IBS – Fact sheet

Treatment Algorithm:

Wilkins T1, Pepitone C, Alex B, Schade RR. Diagnosis and management of IBS in adults. Am Fam Physician. 2012 Sep 1;86(5):419-26.

Definition: Abdominal discomfort or pain associated with altered bowel habits for at least three days
per month in the previous three months, with the absence of organic disease.

Pathophysiology: Not clearly defined.

By the numbers:
 1 of the top 10 reasons to seek primary care.
  1/3 of all GI consults.
 In the G8 nations costing 41 billion dollars annually.
 In NA prevalence is 5 – 10%
 Women > men (1.5 : 1)
 Peak: 20 – 39 years of age.

Diagnosis: Rome III Criteria

 Improved pain with defecation.
 Onset associated with change in frequency of stool.
 Onset associated with change in consistency of stool.
 Above criteria met for the previous 3 months with first symptom onset at least 6 months prior.
***Often patients fall into one of three group defined by their predominant symptom: pain,
diarrhea or alternating constipation-diarrhea (mixed).

Treatment Options (treatment - IBS type - NNT)

1- Peppermint – all types - NNT 2.5

2- Probiotics – all types - NNT 4
3- Rifaximin - diarrhea/mixed - NNT 4
4- Hypnotherapy/acupuncture/CAM – all types - NNT4
5- SSRI and tricyclics - all types - NNT 4-5
6- Lubiprostone – pain - NNT 4-5
7- Exercise – all types - NNT 7
8- Lubiprostone – mixed - NNT 7
9- 5-HT3 antagonists – alosetron, for severe diarrhea in women NNT 7; risk of ischemic
colitis, death.
10- 5-HT4 agonists – tegaserod – constipation predominant NNT 17 risk of MI/stroke/angina
[removed from US market, available only on special dispensation] ***Note this is still in
the AFP algorithm above.

Treatments with less evidence:

• Neomycin – improves constipation/bloating.
• Antispasmodics hyoscyamine and dicyclomine – all types IBS, relieved pain.
• Dietary changes lots of studies, nothing overwhelming evidence wise but there is some evidence for
FODMAP and gluten free diets as well as working through various elimination diets. The Arizona IMR has
good elimination diet handout from the University of Wisconsin in the IBS section.

Treatments not supported by the literature:

• Fiber ineffective.
• OTC laxatives – constipation-diarrhea predominant – some help for constipation little evidence overall.

References:

1. Wilkins T1, Pepitone C, Alex B, Schade RR. Diagnosis and management of IBS in adults. Am Fam
Physician. 2012 Sep 1;86(5):419-26
2. Wall et al. Irritable bowel syndrome: A concise review of current treatment concepts World J
Gastroenterol. 2014 Jul 21; 20(27): 8796–8806.
3. Krasuski, J. Editor. FMX: Comprehensive Review of Family Medicine. 2016. American Physician
Institute.
4. El-Salhy M. Diet in irritable bowel syndrome. Nutr J. 2015 Apr 14;14:36.