eMedicine Specialties > Gastroenterology > Colon
Irritable Bowel Syndrome: Treatment & Medication
Updated: Aug 9, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
- Successful management relies on a strong patient-provider relationship.
- Reassure the patient that the absence of an organic pathology indicates a normal life expectancy.
- Emphasize the expected chronicity of symptoms with periodic exacerbations.
- Teach the patient to acknowledge stressors and to use avoidance techniques.
Consultations
- Consider psychiatric referral. Previous evidence has supported improvement in GI symptoms with successful treatment of psychiatric comorbidities, but 2 studies indicate caution should be used when interpreting such data.
- Zijdenbos et al conducted a meta-analysis of 25 randomized trials consisting of single psychologic interventions with usual care or mock intervention in patients older than 16 years for the years 1966-2008.{Ref44} The treatment modalities evaluated were psychologic interventions as a group and cognitive behavioral therapy (measuring improvements in abdominal pain and quality of life, relative to usual care and placebo); interpersonal psychotherapy; and relaxation/stress management. Long-term results were also assessed. The investigators noted that differences among studies and quality issues made drawing conclusions difficult; however, they suggested that although cognitive behavioral therapy and interpersonal psychotherapy may be effective immediately post treatment completion, there was no convincing evidence for sustained treatment effects after completion of treatment for any treatment modality. Thus, Zijdenbos et al recommended that future research should focus on current IBS treatment guidelines and their long-term effects.44
- Ford et al reached similar conclusions regarding the use of psychologic interventions in IBS. They also performed a systematic review and meta-analysis of randomized controlled trials (up to May 2008) in adults with IBS; however, their selection criteria included trials comparing antidepressants with placebo as well as those comparing psychologic therapies with control therapy or usual care.45 The investigators noted that the quality of studies were generally good for those involving antidepressants but poor for those involving psychologic therapy. Ford et al concluded that antidepressants are effective for IBS treatment, but despite the fact that the available data suggest psychologic therapies may be of comparable efficacy, there is less high-quality evidence for the routine use of psychologic therapies in patients with IBS.45
Diet
- Fiber supplementation may improve symptoms of constipation and diarrhea. Individualize the treatment because few patients experience exacerbated bloating and distention with high-fiber diets. Polycarbophil compounds (eg, Citrucel, FiberCon) may produce less flatulence than psyllium compounds (eg, Metamucil).
- The data regarding the effectiveness of fiber are controversial because 40-70% of patients improve with placebo.
- Judicious water intake in patients who predominantly experience constipation is recommended.
- Caffeine avoidance may limit anxiety and symptom exacerbation.
- Legume avoidance may decrease abdominal bloating.
- Lactose and/or fructose should be limited or avoided in patients with these contributing disorders. Take care to supplement calcium in patients limiting lactose intake.
Activity
No limitation is recommended.
Medication
The selection of pharmacologic treatment remains symptom directed.
The nonabsorbed antibiotic rifaximin (<0.4%) is a broad-spectrum antibiotic specific for enteric pathogens (ie, gram-positive, gram-negative, aerobic and anaerobic) of the GI tract. Rifaximin is a structural analog. It binds to a beta-subunit of bacterial DNA-dependent RNA polymerase, thereby inhibiting RNA synthesis. It is indicated for Escherichia coli (enterotoxigenic and enteroaggregative strains) associated with travelers' diarrhea. Rifaximin has been studied in patients with irritable bowel syndrome and is believed to improve the symptoms of bloating, diarrhea, abdominal pain, and constipation.
Anticholinergics
Are antispasmodics that inhibit intestinal smooth-muscle depolarization at the muscarinic receptor.
Dicyclomine hydrochloride (Bentyl)
This drug decreases fecal urgency and pain. It is useful with diarrhea-predominant symptoms. Blocks the action of acetylcholine at parasympathetic sites in secretory glands, smooth muscle, and CNS. Adverse effects are dose dependent.
Adult
10-40 mg PO qid ac or at onset of pain
Pediatric
Not established
May increase anticholinergic effects with concurrent administration of amantadine, class I antiarrhythmics, antihistamines, antipsychotics, benzodiazepines, MAOIs, narcotics, nitrates, sympathomimetics, and tricyclic antidepressants; dicyclomine may increase serum digoxin concentration; antacids may interfere with absorption of dicyclomine
Documented hypersensitivity; obstructive uropathy; myasthenia gravis; glaucoma; GI tract obstruction; paralytic ileus; toxic megacolon
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution when administering to patients with hepatic or renal insufficiency, cardiovascular disease, urinary tract obstruction, ulcerative colitis, GI obstruction, hyperthyroidism, or hypertension; may cause sedation, constipation, urinary retention, tachycardia, blurred vision, xerostomia, or dizziness
Hyoscyamine sulfate (Levsin)
Blocks action of acetylcholine at parasympathetic sites in smooth muscle, secretory glands, and the CNS, which, in turn, has antispasmodic effects. Decreases fecal urgency and pain. Useful with diarrhea-predominant symptoms.
Adult
0.125-0.25 mg PO q4h or prn; not to exceed 1.5 mg/d (12 tab/d)
Pediatric
<2 years: Not recommended
2-12 years: 0.0625-0.125 mg (1/2-1 tab) PO q4h or prn; not to exceed 0.75 mg/d (6 tab/d)
>2 years: Administer as in adults
May increase anticholinergic effects with amantadine, class I antiarrhythmics, antihistamines, antipsychotics, benzodiazepines, MAOIs, narcotics, nitrates, sympathomimetics, and tricyclic antidepressants; may increase serum digoxin concentration; antacids may interfere with absorption
Documented hypersensitivity; obstructive uropathy; myasthenia gravis; glaucoma; GI tract obstruction; paralytic ileus; toxic megacolon
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in elderly patients; some products contain sodium metabisulfite, which can cause allergic-type reactions; may cause sedation, constipation, urinary retention, tachycardia, blurred vision, xerostomia, or dizziness
Antidiarrheals
Are nonabsorbable synthetic opioids. They prolong GI transit time and decrease secretion via peripheral µ-opioid receptors. They reduce visceral nociception via afferent pathway inhibition.
Diphenoxylate hydrochloride 2.5 mg with atropine sulfate 0.025 mg (Lomotil)
Drug combination that consists of diphenoxylate, which is a constipating meperidine congener, and atropine to discourage abuse. Inhibits excessive GI propulsion and motility. It may exacerbate constipation.
Adult
1-2 tab PO qid ac
Pediatric
<2 years: Not recommended
2-5 years: 2 mg PO tid
5-8 years: 2 mg PO qid
8-12 years: 2 mg PO 5 times/d
>12 years: Administer as in adults
May delay metabolism of drugs in liver; CNS depressants, MAOIs, and antimuscarinic agents may increase toxicity of this drug combination; diphenoxylate HCl may potentiate the action of barbiturates, tranquilizers, and alcohol; atropine sulfate interacts with MAOIs
Documented hypersensitivity; narrow-angle glaucoma; hepatic insufficiency; advanced hepatorenal disease; pseudomembranous colitis; enterotoxigenic infections
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
In young children, dehydration may influence variability of response and predispose patient to delayed diphenoxylate intoxication; caution in patients with ulcerative colitis; a decrease in intestinal motility may be detrimental to patients with diarrhea resulting from Shigella, Salmonella, and toxigenic strains of E coli; may cause sedation, constipation, urinary retention, tachycardia, blurred vision, xerostomia, dizziness, or respiratory depression
Loperamide (Imodium)
Acts on intestinal muscles to inhibit peristalsis and to slow intestinal motility. Prolongs movement of electrolytes and fluid through bowel and increases viscosity and loss of fluids and electrolytes. Available over the counter. Improves stool frequency and consistency, reduces abdominal pain and fecal urgency, and may exacerbate constipation.
Adult
4 mg PO after first loose stool initially; then 2 mg after each subsequent stool; not to exceed 16 mg/d
Pediatric
Maintenance: 0.1 mg/kg PO after each loose stool, not to exceed initial dose
Chronic diarrhea: 0.08-0.24 mg/kg/d divided bid/tid; not to exceed 2 mg/dose
Phenothiazines, tricyclic antidepressants, and CNS depressants may increase loperamide toxicity
Documented hypersensitivity; diarrhea resulting from infections; pseudomembranous colitis
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Discontinue use if no clinical improvement in 48 h; because loperamide primarily metabolized in liver, monitor for CNS toxicity in patients with hepatic insufficiency; do not use medication if high fever or blood in stool coincides with diarrhea
Tricyclic Antidepressants
Provide antidepressive and analgesic properties. Various agents have efficacy; much research has concentrated on imipramine and amitriptyline (off-label use).
Imipramine (Tofranil)
This drug provides a visceral analgesic effect by increasing pain threshold in the gut. It prolongs oral-cecal transit time, reduces abdominal pain, mucorrhea, and stool frequency, and increases global well being variably in studies. The effect at doses subtherapeutic for antidepressive actions suggests an independent mechanism.
Adult
10-100 mg/d PO; start low and titrate as necessary
Pediatric
Not recommended
Increases toxicity of sympathomimetic agents, such as isoproterenol and epinephrine, by potentiating effects and inhibiting antihypertensive effects of clonidine
Documented hypersensitivity; narrow-angle glaucoma; in acute recovery phase following myocardial infarction; avoid in patients taking MAOIs or fluoxetine or in patients who took them in the previous 2 weeks
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
May impair mental or physical abilities required for performance of potentially hazardous tasks; caution in cardiovascular disease, seizure disorders, urinary retention, hyperthyroidism, or receiving thyroid replacement; may cause sedation, confusion, constipation, tachycardia, AV conduction delay, orthostasis, blurred vision, xerostomia
Amitriptyline (Elavil)
This drug provides a visceral analgesic effect by increasing pain threshold in the gut. Prolongs oral-cecal transit time, reduces abdominal pain, mucorrhea, and stool frequency, and increases global well-being variably in studies. The effect at doses subtherapeutic for antidepressive actions suggests an independent mechanism.
Adult
10-100 mg/d PO; start low and titrate as necessary
Pediatric
Not recommended
Phenobarbital may decrease effects; coadministration with CYP2D6 enzyme system inhibitors (eg, cimetidine, quinidine) may increase amitriptyline levels; amitriptyline inhibits hypotensive effects of guanethidine; may interact with thyroid medications, alcohol, CNS depressants, barbiturates, and disulfiram
Documented hypersensitivity; patient has taken MAOIs in past 14 d; history of seizures, cardiac arrhythmias, glaucoma, or urinary retention
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in cardiac conduction disturbances, history of hyperthyroidism, and renal or hepatic impairment; avoid using in elderly persons; may cause sedation, confusion, constipation, urinary retention, tachycardia, AV conduction delay, orthostasis, blurred vision, xerostomia, or dizziness; may provoke psychosis in schizophrenics
Prokinetics
Are promotility agents, proposed for use with constipation-predominant symptoms. Unfortunately, cisapride availability is restricted in the United States, and other motility agents, such as metoclopramide, domperidone, and erythromycin, have not yielded consistent benefits in patients with irritable bowel syndrome.
Tegaserod marketing was temporarily withdrawn from the US market in March 2007; however, as of July 27, 2007, restricted use of tegaserod is now permitted via a treatment investigational new drug (IND) protocol. The treatment IND protocol will allow tegaserod treatment of irritable bowel syndrome with constipation (IBS-C) or chronic idiopathic constipation (CIC) in women younger than 55 years who meet specific guidelines. Its use is further restricted to those in critical need who have no known or preexisting heart disease.
In early 2007, tegaserod marketing was suspended because of a meta-analysis of safety data pooled from 29 clinical trials that involved more than 18,000 patients. The results showed an excess number of serious cardiovascular adverse events, including angina, myocardial infarction, and stroke, in those taking tegaserod compared with placebo. In each study, patients were assigned at random to either tegaserod or placebo. Tegaserod was taken by 11,614 patients, and placebo was taken by 7,031 patients. The average age of patients in these studies was 43 years, and most patients (ie, 88%) were women. Serious and life-threatening cardiovascular adverse effects occurred in 13 patients (0.1%) treated with tegaserod; among these, 4 patients had a heart attack (1 died), 6 had unstable angina, and 3 had a stroke. Among the patients taking placebo, only 1 (0.01%) had symptoms suggesting the beginning of a stroke that went away without complication.
For more information, see the FDA MedWatch Product Safety Alert.
Cisapride monohydrate (Propulsid)
Available only through an investigational limited access program by Janssen Pharmaceutical. Perform 12-lead ECG prior to administration, and do not initiate treatment if QTc value exceeds 450 milliseconds. This information is maintained for those who can acquire cisapride through this program. This is a serotonin receptor agonist (5-HT4) and antagonist (5-HT3) that promotes acetylcholine release at the myenteric plexus. Accelerates GI transit, thus increasing stool frequency and improving consistency.
Adult
5-20 mg PO qac and hs 15-30 min ac
Pediatric
Not established
Fatal ventricular arrhythmia in conjunction with other medications that inhibit cytochrome P-450 3A4 (certain macrolide antibiotics, antifungals, antidepressant, protease inhibitors, antipsychotics, class IA and III antiarrhythmics)
Concomitant administration of medications is metabolized by cytochrome P-450; do not use in GI hemorrhage, mechanical bowel obstruction, or perforation in which enhanced GI motility may be harmful; do not use if QT interval exceeds 450 milliseconds; avoid in hypokalemia, hypocalcemia, and hypomagnesemia
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Potentiates the sedative effects of benzodiazepines and alcohol
Tegaserod (Zelnorm)
Available in US by restricted treatment IND for irritable bowel syndrome with constipation (IBS-C) or chronic idiopathic constipation (CIC) in women younger than 55 years who meet specific guidelines. Used for the treatment of women with irritable bowel syndrome when constipation is the predominant symptom. A selective partial agonist of the serotonin-4 (5HT4) receptor and possesses GI prokinetic activity. Tegaserod has been shown to promote clearance of gas in the small bowel.
Adult
Women: 6 mg PO bid 30 min ac for 4-6 wk; in patients who respond to treatment, an additional 4-6 wk of therapy may be considered
Men: Not established
Pediatric
Not established
None reported
Documented hypersensitivity; moderate or severe renal impairment; history of bowel obstruction, symptomatic gallbladder disease, suspected sphincter of Oddi dysfunction, or abdominal adhesions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
In April 2004, in response to postmarketing reports, the FDA issued an advisory regarding serious side effects of tegaserod use; the advisory indicates that severe diarrhea with dehydration requiring hospitalization, syncope and hypotension, and intestinal ischemia, have been reported with tegaserod use; tegaserod should not be used in patients with diarrhea and should be discontinued if any signs or symptoms of these complications arise
Serotonin (5-HT3) Receptor Antagonists
Inhibit activation of nonselective cation channels, which modulate the enteric nervous system.
Alosetron (Lotronex)
A potent and selective antagonist of the serotonin 5-HT3 receptor type. 5-HT3 receptors are extensively located on enteric neurons of the GI tract, and stimulation causes hypersensitivity and hyperactivity of the intestine. Alosetron blocks these receptors and thus is effective in controlling irritable bowel syndrome symptoms. It is approved only for treatment of women with severe chronic diarrhea-predominant IBS who have not responded to conventional irritable bowel syndrome therapy. Fewer than 5% of irritable bowel syndrome cases are considered severe, and only a fraction of severe cases are diarrhea-predominant IBS. Limiting its use to this severely affected population is intended to maximize the benefit-to-risk ratio. The drug was previously removed from the US market but was reintroduced with new restrictions approved by the FDA on June 7, 2002. Restrictions are because of serious and unpredictable GI adverse events (including some that resulted in death) reported in association with its use following its original approval in February 2000.
Adult
Women: 1 mg PO qd for 4 wk initially, may increase to 1 mg PO bid if qd dose does not control symptoms; discontinue if inadequate response to 1 mg bid after 4 wk
Men: Not established
Pediatric
Not established
Substrate of CYP-450 isoenzymes 2C9, 3A4 (minor), and 1A2 (minor); coadministration with isoenzyme inhibitors (eg, cimetidine, fluvoxamine, fluoxetine, sertraline, metronidazole, omeprazole, co-trimoxazole) may decrease elimination and increase risk of toxicity; coadministration with isoenzyme inducers (eg, phenobarbital, fluconazole, carbamazepine, phenytoin) may increase clearance
Documented hypersensitivity; history of constipation, intestinal obstruction, stricture, toxic megacolon, GI perforation, adhesions, ischemic colitis, impaired intestinal circulation, thrombophlebitis, hypercoagulable state, Crohn disease, ulcerative colitis, or diverticulitis
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Discontinue immediately if serious GI adverse events occur (eg, ischemic colitis, serious complications of constipation), these adverse effects have resulted in hospitalization, blood transfusion, surgery, and death; constipation is a dose-related adverse effect; elderly patients are more prone to the GI risks; caution in hepatic insufficiency (decrease dose); pharmacists may only dispense prescriptions that display a prescribing program sticker affixed by an enrolled clinician, and must distribute a copy of the FDA-approved medication guide with each prescription; to enroll in the prescribing program call GlaxoSmithKline at 1-888-825-5249 or visit www.Lotronex.com
Chloride-Channel Activator
These agents enhance chloride-rich intestinal fluid secretions without altering sodium and potassium concentrations in the serum.
Lubiprostone (Amitiza)
Activates chloride channels on the apical part of the small bowel epithelium. As a result, chloride ions are secreted. Sodium and water passively diffuse into the lumen to maintain isotonicity.
This medication is FDA approved for use in idiopathic constipation.
Studies have shown effectiveness over 12 weeks in patients with constipation-predominant IBS as well.
Adult
24 mcg PO bid with food
Pediatric
Not established
Data limited, none reported
Documented hypersensitivity; history of mechanical GI obstruction; severe diarrhea
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Common adverse effects include headache, nausea, diarrhea, abdominal pain, and abdominal distension; discontinue if diarrhea persists
Bulk-Forming Laxatives
May use these agents as fiber supplementation to improve symptoms of constipation and diarrhea. Use is controversial. These products are made of natural and semisynthetic hydrophilic polysaccharides and cellulose derivatives that dissolve or swell in the intestinal fluid, forming emollient gels that facilitate passage of intestinal contents and stimulate peristalsis.
Methylcellulose (Citrucel)
Promotes bowel evacuation by forming a viscous liquid and promoting peristalsis.
Adult
1-2 wafers, 1-2 packets, or 1-2 rounded teaspoonfuls PO qd/tid dissolved in 240 mL of liquid
Pediatric
<6 years: Not recommended
6-12 years: 1/2-1 rounded teaspoonful PO qd/tid dissolved in 120 mL of liquid
>12 years: Administer as in adults
Psyllium may decrease absorption and thus effects of salicylates, nitrofurantoin, tetracyclines, and diuretics
Documented hypersensitivity; fecal impaction, intestinal obstruction, undiagnosed abdominal pain
Pregnancy
A - Fetal risk not revealed in controlled studies in humans
Precautions
Caution in patients diagnosed with intestinal adhesions, ulcers, or stenosis
Psyllium (Metamucil, Fiberall, Reguloid, Konsyl)
Promotes bowel evacuation by forming viscous liquid and inducing peristalsis.
Adult
1-2 wafers, 1-2 packets, or 1-2 rounded teaspoonfuls PO qd/tid dissolved in 240 mL of liquid
Pediatric
<6 years: Not recommended
6-12 years: 1/2-1 rounded teaspoonful PO qd/tid dissolved in 120 mL of liquid
>12 years: Administer as in adults
May decrease absorption and effects of salicylates, nitrofurantoin, tetracyclines, and diuretics
Documented hypersensitivity; fecal impaction, intestinal obstruction, or undiagnosed abdominal pain
Pregnancy
A - Fetal risk not revealed in controlled studies in humans
Precautions
Caution in intestinal adhesions, ulcers, or stenosis
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 |
| « Previous Page | Next Page » |
References
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].
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].
Camilleri M. Functional Gastrointestinal Disorders: Novel Insights and Treatments. Available at: http://www.medscape.com/viewarticle/407938. Medscape General Medicine. 1999;[Full Text].
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].
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].
Miller V, Hopkins L, Whorwell PJ. Suicidal ideation in patients with irritable bowel syndrome. Clin Gastroenterol Hepatol. Dec 2004;2(12):1064-8. [Medline].
Berstad A. Today's therapy of functional gastrointestinal disorders--does it help?. Eur J Surg Suppl. 1998;92-7. [Medline].
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].
Cash BD, Chey WD. Advances in the management of irritable bowel syndrome. Curr Gastroenterol Rep. Dec 2003;5(6):468-75. [Medline].
Corazziari E. Role of opioid ligands in the irritable bowel syndrome. Can J Gastroenterol. Mar 1999;13 Suppl A:71A-75A. [Medline].
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].
Drossman DA, Whitehead WE, Camilleri M. Irritable bowel syndrome: a technical review for practice guideline development. Gastroenterology. Jun 1997;112(6):2120-37. [Medline].
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].
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].
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].
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].
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].
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].
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].
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].
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].
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].
Kapoor KK, Nigam P, Rastogi CK, et al. Clinical profile of irritable bowel syndrome. Indian J Gastroenterol. Jan 1985;4(1):15-6. [Medline].
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].
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].
Longstreth GF, Thompson WG, Chey WD, et al. Functional bowel disorders. Gastroenterology. Apr 2006;130(5):1480-91. [Medline].
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].
Maxwell PR, Mendall MA, Kumar D. Irritable bowel syndrome. Lancet. Dec 6 1997;350(9092):1691-5. [Medline].
Mayer EA, Chang L, Lembo T. Brain-gut interactions: implications for newer therapy. Eur J Surg Suppl. 1998;50-5. [Medline].
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].
Mertz HR. New concepts of irritable bowel syndrome. Curr Gastroenterol Rep. Oct 1999;1(5):433-40. [Medline].
[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].
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].
Rodríguez LA, Ruigómez A. Increased risk of irritable bowel syndrome after bacterial gastroenteritis: cohort study. BMJ. Feb 27 1999;318(7183):565-6. [Medline].
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].
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].
Spiller RC. Postinfectious irritable bowel syndrome. Gastroenterology. May 2003;124(6):1662-71. [Medline].
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].
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].
Zolotukhina TV. [Determination of the sex and karyotype of the intrauterine fetus]. Akush Ginekol (Mosk). Jan 1972;48(1):38-40. [Medline].
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].
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].
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].
[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].
[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].
Further Reading
Additional resources on asthma are available at Medscape’s Irritable Bowel Syndrome and Chronic Constipation Resource Center.
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
