Best Practices in the Management and Treatment of Irritable Bowel Syndrome

THESIS: Best practices in the management and treatment of Irritable Bowel Syndrome includes treatment combinations tailored to each individual and their proven efficacy.

INTRODUCTION
Irritable bowel syndrome (IBS) is a common gastrointestinal condition characterized by abdominal pain, discomfort, and altered bowel patterns. The pathophysiology of IBS is not explicit. Approximately 10 to 15 percent of the U.S. population is affected by IBS, and women are more likely to have symptoms than are men (Hadley & Gaarder, 2005, p. 2501). No one pharmacological treatment is effective for all symptoms of IBS, and not all clients are in need of drug treatments. The absence of acquired facts regarding the cause and origin of the ambiguous symptoms of IBS impedes research for a cure and effective management.
DIAGNOSIS
The diagnosis of IBS cannot be made by laboratory tests. A focused assessment and patient history should be conducted, noting the intensity of symptoms and their impact on quality of life. Diagnosis is based on clinical signs and symptoms that include abdominal pain, bloating, constipation, and diarrhea (Hadley& Gaarder, 2005, p. 2501). The diagnostic criteria in Table 1 were developed to assist in the diagnosis of IBS.
"The diseases that need to be considered when evaluating gastrointestinal complaints include Irritable Bowel Disease (IBD), which is a condition of inflammation of the intestinal tract, celiac sprue, gallbladder inflammation, infection, including parasites, dietary intolerances, and colon cancer, among others” (Meisler, 2001, p.224).

TABLE 1
Diagnostic Criteria for IBS
Abdominal discomfort or pain, for at least 12 weeks (which need not be consecutive) in the preceding 12 months, with two or more of the following features:
Relief with defecation
Onset associated with a change in stool frequency
Onset associated with a change in form or appearance of stool
These additional symptoms cumulatively support the diagnosis of IBS:
Abnormal stool form (loose and watery or lumpy and hard)
Abnormal stool passage (urgency, frequency, feeling of incomplete evacuation)
Passage of mucus (white material)
Bloating or sensation of abdominal distention
IBS= irritable bowel syndrome
Note: The diagnostic criteria for IBS is adapted from “Treatment of Irritable Bowel Syndrome” [Electronic Version], by S.K. Hadley & S. Gaarder, 2005, American Family Physician, 72(12), pp.2501-2506.

TREATMENT
Management of IBS should begin by initiating a therapeutic provider-client relationship.
Education regarding the nature of the illness and long-term prognosis should be addressed, as well as any concerns the client has. The diagnosis is common and there is no special risk of serious complications may comfort many (Thompson, 2002, p. 1398).
Initial suggestions are related to modification of the client's diet that may reduce symptoms. Frequent exercise, allotting sufficient time to eat and defecate, and consuming a balanced diet can be addressed. "Reported dietary triggers of IBS include caffeine, citrus, corn, dairy lactose, wheat, and wheat gluten, with lactose and caffeine being associated with diarrhea-­predominant IBS" (Hadley & Gaarder, 2005, p. 2502).
Increasing fiber in the diet has been recommended as a treatment for IBS, because of its action on the stool. Fiber enhances the stool's water-holding properties, provides lubrication, aids to bulk the stool, and enhances the binding of agents such as bile (Hadley & Gaarder, 2005, p. 2503). Because fiber is inexpensive and easily accessible, it may be a good starting point, especially for those who experience constipation-predominant IBS. There are a variety of fibers available, including synthetic fibers and natural fibers. The synthetic fibers are more soluble, but may generate gas discomfort. Psyllium seed and linseed are bulking agents with lubrication properties and both contain mucilages that contribute to this (Hadley & Gaarder, 2005, p. 2503).
Sweeteners, such as sorbitol and fructose are added to gum, jams, and soda, for example, and are laxatives that may be upsetting to the bowels. Some medications may provoke IBS, such as opiates, calcium channel blockers, and non-steroidal anti-inflammatory drugs, which may cause constipation. While some antacids, antibiotics, and occult laxatives may induce diarrhea (Thompson, 2002, p. 1399).
Eating stimulates the gut to move and secrete, and an exaggerated gastrocolic response experienced by those with IBS can lead them to believe foods in their diet are the cause. The impact of this response may be relieved by avoiding meals high in fat content (Thompson, 2002, p. 1399). It may be useful for the client to keep a food diary containing foods eaten, bowel habits, and exercise, and their response to those activities.

No drug treatment is efficacious for all symptoms of IBS, and many clients do not need any drugs at all. Drugs should be prescribed based on the predominant symptom, constipation or diarrhea (Thompson, 2002, p. 1395).
Antispasmodics (anticholinergics) temporarily block nerve impulses to the gut, thereby reducing smooth muscle contractions. Dicyclomine (Bentyl) and hyoscyamine (Levsin) act to relax smooth muscle 1. These drugs can offer relief from the cramping of constipation. If used habitually, they may induce constipation (O'Hare, 2001, p. 132).
Loperamide is an opioid agonist and works by inhibiting intestinal secretions and increasing fluid and electrolyte absorption due to increased intestinal transit time (Talley, 2003, p. 364). Loperamide does not cross the blood-brain barrier, therefore side effects are minimal (Hadley & Gaarder, 2005, p. 2503).
5-HT3 receptor antagonists slow colonic transit, relaxes the descending colon, and results in decreased perception of volume in diarrhea-predominant irritable bowel syndrome (Talley, 2003, p. 365). Alosetron (Lotronex), an IBS-specific medication, is available again after being pulled from the market following cases of ischemic colitis and five deaths. It is available for women only with severe diarrhea-predominant symptoms, but with strict prescribing guidelines. Alosetron should only be prescribed after other conventional treatments have failed (Hadley & Gaarder, 2005, p. 2505).
5-HT4 receptor agonists, such as tegaserod (Zelnorm) stimulate the release of neurotransmitters and increases colonic motility. Zelnorm is safe for up to 12 weeks of use, but long-term safety has not been proven. Zelnorm improves general symptoms of IBS in women, although it is minimally advantageous (Hadley & Gaarder, 2005, p. 2505).
Antibiotics may be prescribed for refractory diarrhea due to a bacterial infection, for short-­term use. Long-term use of antibiotics can increase diarrhea by changing the normal flora in the bowel (Hadley & Gaarder, 2005, p. 2505).
Peppermint acts as an antispasmodic and may improve digestion. It also acts by anesthetizing, decreasing nausea, and relaxing smooth muscle. It is inadvisable in clients with gastroesophageal reflux disease (Hadley & Gaarder, 2005, p. 2505).
CONCLUSION
The treatment and management of Irritable bowel syndrome has proven to be difficult due to the lack of understanding about the pathophysiology. IBS presents differently in each client, and treatment should be comprehensive and approached by the provider and client. While many treatment options exist, each client should be treated individually and holistically.

Intervention 1: Patient Education
An important component in treating patients with Irritable Bowel Syndrome is the provision of patient information, including an explanation of the syndrome and reassurance.
Disadvantage 1: Knowledge Deficit
Irritable bowel syndrome remains undiagnosed in many individuals mainly because of failure to seek medical attention for symptoms and lack of recognition of the syndrome (Spinelli, 2007). Manifestations of IBS include constipation, diarrhea, and abdominal pain, which may be interpreted as a "stomach flu" or food allergy. Fear of cancer and malignant disorders may keep the individual from seeking medical care (Mearin, 2006). This may result from an ineffective patient-physician relationship that lacks communication and trust. Therefore, a confident diagnosis and avoidance of repeated or unnecessary tests is important.
Disadvantage 2: Lack of Resources
Irritable bowel syndrome is a disease of unclear, complex pathophysiology (Spinelli, 2007) and research shows healthcare professionals still have limited knowledge of the disorder
(Boyd-Carson, 2004). Providers in busy outpatient practices may have difficulty providing detailed information, advice and support about the disorder, the precipitating factors and treatment options. Studies demonstrate that less than thirty percent of IBS patients under the care of a primary care physician are referred to a specialist (Faresjo et aI, 2006).
Intervention 2: Dietary Modifications
Dietary modifications are frequently recommended as a first step in the management of Irritable bowel syndrome. Although no specific diet can be recommended to all patients with IBS, many will report an improvement in symptoms with the identification and avoidance of specific trigger foods and the inclusion of dietary fiber (Boyd-Carson, 2004).

Disadvantage 1: Exacerbation of Symptoms
Fiber must be introduced gradually, as an increase in fiber initially may worsen symptoms such as bloating and pain ((Boyd-Carson, 2004). Fiber therapy may aggravate symptoms by decreasing pain threshold secondary to distention and by inducing colon distention through the formation of gas from bacterial fermentation (Mearin, 2006).
Disadvantage 2: Altered Nutrition
Limitations on dietary habits may further impair the patient's quality of life (Mearin, 2006). Avoidance of nutrients that induce symptoms may require supplementation, such as calcium supplements (Boyd-Carson, 2004). Insufficient intake of nutrients can have an effect on the metabolic system, as evidenced by weight loss, poor muscle tone, muscle weakness and abnormal lab studies (iron deficiency, electrolyte imbalances).

REFERENCES
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