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Flexibility Key in Diagnosing, Managing IBS
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This month’s Healio Hot Topic focuses on irritable bowel syndrome and the grey areas we encounter as physicians when we evaluate and manage this most commonly diagnosed gastrointestinal condition.
As GIs, even if we subspecialize, we all deal with IBS at some level; therefore, we all need to have familiarity with the diagnosis and management of it. Reading through the overview by William Chey, MD, AGAF, FACG, we can remind ourselves that, right now, we still have primarily a symptom-based diagnosis without a specific pathophysiology to make a “positive diagnosis” of IBS. It’s symptom-based, but we also need to exclude a few conditions that would drastically change our treatment approach.
Chey gives the examples of celiac disease or microscopic colitis. These are not IBS, but can mimic IBS. Depending on the patient’s symptoms, these conditions may need to be excluded through biopsies.
In diagnosis, we need flexibility to find the point where we are comfortable attributing the symptoms to IBS and not continuing to search for other diseases. That’s a dilemma that all of us face weekly or even daily. When do we stop and say these symptoms are compatible with IBS and we should treat them as such? Each GI physician needs to determine that tipping point for themselves and their patient population.
Additionally, we have to be aware of subtypes within that global IBS diagnosis, such as bile acid diarrhea, a secondary diagnosis made with a stool-based bile acid tests and now blood tests. This will present much like traditional IBS-D, but the treatments are vastly different.
After Diagnosis
After we make a diagnosis of IBS, it is important that we explain to patients that this is a common diagnosis. As there may be psychosocial implications, they should realize they are not alone in this journey. We have treatment options in the form of medications well explained by Lin Chang, MD, but treatment for this disease is not all pharmacotherapy. The mental health aspect of IBS should not be ignored. There are other lifestyle factors that we see as borne in this issue here by Megan Riehl, PsyD, and Kate Scarlata, RD.
IBS is a multifactorial process, so we as clinicians should have a low threshold for employing non-medical therapies – from fiber to hypnosis – and referring patients to the requisite specialist.
The low FODMAP diet is something with which we should have passing familiarity and know where to refer. Identify a dietitian in your community who is comfortable with low FODMAP and will work with your patients on their nutritional needs.
Similarly, with a psychologist, find a person in your area who is willing to see patients with GI disorders and talk to them about some of these newer modalities such as cognitive behavioral therapy or even hypnotherapy.
While most GI-specific psychologists are located in academic institutions and larger centers, there are more than there used to be. Still, they don’t have to be a GI psychologist. Often a local psychologist is as helpful to have on-hand for referrals, especially in IBS.
This is a condition where there’s often an overlay of psychological issues, and many patients recognize that when they’re under increased anxiety or stress, their symptoms are magnified. A trained psychologist can help with everyday stress and with health-related anxiety, such as Avoidant Restrictive Food Intake Disorder mentioned by Scarlata. We as physicians can see that some of our patients are paralyzed with fear that anything they eat will worsen their symptoms and it’s distressing. That level of anxiety can be helped by a psychology professional, even one who doesn’t specialize in GI disorders.
Grey Areas
I wish there was an easy answer, showing a black-and-white approach to diagnosis and management of IBS, but it still isn’t there. Until we move further into pathophysiology and identification of biomarkers of this very varied disease, we have to rule out the mimics before we can treat. Stay abreast of the newest treatments, but keep in mind that for IBS-C or IBS-D, neuromodulators like good old-fashioned amitriptyline and nortriptyline are always options.
Remember, too, that pharmacotherapy rarely has the last word in IBS. Patients are best treated through a combination of medical therapy, dietary changes and, in some cases, psychological counseling.
How are you diagnosing and treating IBS in your practice? Tweet us @HealioGastro and tag me: @EdwardLoftus2. Note our IBS experts are active on Twitter as well: Chey tweets under @umfooddoc, Scarlata actively uses @katescarlata_RD and Riehl offered up her username as @DrRiehl.
Disclosure: Loftus reports consulting for Janssen, Takeda, AbbVie, UCB Pharma, Amgen, Pfizer, Celgene, Gilead, Eli Lilly, CVS Caremark, Celltrion Healthcare, and Napo Pharma; and research support from Janssen, Takeda, AbbVie, UCB Pharma, Amgen, Pfizer, Celgene, Gilead, Robarts Clinical Trials, MedImmune, Allergan, Genentech, and Seres Therapeutics.