Elsevier

The Lancet

Volume 360, Issue 9332, 17 August 2002, Pages 555-564
The Lancet

Seminar
Irritable bowel syndrome: a little understood organic bowel disease?

https://doi.org/10.1016/S0140-6736(02)09712-XGet rights and content

Summary

Irritable bowel syndrome affects 10% of adults with an unexplained female predominance. Although only a few people see their family doctor, the disease causes reduced quality of life and represents a multi-billion pound health-care problem. The disorder clusters in families, which is possibly because of intra-familial learning and a genetic predisposition. Visceral hypersensitivity is a key feature in most patients. Results of imaging studies of regional cerebral blood flow during rectal distension suggest underlying disturbances of central processing of afferent signals, though this is not unique to the disorder, since it is seen in other chronic pain syndromes. Environmental factors that are strongly implicated in at least some patients include gastrointestinal infection and inflammation and chronic stress. Diagnosis is based on positive symptoms and absence of any alarm indicators. Treatment remains unsatisfactory and hinges on an excellent doctor-patient relationship, with drugs for symptom exacerbations. Cognitive behavioural treatment, psychotherapy, and hypnosis could provide long-lasting benefit in some patients. Tricyclic antidepressants in low doses seem to be the most effective class of drugs for the disorder on the basis of limited data.

Section snippets

New definitions: confusion and consensus

The term irritable bowel was probably first coined in 1944 by Peters and Bargen.1 Irritable bowel syndrome was deemed a diagnosis of exclusion until Heaton's research group in Bristol reported that six symptoms could discriminate people diagnosed with the disorder (based on an absence of organic disease on follow-up) from those with documented structural bowel disease (panel 1). Presence of two or three symptoms, referred to as the Manning criteria,2 were subsequently applied in many

Epidemiology

Gastrointestinal symptoms are strikingly frequent in the general population: 60–70% of people report one or more troublesome symptoms, suggesting that to be completely asymptomatic could be abnormal.11 Irritable bowel syndrome is clearly one of the most frequent explanations for chronic symptoms, although true prevalence varies—depending on criteria used—from 3% to 22%.6, 11, 12 Prevalence of this disorder is only slightly reduced in elderly people, in whom it is often misdiagnosed.

Health care-seeking behaviour

Not all people with irritable bowel syndrome present for medical care—the proportion who do varies greatly between countries.11, 24, 25 Much of the variation in rates of health care-seeking behaviour is probably attributable to characteristics associated with a country or region's health-care system (including access and who pays).

Social learning in early childhood could contribute to frequent seeking of health care for symptoms of irritable bowel syndrome. Levy26 reported that children whose

Mechanisms

The symptoms of irritable bowel syndrome are pain, bloating, and an altered bowel habit. Putative mechanisms include visceral hypersensitivity, altered motility, abnormal transit of stool and gas, and stress, more than one of which could contribute to symptoms, which after cognitive appraisal lead to patient's behaviour, including consultation (figure 1). Genetic factors affecting pain-signalling and disturbances in central processing of afferents are postulated to predispose to irritable bowel

Diagnosis

There is presently no established biological marker for irritable bowel syndrome. For example, colonic balloon distension testing is invasive and is not sensitive and specific enough to justify its clinical use. One of the main reasons that family doctors refer patients with symptoms of irritable bowel syndrome to hospital is the possibility that they might have another disease. Thus, it is not surprising that incidence of organic disease is higher in patients referred to a specialist than in

Education and support

Authors of several consensus reports107, 114, 115 have made management recommendations and reached similar conclusions (panel 3). After a positive diagnosis based on symptoms, education and support of patients is essential to deal with what is often a lifelong disorder. Establishment of a positive doctor-patient relationship is important to provide good clinical care, especially in view of qualitative evidence that patients with irritable bowel syndrome generally perceive their doctor to have

New and alternative treatments

Several compounds are under development or in early testing for irritable bowel treatment (panel 5). It remains to be seen if pharmacogenetics or other means of subgrouping the disorder will lead to drug advances.

Psychological treatments are thought to be of value in irritable bowel syndrome. Cognitive behavioural therapy, relaxation, and psychotherapy have been reported to be superior to standard care in most patients,130, 131, 132, 133 but methodological concerns have been raised with most of

Conclusions

Irritable bowel syndrome is a major cause of morbidity and deserves serious attention. Although stress can stimulate the colon in this disorder and in health, this factor cannot be the only cause of symptoms. Evidence is growing that irritable bowel syndrome can no longer be purely regarded as a functional disorder—which is a loose term frequently used to describe anything that we cannot adequately explain, or probable psychiatric disease. We prefer to judge the disorder to be a discrete

Search strategy and selection criteria

A comprehensive Medline search was done with the MeSH terms “irritable bowel syndrome” and “functional bowel disease” from 1997 until February, 2002. Only articles published in English were retrieved. Furthermore, a hand search of abstracts published in Gastroenterology on irritable bowel syndrome over the past 4 years was undertaken, but only those that provided important insights or had high further reading value have been cited.

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