Irritable Bowel Syndrome Clinical Presentation: History and Physical Examination, Criteria for Diagnosis

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Presentation

History and Physical Examination

History

A meticulous history is the key to establish a diagnosis of irritable bowel syndrome, which comprises a range of manifestations and aggravation factors.^[53]The Rome criteria provide the construct upon which questions are based (see Diagnostic Considerations).

Altered bowel habits

Constipation 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 bloating/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 computed tomography (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 or older age
Acute symptoms (irritable bowel syndrome is defined by chronicity)
Progressive symptoms
Nocturnal symptoms
Anorexia or weight loss
Fever
Rectal bleeding
Painless diarrhea
Steatorrhea
Gluten intolerance

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.

Criteria for Diagnosis

A consensus panel created and continually updates the Rome diagnostic criteria to provide a standardized diagnosis for research and clinical practice. The Rome IV criteria for the diagnosis of irritable bowel syndrome (IBS) were released in 2016 and require that patients have had recurrent abdominal pain on average at least 1 day per week during the previous 3 months that is associated with two or more of the following^[2]:

Related to defecation (may be increased or unchanged by defecation)
Associated with a change in stool frequency
Associated with a change in stool form or appearance

Unlike the Rome III criteria, the Rome IV criteria only require abdominal pain in defining this condition; "discomfort" is no longer included owing to its ambiguity and different meanings across cultures and languages.^[2]

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, and these remain unchanged in the Rome IV classification.^[2]These patterns include the following:

IBS-D (diarrhea predominant)
IBS-C (constipation predominant)
IBS-M (mixed diarrhea and constipation)
IBS-U (unclassified; the symptoms cannot be categorized into one of the above three subtypes)

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. The Rome IV criteria differ from the Rome III criteria in basing bowel habits on stool forms solely during days with abnormal bowel movements rather than on the total number of bowel movements.^[2]

Differential Diagnoses

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Halmos EP, Power VA, Shepherd SJ, Gibson PR, Muir JG. A diet low in FODMAPs reduces symptoms of irritable bowel syndrome. Gastroenterology. 2014 Jan. 146 (1):67-75.e5. [Medline].
Moayyedi P, Ford AC, Talley NJ, et al. The efficacy of probiotics in the treatment of irritable bowel syndrome: a systematic review. Gut. 2010 Mar. 59 (3):325-32. [Medline].
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Brenner DM, Moeller MJ, Chey WD, Schoenfeld PS. The utility of probiotics in the treatment of irritable bowel syndrome: a systematic review. Am J Gastroenterol. 2009 Apr. 104 (4):1033-49; quiz 1050. [Medline].
Liu HN, Wu H, Chen YZ, Chen YJ, Shen XZ, Liu TT. Altered molecular signature of intestinal microbiota in irritable bowel syndrome patients compared with healthy controls: A systematic review and meta-analysis. Dig Liver Dis. 2017 Apr. 49 (4):331-7. [Medline].
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Cremon C, Stanghellini V, Barbaro MR, et al. Randomised clinical trial: the analgesic properties of dietary supplementation with palmitoylethanolamide and polydatin in irritable bowel syndrome. Aliment Pharmacol Ther. 2017 Apr. 45 (7):909-22. [Medline].
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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. 2012 Jan. 107 (1):28-35; quiz 36. [Medline].
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Media Gallery

What is irritable bowel syndrome (IBS)? IBS is a condition that involves recurrent abdominal pain as well as abnormal bowel motility, which can include diarrhea and/or constipation.

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Author

Jenifer K Lehrer, MD Attending Physician, Department of Gastroenterology, Jefferson Health System Torresdale Campus, Philadelphia

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

Disclosure: Nothing to disclose.

Coauthor(s)

Gary R Lichtenstein, MD Professor of Medicine, Director, Center for Inflammatory Bowel Disease, Department of Medicine, Division of Gastroenterology, Perelman School of Medicine at the 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, American Society for Gastrointestinal Endoscopy

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Abbott Corp/Abbvie; Actavis; Alaven; CellCeutrix; Celgene; Ferring; Gilead; Hospira; Janssen Orthobiotech; Luitpold/American Regent; Pfizer Pharm; Prometheus Labs; Romark; Salix Pharma/Valeant; Santarus/Receptos/Celgene; Shire Pharma; Takeda; UCB<br/>Received research grant from: Salix Pharm/Valeant; Santarus/Receptos/Celgene; Shire Pharm; UCB<br/>Received author or editor honorarium or book royalty from for: Clinical Advances in Gastroenterology; Gastroenterology and Hepatology; Gastro-Hep Communications; Ironwood; Luitpold/American Regent; Merck; McMahon Publishing; Romark; SLACK Inc; Springer Science and Business Media; Up-To-Date.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief Editor

BS Anand, MD Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine

BS Anand, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Acknowledgements

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

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

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

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