Irritable Bowel Syndrome Workup

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

Approach Considerations

A comprehensive history, a physical examination, and tailored laboratory and radiographic studies can establish a diagnosis of irritable bowel syndrome in most patients.

The 2009 American College of Gastroenterologists (ACG) evidence-based position statement on the management of IBS does not recommend laboratory testing or diagnostic imaging in patients younger than 50 years with typical IBS symptoms and without “alarm features”. Alarm features include the following symptoms and history:[14]

  • Weight loss
  • Iron deficiency anemia
  • Family history of certain organic GI illnesses (eg, inflammatory bowel disease, celiac sprue, colorectal cancer)

While rectal bleeding and nocturnal symptoms have also been considered alarm features, they are not specific for organic disease. Patients with IBS-D or IBS-M should have serologic testing for celiac sprue. Patients aged 50 years and older should have more extensive testing, including a colonoscopy.[14]

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Blood Studies

A CBC count with differential to screen for anemia, inflammation, and infection is indicated. A comprehensive metabolic panel to evaluate for metabolic disorders and to rule out dehydration/electrolyte abnormalities in patients with diarrhea is also indicated.

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Stool Examinations

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
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History-Specific Examinations

Hydrogen breath testing to exclude bacterial overgrowth may be considered in patients with diarrhea to screen for lactose and/or fructose intolerance. Tissue transglutaminase antibody testing and small bowel biopsy are used especially in diarrhea-predominant irritable bowel syndrome to diagnose celiac disease.

Thyroid function tests are used to screen for hyperthyroidism or hypothyroidism. Serum calcium testing is used to screen for hyperparathyroidism.

Erythrocyte sedimentation rate and C-reactive protein measurement are nonspecific screening tests for inflammation.

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History-Specific Imaging Studies

Upper GI barium study with small bowel follow-through is used to screen for tumor, inflammation, obstruction, and Crohn disease. Double-contrast barium enema is used to screen for colorectal neoplasm and inflammation. Gallbladder ultrasonography should be considered if the patient has recurrent dyspepsia or characteristic postprandial pain.

Abdominal CT scan is appropriate to screen for tumors, obstruction, and pancreatic disease.

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Dietary Studies

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.

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History-Specific Procedures

Anal manometry may reveal a spastic response to rectal distention or other problems. For many patients with irritable bowel syndrome, endoscopy appropriately includes flexible sigmoidoscopy to assess for inflammation or distal obstruction.

Esophagogastroduodenoscopy with possible biopsy is indicated in patients with persistent dyspepsia, if weight loss or symptoms suggest malabsorption, or if celiac disease is a concern. Colonoscopy is 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.

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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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  3. Bercik P, Verdu EF, Collins SM. Is irritable bowel syndrome a low-grade inflammatory bowel disease?. Gastroenterol Clin North Am. Jun 2005;34(2):235-45, vi-vii. [Medline].

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  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].

  10. Shepherd SJ, Parker FC, Muir JG, Gibson PR. 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].

  11. Khashan AS, Quigley EM, McNamee R, McCarthy FP, Shanahan F, Kenny LC. Increased Risk of Miscarriage and Ectopic Pregnancy Among Women With Irritable Bowel Syndrome. Clin Gastroenterol Hepatol. Feb 25 2012;[Medline].

  12. Longstreth GF, Thompson WG, Chey WD, Houghton LA, Mearin F, Spiller RC. Functional bowel disorders. Gastroenterology. Apr 2006;130(5):1480-91. [Medline].

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

  14. Brandt LJ, Chey WD, Foxx-Orenstein AE, Schiller LR, Schoenfeld PS, Spiegel BM, et al. An evidence-based position statement on the management of irritable bowel syndrome. Am J Gastroenterol. Jan 2009;104 Suppl 1:S1-35. [Medline].

  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].

  18. [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].

  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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