Irritable Bowel Syndrome, Emergency Medicine

Basics

Description

- Consider further diagnostic workup if any of the following "alarm " ¯ features are present: - Onset >50 - Nocturnal symptoms - Unintentional weight loss - Iron-deficiency anemia - Hematochezia - Family history of colorectal cancer, inflammatory bowel disease, or celiac sprue

- Other symptoms consistent with IBS: - Abdominal distention or bloating - Passage of mucus in stools - Altered stool passage (straining, urgency, or feeling of incomplete evacuation) - Postprandial upper abdominal discomfort - Symptoms of gastroesophageal reflux - Flatulence

- Celiac disease - Inflammatory bowel disease: - Ulcerative colitis/proctitis - Crohns disease

Syndrome of abdominal pain or discomfort associated with altered bowel habits and no other pathology explaining symptoms
Prevalence estimated to be 10 " “20%

Etiology

Uncertain pathophysiology, but many possibilities
Altered GI motility:Increased gut sensitivity (visceral hyperalgesia):Exaggerated response to normal GI physiology
Mucosal inflammation:Postinfectious:After bacterial enteritis, 10% have persistent IBS symptoms
Mucosal lymphocyte infiltration
Altered microflora in small bowel or feces
Food sensitivity is a possibility but not proven
Psychosocial dysfunction:More anxiety, somatoform disorders, and history of abuse in patients who seek careNo evidence of increased psychiatric illness in those who do not seek care

Diagnosis

Signs and Symptoms

Abdominal pain or discomfort:
Altered stool frequency
Altered stool consistency
Bloating or distention
Passage of mucus
Feeling of incomplete emptying

Consider further diagnostic workup if any of the following "alarm " ¯ features are present:Onset >50Nocturnal symptomsUnintentional weight lossIron-deficiency anemiaHematocheziaFamily history of colorectal cancer, inflammatory bowel disease, or celiac sprue

History

Rome III diagnostic criteria: Recurrent abdominal pain or discomfort 3 days/mo in the last 3 mo associated with ≥2 of:Improvement with defecationOnset associated with a change in frequency of stoolOnset associated with a change in form (appearance) of stool
Other symptoms consistent with IBS:Abdominal distention or bloatingPassage of mucus in stoolsAltered stool passage (straining, urgency, or feeling of incomplete evacuation)Postprandial upper abdominal discomfortSymptoms of gastroesophageal refluxFlatulence
Female < male, 1.5 " “2:1 overall, higher in those who seek care

Physical Exam

Usually well appearing with normal physical
May have tender sigmoid or palpable sigmoid cord

Essential Workup

Clinical diagnosis: Careful history crucial ‚

Diagnosis Tests & Interpretation

Lab

Typically no abnormalities found
Labs to be considered (to exclude other pathology), but not required:CBC:Should not have leukocytosis or anemiaNormal ESR and CRP useful in excluding inflammatory conditionsSerum chemistry, thyroid studies unlikely to be usefulStool for ova and parasites:Most useful for diarrhea workupConsider outpatient serum test for celiac

Imaging

Only necessary if excluding emergent pathology ‚

Diagnostic Procedures/Surgery

Colonoscopy/flexible sigmoidoscopy for select patients (outpatient) ‚

Differential Diagnosis

Celiac disease
Inflammatory bowel disease:Ulcerative colitis/proctitisCrohns disease
Infectious enteritis
Small-intestinal bacterial overgrowth
Lactose intolerance
Colorectal cancer
Diverticular disease
Biliary disease
Diabetic gastroparesis
Pancreatitis
Thyroid malfunction
Obstruction
Peptic ulcer disease
Acute intermittent porphyria

Treatment

Pre-Hospital

No specific treatment required ‚

Initial Stabilization/Therapy

Symptomatic treatment
Pain control
Administer fluids if dehydrated

Ed Treatment/Procedures

Empathetic approach and therapeutic physician " “patient relationship is most important.
Exercise:Improves gastric emptying and constipation
Diet:Many believe symptoms have a food trigger, but not yet proven.Exclusion diets starting with gluten or lactose can be empirically considered.Avoid beans, cabbage, uncooked broccoli, other flatulent foods if symptomatic.
Constipation symptoms:High-fiber diet, fiber supplements
Abdominal pain:Antispasmodics like hyoscyamine and dicyclomine may be helpful short-term
Probiotics:Bifidobacteria appear more effective than lactobacilli
Antidepressants:TCAs and possibly SSRIs appear to be effective at relieving global IBS symptoms and reducing abdominal pain.
Psychological therapies appear effective.

Medication

First Line

Dicyclomine: 10 " “20 mg PO q6h
Hyoscyamine: 0.125 " “0.25 mg PO or sublingual not to exceed 12 tab/day

Second Line

Amitriptyline: 25 mg PO at bedtime (or another TCA)
Fluoxetine: 20 mg PO daily (or another SSRI)
Bifidobacteria probiotic

Follow-Up

Disposition

Admission Criteria

Uncertain diagnosis with suspicion of an emergent abdominal condition ‚

Discharge Criteria

Almost all patients can be managed as outpatients. ‚

Issues for Referral

Some may benefit from GI or psychiatric referral. ‚

Followup Recommendations

Most important is follow-up with primary care physician to foster a therapeutic physician " “patient relationship. ‚

Pearls and Pitfalls

Beware of other emergent pathology.
IBS is common, so it is likely the underlying cause of many abdominal workups done in the ED.

Additional Reading

American College of Gastroenterology Task Force on Irritable Bowel Syndrome, Brandt ‚ LJ, Chey ‚ WD, et al. An evidence-based position statement on the management of irritable bowel syndrome. Am J Gastroenterol. 2009;104 (Suppl 1):S1 " “S35.
Whelan ‚ K, Quigley ‚ EM. Probiotics in the management of irritable bowel syndrome and inflammatory bowel disease. Curr Opin Gastroenterol. 2013;29(2):184 " “189.
Videlock ‚ EJ, Chang, ‚ L. Irritable bowel syndrome: Current approach to symptoms, evaluation, and treatment. Gastroenterol Clin North Am. 2007;36(3):665 " “685, x.

Codes

ICD9

306.4 Gastrointestinal malfunction arising from mental factors
564.1 Irritable bowel syndrome

ICD10

F45.8 Other somatoform disorders
K58.0 Irritable bowel syndrome with diarrhea
K58.9 Irritable bowel syndrome without diarrhea
K58 Irritable bowel syndrome

SNOMED

10743008 Irritable bowel syndrome (disorder)
197125005 Irritable bowel syndrome with diarrhea (disorder)
268650001 Somatoform autonomic dysfunction - gastrointestinal tract (disorder)