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Emergency and Acute Medicine – Irritable bowel syndrome
Irritable bowel syndrome (IBS) is a functional gastrointestinal disorder characterized by chronic abdominal pain or discomfort associated with altered bowel habits, without identifiable structural or biochemical pathology to explain the symptoms. It is common, with an estimated prevalence of 10–20% of the population.
The pathophysiology of IBS is uncertain and likely multifactorial. Proposed mechanisms include altered gastrointestinal motility and increased gut sensitivity (visceral hyperalgesia), leading to exaggerated pain responses to normal bowel activity. Mucosal inflammation may play a role, particularly in postinfectious IBS, which can occur in up to 10% of patients following bacterial enteritis and is associated with mucosal lymphocyte infiltration. Altered intestinal microflora has also been described. Food sensitivity is frequently reported by patients but remains unproven as a primary cause. Psychosocial factors are important in some patients, especially those who seek medical care, with higher rates of anxiety, somatoform disorders, and prior abuse histories; however, there is no clear increase in psychiatric illness among individuals with IBS who do not seek care.
Clinically, IBS presents with recurrent abdominal pain or discomfort that is often relieved by defecation and associated with changes in stool frequency or consistency. Common accompanying symptoms include bloating or abdominal distention, passage of mucus, and a sensation of incomplete evacuation. The Rome III criteria define IBS as recurrent abdominal pain or discomfort at least 3 days per month over the past 3 months, associated with at least two of the following: improvement with defecation, onset associated with a change in stool frequency, or onset associated with a change in stool form. IBS is more common in women than men, particularly among those who seek medical attention.
A careful history is central to diagnosis, as IBS is a clinical diagnosis. Alarm features that warrant further evaluation include onset after age 50, nocturnal symptoms, unintentional weight loss, iron-deficiency anemia, hematochezia, or a family history of colorectal cancer, inflammatory bowel disease, or celiac disease. Physical examination is usually normal, though mild sigmoid tenderness or a palpable sigmoid cord may be noted.
Laboratory testing is typically normal and is not required to establish the diagnosis. When indicated to exclude alternative diagnoses, basic studies such as a CBC (to rule out anemia or leukocytosis), ESR or CRP (to exclude inflammatory disease), and selective stool studies for diarrhea may be considered. Testing for celiac disease may be appropriate in the outpatient setting. Imaging and endoscopic evaluation are reserved for patients with alarm features or diagnostic uncertainty.
Management in the emergency setting is supportive and focused on reassurance. Establishing an empathetic physician–patient relationship is essential. Treatment is individualized and symptom based. Lifestyle interventions such as regular exercise may improve constipation and overall symptoms. Dietary modification can be empirically attempted, including exclusion of lactose or gluten and avoidance of gas-producing foods if these worsen symptoms. Constipation-predominant symptoms may benefit from increased dietary fiber or fiber supplementation. Abdominal pain may improve with short-term use of antispasmodics such as dicyclomine or hyoscyamine. Probiotics, particularly those containing bifidobacteria, may provide benefit. Low-dose tricyclic antidepressants or selective serotonin reuptake inhibitors can reduce global IBS symptoms and abdominal pain, and psychological therapies are effective in selected patients.
Most patients with IBS can be safely discharged from the emergency department with reassurance and outpatient follow-up. Admission is rarely indicated and should be reserved for patients with diagnostic uncertainty or concern for emergent abdominal pathology. Ongoing care with a primary care physician is critical, and some patients may benefit from gastroenterology or mental health referral.
A key pitfall is prematurely attributing symptoms to IBS without adequately considering alternative or emergent diagnoses. Although IBS is common and often underlies repeated emergency evaluations, alarm features or atypical presentations should prompt further investigation.
Irritable bowel syndrome (IBS) is a functional gastrointestinal disorder characterized by chronic abdominal pain or discomfort associated with altered bowel habits, without identifiable structural or biochemical pathology to explain the symptoms. It is common, with an estimated prevalence of 10–20% of the population.
The pathophysiology of IBS is uncertain and likely multifactorial. Proposed mechanisms include altered gastrointestinal motility and increased gut sensitivity (visceral hyperalgesia), leading to exaggerated pain responses to normal bowel activity. Mucosal inflammation may play a role, particularly in postinfectious IBS, which can occur in up to 10% of patients following bacterial enteritis and is associated with mucosal lymphocyte infiltration. Altered intestinal microflora has also been described. Food sensitivity is frequently reported by patients but remains unproven as a primary cause. Psychosocial factors are important in some patients, especially those who seek medical care, with higher rates of anxiety, somatoform disorders, and prior abuse histories; however, there is no clear increase in psychiatric illness among individuals with IBS who do not seek care.
Clinically, IBS presents with recurrent abdominal pain or discomfort that is often relieved by defecation and associated with changes in stool frequency or consistency. Common accompanying symptoms include bloating or abdominal distention, passage of mucus, and a sensation of incomplete evacuation. The Rome III criteria define IBS as recurrent abdominal pain or discomfort at least 3 days per month over the past 3 months, associated with at least two of the following: improvement with defecation, onset associated with a change in stool frequency, or onset associated with a change in stool form. IBS is more common in women than men, particularly among those who seek medical attention.
A careful history is central to diagnosis, as IBS is a clinical diagnosis. Alarm features that warrant further evaluation include onset after age 50, nocturnal symptoms, unintentional weight loss, iron-deficiency anemia, hematochezia, or a family history of colorectal cancer, inflammatory bowel disease, or celiac disease. Physical examination is usually normal, though mild sigmoid tenderness or a palpable sigmoid cord may be noted.
Laboratory testing is typically normal and is not required to establish the diagnosis. When indicated to exclude alternative diagnoses, basic studies such as a CBC (to rule out anemia or leukocytosis), ESR or CRP (to exclude inflammatory disease), and selective stool studies for diarrhea may be considered. Testing for celiac disease may be appropriate in the outpatient setting. Imaging and endoscopic evaluation are reserved for patients with alarm features or diagnostic uncertainty.
Management in the emergency setting is supportive and focused on reassurance. Establishing an empathetic physician–patient relationship is essential. Treatment is individualized and symptom based. Lifestyle interventions such as regular exercise may improve constipation and overall symptoms. Dietary modification can be empirically attempted, including exclusion of lactose or gluten and avoidance of gas-producing foods if these worsen symptoms. Constipation-predominant symptoms may benefit from increased dietary fiber or fiber supplementation. Abdominal pain may improve with short-term use of antispasmodics such as dicyclomine or hyoscyamine. Probiotics, particularly those containing bifidobacteria, may provide benefit. Low-dose tricyclic antidepressants or selective serotonin reuptake inhibitors can reduce global IBS symptoms and abdominal pain, and psychological therapies are effective in selected patients.
Most patients with IBS can be safely discharged from the emergency department with reassurance and outpatient follow-up. Admission is rarely indicated and should be reserved for patients with diagnostic uncertainty or concern for emergent abdominal pathology. Ongoing care with a primary care physician is critical, and some patients may benefit from gastroenterology or mental health referral.
A key pitfall is prematurely attributing symptoms to IBS without adequately considering alternative or emergent diagnoses. Although IBS is common and often underlies repeated emergency evaluations, alarm features or atypical presentations should prompt further investigation.
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