorrhea, Manning criteria, abdominal pain, abdominal colic, Rome criteria, altered bowel habits, postprandial urgency, constipation, diarrhea, bloating, colonic dysmotility, colon motility disturbances

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Contributor Information and Disclosures

Author

Jenifer K Lehrer, MD, Attending Physician, Jefferson Health System, Frankford-Torresdale Campus
Jenifer K Lehrer, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, and Pennsylvania Medical Society
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.

Medical Editor

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

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Douglas M Heuman, MD, FACP, FACG, AGAF, Chief of Hepatology, Hunter Holmes McGuire Department of Veterans Affairs Medical Center; Professor, Department of Internal Medicine, Division of Gastroenterology, Virginia Commonwealth University 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: Nothing to disclose.

CME Editor

Alex J Mechaber, MD, FACP, Associate Dean for Undergraduate Medical Education, Associate Professor of Medicine, University of Miami Miller School of Medicine
Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD, Clinical Professor of Medicine, Drexel University College of Medicine; Consulting Staff, Department of Medicine, Section of Gastroenterology and Hepatology, Hospital of the Medical College of Pennsylvania
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 and Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

 
 
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