Practical Management of Irritable Bowel Syndrome

Darren Brenner, MD, spoke about making the diagnosis of IBS in primary care, the 8 Simple Rules of IBS diagnosis, and subtyping the disease.

Darren Brenner, MD is an associate professor of medicine and surgery at Northwestern University Feinberg School of Medicine.

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TRANSCRIPT:

DB: My name is Darren Brenner. I'm the associate professor of medicine and surgery in the Northwestern University Feinberg School of Medicine. I run our GI motility, functional bowel, and integrated bowel dysfunction programs.

I hope you had a good experience with our discussion this afternoon at PUPC. I hope there are a few key points that you took away from this conversation. First and foremost, I hope you feel much more comfortable with making the diagnosis of irritable bowel syndrome, whether it's diarrhea, constipation, or the mixed subtype.

As I mentioned during our discussion, the average individual suffers through three to four years before the diagnosis is made, and they see three to four practitioners. My goal was that you now understand that it should take about three to four minutes to make this diagnosis.

Remember, don't forget the eight simple rules for making the diagnosis of irritable bowel syndrome. The three rule‑in questions. Do you have pain or discomfort? Is it better or worse with a bowel movement? Do you notice a change in the frequency and/or the texture of your stools?

The five rule‑out questions. Are you over the age of 50? Over the age of 50, IBS becomes a diagnosis of exclusion. Are you having recurrent bleeding, or are you anemic? Is there unexplained weight loss? Is this an acute change in your bowel habits, or is there a family history of colorectal cancer, inflammatory bowel disease, or celiac?

If you answered yes to the first three and no to the first five, remember that the predictive value of these questions is about 97 to 98 percent accuracy for making the diagnosis of irritable bowel. Then don't forget the subtype. Is it IBS‑C, IBS‑D, or IBS‑M? It's those subtypes that differentiate the different diagnostic studies that we recommend.

If your patient has irritable bowel syndrome with constipation, go ahead and treat them. There are no tests that we recommend. Again, most patients do not need a colonoscopy before the diagnosis of IBS‑C is made.

If it's IBS‑D, then yes, we recommend that you test to rule out celiac because there are overlapping symptoms. Yes, you can order a stool fecal calprotectin to potentially rule out inflammatory bowel disease without needing a colonoscopy.

Then we talked about treatments. You can use the pharmaceuticals if you're comfortable with them. I know a lot of you have experience with diets like the low‑FODMAP diet, and it's absolutely fine.

About 60 percent of patients will feel better on a low‑FODMAP diet, especially with their abdominal symptoms, abdominal pain, discomfort, bloating and distension. When it comes to the bowel symptoms, people respond better to the low‑FODMAP diet if they had diarrhea, more so than constipation or the mixed subtype.

We have the complementary therapies. You can try peppermint oils. You can try probiotics although the data is not as strong. You can talk to one of our behavioral therapists that can use cognitive behavioral therapy or hypnotherapy, which has been shown in numerous trials to be effective for treating this syndrome as well.

One of the things we also discussed that I want to stress, fecal transplants. People are trying this. They are in vogue. For irritable bowel syndrome, they're just not ready for primetime yet, so I'm not recommending individuals use FMT to treat their patients with IBS.

Again, I hope you found our discussion informative. If you have any questions or concerns, I'm always happy to answer them. Thank you for your time.