1770

GUIDELINES

Guidelines on the irritable bowel syndrome: mechanisms and practical management

R Spiller, Q Aziz, F Creed, A Emmanuel, L Houghton, P Hungin, R Jones, D Kumar, G Rubin, N Trudgill, P Whorwell
................................................................................................................................... Gut 2007;56:17701798. doi: 10.1136/gut.2007.119446

Supplementary documents are available at http:// gut.bmj.com/supplemental See end of article for authors affiliations ........................ Correspondence to: Professor R C Spiller, The Wolfson Digestive Diseases Centre, University Hospital, Nottingham NG7 2UH, UK; robin.spiller@nottingham. ac.uk Revised 20 April 2007 Accepted 1 May 2007 Published online first 8 May 2007 ........................

Background: IBS affects 511% of the population of most countries. Prevalence peaks in the third and fourth decades, with a female predominance. Aim: To provide a guide for the assessment and management of adult patients with irritable bowel syndrome. Methods: Members of the Clinical Services Committee of The British Society of Gastroenterology were allocated particular areas to produce review documents. Literature searching included systematic searches using electronic databases such as Pubmed, EMBASE, MEDLINE, Web of Science, and Cochrane databases and extensive personal reference databases. Results: Patients can usefully be classified by predominant bowel habit. Few investigations are needed except when diarrhoea is a prominent feature. Alarm features may warrant further investigation. Adverse psychological features and somatisation are often present. Ascertaining the patients concerns and explaining symptoms in simple terms improves outcome. IBS is a heterogeneous condition with a range of treatments, each of which benefits a small proportion of patients. Treatment of associated anxiety and depression often improves bowel and other symptoms. Randomised placebo controlled trials show benefit as follows: cognitive behavioural therapy and psychodynamic interpersonal therapy improve coping; hypnotherapy benefits global symptoms in otherwise refractory patients; antispasmodics and tricyclic antidepressants improve pain; ispaghula improves pain and bowel habit; 5-HT3 antagonists improve global symptoms, diarrhoea, and pain but may rarely cause unexplained colitis; 5-HT4 agonists improve global symptoms, constipation, and bloating; selective serotonin reuptake inhibitors improve global symptoms. Conclusions: Better ways of identifying which patients will respond to specific treatments are urgently needed.

1 SCOPE AND PURPOSE

1.1 Aims These guidelines were compiled at the request of the Chairman of the Clinical Services Committee of the British Society of Gastroenterology. The committees aim was to provide a guide for the assessment and management of adult patients with irritable bowel syndrome (IBS). These patients comprise such a large proportion of gastroenterology outpatients that their streamlined and effective management would have a favourable effect on any gastroenterology departments overall performance, and hence improve the management of all gastrointestinal diseases. There are many questions to be addressed (box 1). These guidelines are designed to be applied to adults with IBS, though they are also likely to apply to most adolescents. The guideline committee was chosen from members of the British Society of Gastroenterology, aiming to include individuals with a longstanding interest and expertise in the topics to be discussed. Members were chosen to be representative of the spectrum of individuals likely to see such patients, including general practitioners, gastroenterologists from district general hospitals and university hospitals, surgeons and clinical physiologists. People who suffer from IBS and members of the United Kingdom based IBS Network were also shown this document and their comments have influenced the final version. The guidelines are aimed primarily at consultant gastroenterologists and trainees in gastroenterology, together with general practitioners with a special interest in gastroenterology. A summary form of this document is available with when to
www.gutjnl.com

refer advice for use in primary care (see page 82) which is available online at the Journal website (http://gut.bmj.com/ supplemental). 1.2 Development of guidelines Members of the committee were allocated particular areas to produce review documents for. Literature searching included systematic searches using electronic databases such as Pubmed, EMBASE, MEDLINE, Web of Science, and Cochrane databases and extensive personal reference databases. Citation of the literature is however selective and in particular many low quality studies were discounted. Special attention was paid to high quality studies which used established methodology and substantial patient numbers with clearly defined entry criteria. For trials of treatment, randomisation and placebo control were considered essential. These documents were collated and edited by the Chairman, and the resulting document discussed at a one day face to face meeting. Detailed internal review by members of the committee was followed by revision and teleconferences to establish a consensus. These documents were sent out to patient groups and for external independent review,
Abbreviations: CBT, cognitive behavioural therapy; CCK, cholecystokinin; CRF, corticotropin releasing factor; CRH, corticotrophin releasing hormone; EMA, endomysial antibodies; fMRI, functional magnetic resonance imaging; HPA, hypothalamo-pituitary-adrenal; IBS, irritable bowel syndrome; IBS-C, constipation predominant IBS; IBS-D, diarrhoea predominant IBS; IBS-M, IBS with mixed bowel pattern; MMC, migrating motor complex; NNT, number needed to treat; PIT, psychodynamic interpersonal therapy; RCT, randomised controlled trial; SSRI, selective serotonin reuptake inhibitor

Guidelines on the irritable bowel syndrome

1771

both nationally through the BSG Clinical Services Committee and Council and internationally. The final document represents the consensus of the committee, adjusted in response to reviewers and patients comments. 1.3 Link between supporting evidence and recommendations Evidence was graded according to the type of evidence, giving greatest emphasis to randomised, placebo controlled trials (RCTs). These grades were decreased if there were serious limitations to study quality, important inconsistencies between different studies, or uncertainty about the relevance of the particular study population for the group of patients under consideration. The grade was considered to be further reduced if data were sparse or there was a suggestion of reporting bias, but increased if the evidence of association was strong or if there was clear evidence of a doseresponse gradient. Combining the elements of study design, study quality, consistency, and directness, we followed the GRADE working group advice1 and categorised the quality of evidence as follows:

complaints as being not only self evident, but also part of the obligations of being a medical practitioner. Finally, we considered whether the intervention was likely to be cost-effective and what barriers there might be to its use in clinical practice. 1.4 Scheduled review of these guidelines These guidelines are presented on the BSG website and are freely available to all. They should be reviewed and revised within four years, depending on changes in evidence and clinical practice. Comments on the guidelines should be sent to the authors or posted on the BSG notice board. 1.5 Editorial independence This document represents a consensus view of the members of the working party and incorporates their response to reviewers comments. All members completed conflict of interest statements.

2 EPIDEMIOLOGY
2.1 Introduction IBS is a chronic, relapsing gastrointestinal problem, characterised by abdominal pain, bloating, and changes in bowel habit. While the precise prevalence and incidence depends on the criteria used, all studies agree that it is a common disorder, affecting a substantial proportion of individuals in the general population and presenting frequently to general practitioners and to specialists. IBS is troublesome, with a significant negative impact on quality of life and social functioning in many patients,25 but it is not known to be associated with the development of serious disease or with excess mortality. IBS generates significant health care costs, both direct, because of IBS symptoms and associated disorders, and indirect, because of time off work. 2.2 Definitions The first attempt to establish diagnostic criteria to define IBS was made in the 1970s by Manning and colleagues.6 The Manning criteria (box 2) were identified by comparing symptoms in patients with abdominal pain who turned out either to have or not to have organic disease. Over the past 10 years considerably more attention has been paid to IBS, and the successive Rome working parties have elaborated more detailed, accurate, and useful definitions of the syndrome. The Rome I criteria, which were published in 1990,7 adopted most of the Manning criteria but subsequent factor analysis indicated that items 13 clustered well together while 46 did not.8 9 The Rome II criteria which appeared in 199910 took account of this fact but also recognised that pain might be associated with hard as well as loose stools. The Rome III criteria in 200611 are shown in box 3. The majority of studies quoted below used Rome II criteria. Rome III modifies Rome II slightly by being more precise, specifying that pain must be present for three or more days a month in the past three months and that criteria need to be fulfilled for the past three months for the patient to be considered as currently having IBS. However, comparative studies suggest these subtle changes will have little effect on prevalence. The Rome III committee also advised that in pathophysiology research and clinical trials a pain/discomfort frequency of at least two days a week is recommended for subject eligibility. 2.3 Classification Recently attempts have been made to subclassify IBS according to the predominant bowel habit. Most studies report that around one third of patients have diarrhoea predominant IBS (IBS-D) and one third have constipation predominant IBS
www.gutjnl.com

N N N N

Highfurther research is very unlikely to change our confidence in the estimate of effect. Moderatefurther research is likely to have an important effect on our confidence in the estimated effect and may change the estimate. Lowfurther research is very likely to have an important impact on our confidence in the estimated effect and is likely to change the estimate. Very lowestimate of effect is very uncertain.

In making recommendations for any intervention, we then considered the trade-off between benefit and harm, categorised as follows:

N N N N

Net benefitthe intervention clearly does more good than harm. Trade-offthere are important trade-offs between the benefits and harm. Uncertain trade-offit is not clear whether the intervention does more good than harm. No net benefitsthe intervention clearly does not do more good than harm.

Our final recommendations are characterised slightly differently from the GRADE systems in that we classified as definitive a judgment that most informed people would make, and as qualified, a judgment that the majority of well informed clinicians would make but a substantial minority would not. It should be noted that many aspects of medical practice have not been formally evaluated using robust methodology; however, the committee still recommended some behaviours such as taking a careful history and listening to the patients

Box 1
Main questions to be addressed

N N N

What is the best way to identify IBS patients? What are the minimum number of relevant investigations? What is the optimum management? (This may include lifestyle adjustments, psychological treatments, dietary modification, and pharmacological treatments.)

1772

Spiller, Aziz, Creed, et al

(IBS-C), the remainder having a mixed bowel pattern (IBS-M) with both loose and hard stools.1214 However, most of the published data on the incidence, prevalence, and natural history of IBS do not distinguish these subtypes. Furthermore some individualsnow called alternators11switch subtype over time, mostly those with IBS-D or IBS-C switching to a mixed pattern, though in one study a change from IBS-D to IBS-C occurred in 29% over a one year period.14 2.4 Prevalence Most of our knowledge of the descriptive epidemiology of IBS has been obtained from the use of validated postal questionnaires, employing either the Manning or the Rome criteria, completed by individuals in the general population. We were able to identify 37 epidemiological studies of acceptable quality (table 1). Prevalence appears generally higher and more variable using Manning criteria, while Rome I and II yield comparable but less variable results. The number of Manning criteria (one to six) strongly influences the prevalence estimates, which range from 2.5% to 37%. Studies which require three criteria give prevalences of around 10%. The incidence is similar in many countries in spite of substantial differences in lifestylefor example, the incidence in Mexico is very similar to that in the USA.45 2.5 Predictors of health care seeking Consultation behaviour is likely to be an important determinant of the prevalence of clinically diagnosed IBS. It appears that 3390% of sufferers do not consult, and that a proportion of consulters meeting IBS criteria are not labelled as having IBS by their clinicians. Although the prevalence of IBS is relatively similar across Europe and the USA (Italy being an exception, with a higher incidence than the rest), the rate of undiagnosed IBS shows a wider variation, with the majority being undiagnosed in all countries except for Italy and the United Kingdom, where around 50% are diagnosed. Most data on prevalence and health care seeking behaviour are from community based samples, indicating that health care seeking behaviour is greater in this population and not just in the group of IBS patients with severe or longstanding symptoms. The main predictors of health care seeking are abdominal pain or distension, pain severity, and symptoms conforming to the Rome II criteria, although psychological and social factors also play a key role in the decision to seek medical advice.5357 Overall, health care seeking is greater in IBS patients than in non-IBS patients.16 17 5862 The frequency of IBS symptoms peaks in the third and fourth decades, and in most surveys there is a female predominance of approximately 2:1 in the 20s and 30s, although this bias is less apparent in older patients.63 IBS symptoms persist beyond middle life, and continue to be reported by a substantial proportion of individuals in their seventh and eighth decades.24

2.6 Natural history and prognosis Few studies have assessed the incidence of new cases of IBS, but those that have provide widely varying estimates of incidence (270/1000 patient years).40 6466 Most current IBS patients will have had symptoms for some years, the mean durations in recent clinical trials being 5, 11, and 13 years, depending on the source of the patients.6769 Such patients rarely develop other gastroenterological diseases, though the exact manifestations and stool pattern may change over the years. Once the diagnosis has been made, new diagnoses are rare and are likely to be coincidental.70 Few studies have examined the progression of IBS over time. One study in Scandinavia studied the stability of the diagnoses of dyspepsia and IBS in the population over one and seven year periods.65 This showed that 55% still had IBS at seven years, 13% were completely symptom-free, while 21% had lesser symptoms, no longer meeting the Rome I criteria. It appears that IBS is not associated with the long term development of any serious disease71 72 and there is no evidence that IBS is linked to excess mortality, although it has been shown that patients with IBS are more likely to undergo certain surgical operations, including hysterectomy and cholecystectomy, than matched non-IBS controls.18 Prognosis depends on the length of history, those with a long history being less likely to improve.7376 The other key prognostic factor is chronic ongoing life stress which virtually precluded recovery in one study in which no patient with ongoing life stresses recovered over a 16 month follow up, compared with 41% without such stresses.77

3 CLINICAL FEATURES OF IBS

The key features are chronic, recurring abdominal pain or discomfort associated with disturbed bowel habit, or both, in the absence of structural abnormalities likely to account for these symptoms. Symptoms should be present for at least six months to distinguish them from those caused by other conditions such as infections, where the effects are often transient, or progressive diseases such as bowel cancer, which are usually diagnosed within six months of symptom onset. 3.1 Symptoms As the Rome III criteria indicate (see 2.1), the key features are abdominal pain or discomfort which is clearly linked to bowel function, being either relieved by defecation (suggesting a colonic origin) or associated with change in stool frequency or consistency (suggesting a link to changes in intestinal transit,

Box 3
Rome III diagnostic criteria * for irritable bowel syndrome Recurrent abdominal pain or discomfort at least 3 days a month in the past 3 months, associated with two or more of the following:

Box 2
Manning criteria 1. Pain relieved by defecation 2. More frequent stools at onset of pain 3. Looser stools at onset of pain 4. Visible abdominal distension 5. Passage of mucus per rectum 6. Sense of incomplete evacuation

N N N

Improvement with defecation Onset associated with a change in frequency of stool Onset associated with a change in form (appearance) of stool

*Criteria fulfilled for the past 3 months with symptom onset at least 6 months before diagnosis. Discomfort means an uncomfortable sensation not described as pain.

www.gutjnl.com

Guidelines on the irritable bowel syndrome

1773

Table 1 Prevalence of irritable bowel syndrome in the United Kingdom and in other Western and Eastern populations, using Manning, Rome I, and Rome II diagnostic criteria
Prevalence and criteria used (%) Country UK UK UK UK UK UK USA USA USA USA USA USA USA USA USA Canada Canada Australia New Zealand Netherlands Spain Italy France Denmark Finland Sweden Iran Turkey Turkey Bangladesh Hong Kong Hong Kong Japan Singapore South China Singapore Malaysia Sample size 301 1620 1896 3179 3111 (PC*) 4807 789 566 835 325 5430 3022 643 643 5009 1149 437 2910 980 438 2000 533 20,000 4581 3631 1290 4762 998 1766 2426 1000 1298 231 696 4178 2276 949 Manning 13.6 22 9.5 16.7 2.5 10.5 17.1 15.0 8.7 to 17.0 4.9 to 10.9 11.6 20.0 8.6 to 20.4 6.8 14.1 13.5 16.7 18.8 5.8 4.4 to 13.6 8.5 6.6 9.7 to 16.2 14.0 13.1 2.5 3.3 4.7 Rome I Rome II Reference Thomson & Heaton, 198015 Jones & Lydeard, 199216 Heaton et al, 199217 Kennedy & Jones, 200018 Thomson et al, 200019 Wilson et al, 200520 Drossman et al, 198221 Sandler et al, 198422 Talley et al, 199123 Talley et al, 199224 Drossman et al, 199325 Talley et al, 199526 Saito et al, 200027 Saito et al, 200328 Hungin et al, 200529 Thompson et al, 200230 Li et al, 200331 Boyce et al, 200032 Barbezat et al, 200233 Boekema et al, 200134 Mearin et al, 200135 Gaburri et al, 198936 Coffin et al, 200437 Agreus et al, 199538 Hillila & Farkkila, 200439 Kay et al, 199440 Hoseini-Asl & Amra, 200341 Karaman et al, 200342 Celebi et al, 200443 Masud et al, 200144 Kwan et al, 200246 Lau et al, 200247 Schlemper et al, 199348 Ho et al, 199849 Xiong et al, 200450 Gwee et al, 200451 Rajendra & Alahuddin, 200452

4.7 5.5 5.1 5.8 19.1 6.3 8.5 6.6 3.7

17.4 25.0 2.3 13.0 11.0

10.4

8.6 15.7

*PC, primary care patients.

which might reflect changes in either motor patterns or secretion). Symptoms that are common in IBS but not part of the diagnostic criteria include those originally described by Manning6namely, bloating, abnormal stool form (hard and/ or loose), abnormal stool frequency (,36/week or .36/day), straining at defecation, urgency, feeling of incomplete evacuation, and the passage of mucus per rectum. Most patients experience symptoms intermittently, with flares lasting two to four days followed by periods of remission.78 79 One important exception is the subgroup of patients with pain which is felt continuously. The diagnosis in this case is usually functional abdominal pain, an unusual and particularly severe condition which needs early recognition, as such patients respond poorly to conventional treatment and often have severe underlying psychological disturbances.80

IBS is considered a painful condition and those with painless bowel dysfunction are labelled as having functional constipation or functional diarrhoea, though it is likely that some share underlying pathology with their respective IBS subtypes. 3.2 Stool patterns These vary widely and are the source of some confusion. The Rome II classification used a complex multidimensional set of criteria which included stool frequency, stool consistency, urgency, and straining. Unfortunately these features do not correlate well. Thus both straining and urgency can be seen with both hard and loose stools, which can also be associated with both frequent and infrequent defecation.12 The Rome III subclassification is based solely on stool consistency11 and is hence easier to apply. Patients with hard stools more than 25% of the time and loose stools less than 25% of the time are defined as IBS with constipation (IBS-C) while IBS with diarrhoea (IBS-D) patients have loose stools more than 25% of the time and hard stools less than 25% of the time. About one third to one half of IBS patients are IBS-mixed (IBS-M), who describe both hard and soft stools more than 25% of the time, with a small (4%) unclassified (IBS-U), with neither loose nor hard stools more than 25% of the time.12 Those whose bowel habit changes from one subtype to another during follow up over months and years are termed alternators (see 2.3). These simple categorisations miss some important details about bowel habits. One pattern, familiar to most clinicians but rarely studied, is repeated defecation in the morning (morning
www.gutjnl.com

Box 4
Helpful diagnostic behavioural features of irritable bowel syndrome in general practice:

N N N N

Symptoms present for more than 6 months Frequent consultations for non-gastrointestinal symptoms Previous medically unexplained symptoms Patient reports that stress aggravates symptoms

1774

Spiller, Aziz, Creed, et al

Box 5
Alarm features in irritable bowel syndrome

United Kingdom suggested that consultation style (see box 4) was also predictive of a final diagnosis of IBS.19

N N N N N N N N N

Age .50 years Short history of symptoms Documented weight loss Nocturnal symptoms Male sex Family history of colon cancer Anaemia Rectal bleeding Recent antibiotic use

rush), when stool consistency changes from an initial formed stool to a progressively looser stool as the colonic contents are cleared from left to right. This may best be thought of as an exaggerated colonic response to the stress of waking and starting the day. Regrettably these patterns have not been studied in detail and there is no evidence that such features are more characteristic of those with stress. Although 60% of IBS patients believe that stress aggravates their symptoms, this is also true of organic disease in 40%,19 so this is not helpful diagnostically in clinical practice. 3.3 Food related symptoms Many patients believe their symptoms are aggravated by meals and in this respect there is considerable overlap with functional dyspepsia, which is reported in from 42% to 87% of IBS patients.38 8184 Thus epigastric pain, nausea, vomiting, weight loss, and early satiety are also common. Furthermore, as the criteria originally developed by Manning6 were those that distinguished IBS from other gastrointestinal complaints including dyspepsia, aggravation by eating was excluded as a symptom from the definition. However, when symptoms were systematically investigated using a detailed diary, Ragnarsson found that, although 50% of patients said that defecation relieved their pain, in practice this only occurred within 30 minutes of defecation on 10% of occasions, whereas on 50% of occasions pain was aggravated within 90 minutes of eating.85 This may represent either symptoms originating in the small intestine or an exaggerated colonic response to food, which has been described in IBS by some86 but not all87 investigators. It may also reflect the increased sensitivity to intestinal distension induced by eating, an effect particularly obvious after fat ingestion.88 3.4 Limitations of the Rome criteria Several studies suggest that few clinicians systematically use the Rome II criteria89 but instead tend to rely more on a holistic approach which takes note of features beyond the gut. Primary care physicians are particularly well placed to make such assessments, while specialists, trained to focus solely on gastrointestinal symptoms, are in danger of missing these important clues. 3.5 Associated non-gastrointestinal symptoms Associated non-gastrointestinal symptoms include lethargy, backache, headache, urinary symptoms such as nocturia, frequency and urgency of micturition, incomplete bladder emptying, and in women, dyspareunia.90 These are important because they can result in patients being referred to other specialties, where they may receive inappropriate investigation or even treatment (see 2.6).91 92 Furthermore, there is evidence that these symptoms can be used clinically to improve diagnostic accuracy.93 A large study in primary care in the
www.gutjnl.com

3.6 Comorbidity with other diseases Between 20% and 50% of IBS patients also have fibromyalgia94 95; conversely IBS is common in several other chronic pain disorders,96 being found in 51% of patients with chronic fatigue syndrome, in 64% with temporomandibular joint disorder, and in 50% with chronic pelvic pain.9799 The lifetime rates of IBS in patients with these syndromes are even higher, being 77% in fibromyalgia, 92% in chronic fatigue syndrome, and 64% in temporomandibular joint disorder.100 Those with overlap syndromes tend to have more severe IBS.95 IBS patients in primary care with numerous other somatic complaints report higher levels of mood disorder, health anxiety, neuroticism, adverse life events, and reduced quality of life, and increased health care seeking.101 Systematic questioning to identify these comorbid disorders is helpful in identifying patients who are likely to have severe IBS and associated psychiatric disorder. 3.7 Psychological features At least half the IBS patients can be described as depressed, anxious, or hypochondriacal.64 96 102104 While previous studies suggested that this proportion was increased in secondary and tertiary care, more recent large population based surveys suggest that even non-consulters have increased psychological distress64 96 103 compared with people who do not have IBS. Studies from tertiary care suggest that up to two thirds have a psychiatric disordermost commonly anxiety or depressive disorder.102 104 105 The polysymptomatic nature of IBS suggests that hypochondriasis and somatisation106 may play a role in some patients. Recognising this will help, as it should indicate that focusing on specific bowel symptoms may not be profitable; thus avoiding endless investigation of new symptoms. The effectiveness of antidepressants and the response to anxiolytic treatment and some psychological treatments also argue for an important psychological component to IBS symptomatology in some patients.96 Symptoms may in many cases be caused by altered cerebral interpretation of gastrointestinal symptoms. These often subside during sleep. Waking from sleep with pain or diarrhoea is usually an indication that other diagnosis should be considered. 3.8 Alarm features While IBS should and can be diagnosed by its characteristic features, recognising when a patient does not have IBS is equally important. Several studies suggest that alarm features (box 5) improve the predictive value of the Rome criteria substantially in the outpatient setting. A follow up observational study lasting 24 months107 found that, in the absence of alarm features and after a full history, examination, and investigation, no IBS patients meeting the Rome II criteria had another diagnosis. By contrast, a substantial number of those not meeting the Rome II criteria were left with a final diagnosis of IBS, suggesting that the Rome criteria in the absence of alarm symptoms were highly specific but not particularly sensitive. A more recent study which looked at a range of alarm features found that age over 50 years at onset of symptoms, male sex, blood mixed in the stool, and blood on the toilet paper were all predictors of an organic diagnosis.108 Characteristic features of IBS in this study were pain on more than six occasions in the past year, pain that radiated outside the abdomen, and pain associated with looser bowel movements, all of which were much commoner in IBS than in patients with organic disease.108 Other features commoner in IBS than in organic lower gastrointestinal disease

Guidelines on the irritable bowel syndrome

1775

included incomplete evacuation, nausea, acid regurgitation, bloating, and a history of abdominal pain in childhood, which was found in a quarter of subjects. Broad spectrum antibiotics lead to transient diarrhoea in around 10% of cases, which if severe and persistent should lead to consideration of testing for C difficile toxin or sigmoidoscopy to exclude pseudomembranous colitis. This recommendation is based on expert opinion, as there are no data on the costeffectiveness of such an approach.

4.1.3 Candidate genes

Associations between various candidate genes and IBS have been studied. Polymorphisms of the serotonin transporter 5HTT, a adrenergic receptor, interleukin (IL)-10, and tumour necrosis factor a (TNFa) genes have been associated with some forms of IBS.122 123 The most intriguing of these studies found that 5-HTT polymorphisms were linked to a greater slowing of colonic transit in response to the 5-hydroxytryptamine 3 (5HT3) antagonist alosetron.124 However, published candidate gene studies often have small sample sizes and are therefore underpowered to detect what is likely to be a small effect. This is exacerbated by inadequate stratification for ethnicity and inherent difficulties in defining phenotype in IBS122 125 which lead to inconsistent results.126 Reported associations with 5-HTT polymorphisms may plausibly relate not to an association with IBS per se but rather to confounding by the recognised association of the polymorphisms with anxiety or somatisation.127 Somatisation also explains most of the reported familial aggregation,115 is largely genetically determined,128 129 and may be responsible for the genetic contribution to IBS noted in some twin studies.116118 Interpretation of genetic polymorphism studies is also hampered by the frequently poor replication of such associations, particularly from small studies.126 Familial aggregation of IBS appears from available evidence to result largely from environmental influences, such as parentalchild interactions. Genetic factors may make a minor contribution but future studies of this heterogeneous disease must establish IBS phenotypes more clearly and in particular allow for confounding because of psychological factors. 4.2 Disturbances of gastrointestinal motility Antecedent terms used to describe the clinical entity now known as IBS include spastic colon and irritable colon. These terms indicate that clinicians of the day thought that this condition reflected an underlying motility disorder. This perception is further supported by routine prescription of antispasmodic agents in the clinical management of IBS patients, though as we shall see in section 7, their efficacy is limited. Although motor disturbances do occur in IBS, these vary between patient subtypes130 and, as around one quarter of IBS patients change their bowel habit predominance at least once within a year,14 it is likely that motility patterns may also change with time.

3.9 Assessment of severity It is characteristic of IBS patients that the pain is reported as severe and debilitating and yet there are no abnormal physical findings. The patient has not lost weight and may look anxious but otherwise well. Several attempts have been made to assess severity.109 110 The functional bowel disorder severity index (FBDSI) uses severity of abdominal pain, the diagnosis of chronic functional abdominal pain, and the number doctor visits in the past six months to calculate an index which correlates reasonably well with physician rating of severity. The other index, the IBS severity scoring system (IBS SSS), also uses a visual analogue scale to measure severity of abdominal pain but includes an assessment of pain frequency, bloating, dissatisfaction with bowel habit, and interference with life. The score obtained with the IBS SSS can assess change over a relatively short period and has been used to assess response to treatment for audit purposes and in clinical trials.111 112 The patients view of severity is important. This is not related to the severity of symptoms but is associated with a degree to which the symptoms interfere with daily life.113

4 MECHANISMS OF IRRITABLE BOWEL SYNDROME

4.1 Genetics and family learning Clinicians have long been aware that a family history of IBS is of value in establishing the diagnosis of this condition.114 IBS clearly aggregates within families. First degree relatives of IBS patients are twice as likely to have IBS as the relatives of the IBS patients spouse.115 Such studies cannot, however, distinguish the influence of genetic and shared environmental factors.

4.1.1 Twin studies

These assume that monozygotic (MZ) and dizygotic (DZ) twin pairs are exposed to the same family environment and therefore any greater similarity or concordance between MZ twins is caused by genetic influences. Two studies have reported higher concordance rates for diagnosed functional bowel disorders among MZ twins, suggesting a genetic contribution to IBS.116 117 However, Levy et al noted that among DZ twins, parent/child concordance was greater than concordance between the twins.117 As a parent and child share a similar number of genes to a pair of DZ twins, this strongly suggests that parentchild interactions are more important than genetic influences. A recent study of IBS symptoms using the Rome II criteria found no difference in concordance rates in MZ and DZ twins, suggesting no significant genetic contribution to IBS.118 In summary, twin studies suggest a strong environmental contribution to IBS and possibly a minor genetic contribution.

4.2.1 Alterations of gastric motility

A proportion of IBS patients have delayed gastric emptying, particularly of solids.82 131135 This appears is especially noticeable in patients with constipation133 or those with overlapping dyspeptic symptoms.82 Disturbed gastric emptying correlates highly with a lack of a postprandial increase in electrogastrography (EGG) amplitude (r = 0.8; p,0.005).136 Furthermore, emotions such as anger suppress antral contractility in IBS patients but increase it in healthy volunteers.137

4.2.2 Abnormalities of small bowel motility

While various abnormalities of small bowel motor activity have been demonstrated in IBS under study conditions, none appears to be specific for the condition. Small bowel motility shows marked diurnal variability and hence consistent results can only be obtained with prolonged (at least 24 hour) recordings and large numbers of subjects. This may account for some inconsistencies in published reports, as many studies have been small and of short duration. Small bowel motor disturbances reported include: increased frequency and duration of discrete cluster contractions,138141 increased frequency of the migrating motor complex (MMC),140142 more retrograde
www.gutjnl.com

4.1.2 Parental influences

Parental reinforcement of illness behaviour and children modelling their parents behaviour are likely to contribute to the development of IBS. Children of IBS patients make more health care visits,119 complain of more gastrointestinal and nongastrointestinal symptoms, and have more school absences.120 Parental encouragement of the sick role during menstruation or colds is associated with more absenteeism and more menstrual and non-gynaecological symptoms, respectively.121

1776

Spiller, Aziz, Creed, et al

duodenal and jejunal contractions,140 143 and an exaggerated motor response to meal ingestion,140 142 ileal distension, and cholecystokinin (CCK).142 Corticotrophin releasing hormone (CRH) has been reported to increase the number of discrete cluster contractions.144 These observations appear more relevant to IBS patients with diarrhoea than with constipation.139142 Small bowel transit is faster in IBS patients with diarrhoea than with constipation145 and, in contrast to healthy controls, colonic distension does not appear to reduce duodenal motility in IBS patients, suggesting an impaired intestino-intestinal inhibitory reflex.146

which is available on the journal website (http://www.gutjnl.com/supplemental). 4.3 Visceral hypersensitivity Abdominal pain and discomfort cause considerable morbidity in IBS patients and are essential components of the diagnostic criteria.10 11 Approximately two thirds of the patients show enhanced pain sensitivity to experimental gut stimulation, a phenomenon known as visceral hypersensitivity. Visceral hypersensitivity is thought to play an important role in the development of chronic pain and discomfort in IBS patients.185 186

4.2.3 Colonic response to feeding and emotion

As the predominant symptom in IBS is a change in defecatory habit, colonic dysmotility was initially thought to be the likely cause. The most consistent motor abnormality recorded in the colon is an exaggerated motility response to meal ingestion.105 130 147151 Enhanced colonic motility in response to emotional stress,152 CRH,144 CCK151 153 and recto-sigmoid balloon distension has also been reported in IBS.154 However, not all studies have reproduced these findings155159 and studies under fasting conditions are even more variable.151 160163 Some of this confusion might be explained because earlier studies failed to distinguish subtypes of IBS, yet we now know that IBS patients with diarrhoea appear to have increased colonic motilityparticularly the number of high amplitude propagating contractions (HAPCs)151 154and accelerated colonic transit,145 164 while those with constipation have reduced motility, fewer HAPCs, and delayed transit.145 154 165167 The significance of bowel habit is further emphasised by the recent observations that postprandial platelet-depleted plasma 5-HT concentrationsa possible mediator of colonic motility168are increased in patients with diarrhoea but reduced in those with constipation predominant IBS.169 Interestingly, postprandial distal colonic tone has been shown to be reduced in patients with both constipation170 and diarrhoea171 172 but not to differ significantly from healthy controls under fasting conditions.173

4.3.1 Mechanisms of visceral hypersensitivity

Both animal and human studies suggest that visceral hypersensitivity is caused by a combination of factors that involve heightened sensitivity of both the peripheral and the central nervous system. Mechanisms that lead to heightened nervous system sensitivity have been well described in models of inflammation or injury to tissues, and these will be briefly outlined.
4.3.1.1 Peripheral sensitisation

During tissue injury and inflammation, peripheral nociceptor terminals are exposed to a mixture of immune and inflammatory mediators such as prostaglandins, leukotrienes, serotonin, histamine, cytokines, neurotrophic factors, and reactive metabolites.187 188 These inflammatory mediators act on nociceptor terminals, leading to the activation of intracellular signalling pathways, which in turn upregulate their sensitivity and excitability. This phenomenon has been termed peripheral sensitisation. Peripheral sensitisation is believed to cause pain hypersensitivity at the site of injury or inflammation, also known as primary hyperalgesia (increased sensitivity to painful stimuli) and allodynia (non-painful stimuli perceived as painful).189 190
4.3.1.2 Central sensitisation

4.2.4 Rectal compliance and tension

Rectal motor physiology has been mainly studied with respect to compliance and tension, with some174177 but not all studies154 177182 reporting lower rectal compliance or increased tension, or both, in patients with IBS. This has been proposed as a possible mechanism for enhanced visceral sensation to balloon distension in IBS.183

A secondary consequence of peripheral sensitisation is the development of an area of hypersensitivity in the surrounding uninjured tissue (secondary hyperalgesia/allodynia). This phenomenon occurs because of an increase in the excitability and receptive fields of spinal neurones and results in recruitment and amplification of both non-nociceptive and nociceptive inputs from the adjacent healthy tissue.191

4.2.5 Relation between motor patterns and symptoms

Whether the above changes in gastrointestinal motility account for the symptoms of IBS continues to be debated, but one study has shown that over 90% of HAPCs coincide with abdominal pain or cramps, while 40% of postprandial HAPCs occurred immediately before defecation in IBS patients with diarrhoea.151 Small bowel disturbances, such as discrete cluster contractions, are also associated with pain,138 139 141 142 while higher rates of duodenal retrograde contractions during phase II of the MMC directly correlate with worsening gastrointestinal symptoms in IBS patients with diarrhoea.140 Gastric dysmotility may be associated with dyspeptic symptoms in some patients with IBS,82 184 although not all studies have found such a correlation.131 Finally, it must be recalled that many of the phasic motor events described above occur in healthy subjects, albeit at a lower incidence, and are not associated with concomitant symptomatology, suggesting that in IBS heightened visceral sensation may also play an important role in the perception of these motor events (see 4.3). A comprehensive summary of all the above studies on motility in IBS is provided in appendix 1,
www.gutjnl.com

4.3.2 Evidence of sensitisation in IBS

Depending on the setting, between 6% and 17% of patients with IBS report that their symptoms began with an episode of gut inflammation related to gastroenteritis.192 Furthermore, an increase in mucosal T lymphocytes has been reported by several investigators in subjects with postinfectious IBS (see 4.5). Therefore the environment of nociceptor terminals in the gut of IBS patients is likely to be altered, suggesting a role for peripheral sensitisation. Evidence for central sensitisation as an important mechanism for the development of visceral hypersensitivity in IBS patients comes from three main observations. First, in response to colonic stimulation, patients with IBS have greater radiation of pain to somatic structures in comparison with healthy subjects.193 Second, some IBS patients also suffer from fibromyalgia, a condition characterised by somatic hyperalgesia.194 Finally, patients with IBS also often show hypersensitivity of more proximal regions of the gut.186 These observations may be explained by the fact that the innervation of different gut organs overlaps and converges with that of the somatic structures at the level of the spinal cord. Therefore the

Guidelines on the irritable bowel syndrome

1777

sensitisation of proximal organs in IBS patients, and greater radiation of pain to somatic structures in response to visceral stimulation in patients who also have fibromyalgia, could all be explained by the phenomenon of central sensitisation of the spinal segments that demonstrate this viscero-visceral and viscero-somatic convergence.

4.3.3 Central pain processing

Peripheral and central sensitisation are by no means the only mechanisms that can explain the development of visceral hypersensitivity observed in IBS patients. This is because the perception of pain in humans involves processing of sensory inputs in various cortical and subcortical brain structures. Our understanding of the brain processing of visceral sensation has improved significantly because of the availability of functional brain imaging techniques such as cortical evoked potentials, magnetoencephalography, functional magnetic resonance imaging (fMRI), and positron emission tomography (PET). These functional brain imaging studies have shown that, like somatic sensation, visceral sensation is represented in both the primary (S1) and the secondary somatosensory cortex (S2), and this representation most probably mediates the sensory discriminative aspects of sensation. Furthermore, visceral sensation is also represented in the paralimbic and limbic structures such as the anterior insula, anterior cingulate, and prefrontal cortices.195 196 These areas are likely to mediate the affective and cognitive components of visceral sensation. Activation of subcortical regions such as the thalamus and periaqueductal grey matter in response to rectal stimulation has also been demonstrated.196

activation patterns in IBS patients have been reported, and the role of these functional brain imaging studies is not clearly established in helping us to understand the mechanism of visceral hypersensitivity in IBS patients.204 The main reason for this is that most of the functional brain imaging techniques used so far in assessing the brain processing of visceral sensation in IBS patients have relied on techniques such as fMRI and PET. These techniques image minute changes in cortical blood flow in response to a stimulus and, because of the very small effects being measured, require group studies to detect significant differences. As visceral hypersensitivity in IBS patients may be caused by a variety of mechanisms, unless the groups under study consist of a very homogeneous population with similar mechanisms, significant differences are hard to detect. In contrast, studies using neurophysiological techniques such as cortical evoked potentials and magnetoencephalography rely on identifying electromagnetic fields generated in response to a peripheral stimulus and can be used to study individual patients. Recently, cortical evoked potentials have been used in non-cardiac chest pain patients and the results suggest that it may be possible to differentiate visceral hypersensitivity caused by sensitisation of afferent nerves from that caused by psychological influences.205

4.3.6 Summary
Patients with IBS characteristically complain of abdominal pain. A proportion of these patients display heightened pain sensitivity to experimental gut stimulation (visceral hypersensitivity). Chronic pain in these patients can occur through various central and peripheral mechanisms. The challenge for the future is to be able to differentiate between these mechanisms so that patients can be treated more specifically. 4.4 Stress response

4.3.4 Descending and spinal modulation of pain processing

Animal studies have shown that stimulation of the periaqueductal grey matter in the midbrain inhibits behavioural responses to noxious stimulation because of inhibition of spinal neurones.197 The periaqueductal grey matter receives direct inputs from the hypothalamus and the limbic cortex and controls spinal nociceptive transmission through descending pathways. These selectively target the dorsal horn laminae that house the nociceptive relay neurones. This circuit can therefore selectively modulate nociceptive transmission by its anatomical proximity to central ends of the primary afferent nociceptor terminals and dorsal horn neurones that respond to noxious stimulation. Furthermore, some neurones in the dorsal horn of the spinal cord are strongly inhibited when a nociceptive stimulus is applied to any part of the body, distinct from their excitatory receptive fields. This phenomenon is termed diffuse noxious inhibitory control (DNIC)198 and refers to a neurophysiological mechanism that underlies the long established clinical phenomenon of counterirritation, in which application of an acute aversive stimulus provides temporary relief of chronic and recurrent pain.199 Several animal and human studies have assessed the role of spinal nociceptive processes using DNIC paradigms and have demonstrated hyperexcitability of spinal nociceptive processes in a subgroup of IBS patients associated with failure of descending inhibitory control.200

4.4.1 The hypothalamo-pituitary-adrenal axis

The response of an organism to external stressors is mediated through the integration of the hypothalamo-pituitary-adrenal (HPA) axis and the sympathetic branch of the autonomic nervous system with the host immune system.206 A potential novel aetiopathological model for IBS combines the classical observation of high levels of anxiety in IBS patients and the demographic similarity between patients with IBS and other functional disorders (such as fibromyalgia and chronic fatigue syndrome). The model proposes altered central stress circuits, in predisposed individuals, which are triggered by external stressors resulting in the development of gut and extraintestinal symptoms. The HPA axis is part of that circuit: in the hypothalamus, paraventricular nucleus neurones release corticotropin releasing factor (CRF), which stimulates anterior pituitary secretion of adrenocorticotropin hormone (ACTH). This in turn acts on the adrenal medulla, resulting in cortisol secretion into the circulation. Release of CRF is dependent on input from the limbic structures in the brain and from peripheral feedback by ACTH and cortisol. The production and release of CRF is therefore under multiple control systems, reflecting the pluripotent role of this peptide in controlling autonomic, immunological, and emotional responses to stress.207 Circulating peripheral levels of CRF do not reflect levels released into the hypophyseal circulation, so HPA axis activity is traditionally assessed by ACTH and cortisol measurements.

4.3.5 Altered central processing

Brain imaging studies have begun to address the possible neural mechanisms of hypersensitivity in IBS patients, and a common finding has been that, compared with healthy controls, patients with IBS show altered or enhanced activation of regions involved in pain processing, such as the anterior cingulate cortex, thalamus, insula, and prefrontal cortex, in response to experimental rectal pain.201203 However, variable

4.4.2 Neuroimmune interactions

The emerging recognition that a distinct subgroup of IBS patients develops postinfectious IBS has led to the speculation that altered HPA axis activity may be causally involved in generating symptoms. The persistence of chronic inflammatory
www.gutjnl.com

1778

Spiller, Aziz, Creed, et al

mucosal changes and enterochromaffin cell hyperplasia that persists after eradication of the infectious organism208 are consistent with an inadequate physiological response to acute gut inflammation, in particular an inadequate cortisol or altered sympathetic response. The key interplay between the autonomic nervous system and the HPA axis in regulating gut mucosal immunology has led to a rapidly emerging body of work looking at how the stress response, which activates both these effector systems, may be aetiologically important in IBS. The stress response may thus be of central pathophysiological importance in uniting the sensory, motor, immunological, and possibly even genetic abnormalities that have been observed in IBS. Epidemiological observations have pointed to the importance of environmental stressors both in predisposing towards developing IBS and in perpetuating the symptoms of IBS. Previous life stressors209211 and past exposure to childhood abuse212 predispose to the risk of developing IBS in later life. Psychiatric illness episodes or anxiety-provoking situations preceded the onset of bowel symptoms in two thirds of IBS patients attending outpatients,213 and IBS patients report significantly more negative life events than matched peptic ulcer patients.210 Additionally, psychological traits such as hypochondriasis,214 anxiety, and depression predispose previously healthy individuals who develop gastroenteritis to developing symptoms of IBS.215

coeruleus, and hypothalamus.228 These structures are closely interconnected and it is suggested that the amygdala processes the emotional component of the response to stress, the locus coeruleus the autonomic response, and the hypothalamus the endocrine response.227

4.4.5 Implications for treatment

This ever increasing understanding offers the potential for manipulating the stress response to provide novel treatments for IBS. Potential mechanisms include non-specific approaches, such as with tricyclic antidepressants,227 or the use of selective compounds, such as the CRF antagonists. The potential for these latter drugs is enormous, given the core role of CRF in modulating the stress response.229 4.5 Postinfective IBS A small subgroup of IBS patients relate the onset of their symptoms to a bout of infectious gastroenteritis and these have proved a useful model in helping to understand other nonpostinfectious types of IBS. The prevalence of postinfective IBS varies from 17% in primary care in the United Kingdom to as little as 6% in tertiary care in the USA.192 Population surveys indicate a relative risk of 11.1230 to 11.9231 of developing IBS in the year following a bout of gastroenteritis. Such IBS patients are an attractive group in whom to study the mechanisms underlying IBS as they represent natures experiment, with less confounding by psychological factors and a clearly defined start date.

4.4.3 Abnormalities of emotional motor system

Allied to the evidence from animal experiments, clinical observations, and brain imaging studies, these epidemiological data have led to the development of the notion of a central emotional motor system.216 The outputs from this system probably involve the HPA, which is the key endocrine stress system in humans.217 218 The inputs to this system involve both altered visceral sensory input178 219 and altered visceral perception.220 221 It is likely that the autonomic nervous system is of prime importance to these input and output circuits, given its neuroanatomical and neurophysiological connections, and there is increasing evidence of autonomic dysfunction in IBS.144 222 223 In terms of motor change, diarrhoea predominant IBS seems to be associated with sympathetic adrenergic dysfunction while constipation predominant IBS seems to be associated with parasympathetic dysfunction.224 225 Approximately three quarters of patients report that stress leads to acute abdominal pain and changes in stool pattern.21 In terms of sensory change, recent evidence has pointed to a dissociation between visceral sensitivity and autonomic function in IBS patients in response to acute physical and psychological stress.223 This would suggest involvement of a different regulatory mechanism (either central or peripheral) in IBS patients in response to stress. That this mechanism may be endocrine is suggested by the finding that a subgroup of IBS patients has an exaggerated endocrine stress response, as shown by a heightened release of ACTH and cortisol in response to exogenous CRF administration.217 226 This exaggerated stress HPA response seems to be associated with mucosal immune activation.226

4.5.1 Risk factors

Known risk factors in order of importance include the severity of the initial illness, bacterial toxigenicity,232 female sex, a range of adverse psychological factors including neuroticism, hypochondriasis,233 anxiety, and depression,215 and adverse life events214 (for a review see Spiller208). Postinfective IBS has been reported after shigella,234 salmonella,235 236 and campylobacter215 infections and does not appear specific to any particular organism.237

4.5.2 Mucosal abnormalities

Histological studies indicate that postinfective IBS is characterised by increased lymphocyte numbers in mucosal biopsies,215 234 an effect which is seen throughout the colon.234 Where the terminal ileum has been biopsied, increased mast cells have also been noted.234 Another change following inflammation is enterochromaffin cell hyperplasia, a feature which, as animal models demonstrate, is dependent on functioning T cells.238 While in most subjects this change resolves over the ensuing three months, in postinfective IBS levels of both lymphocytes and enteroendocrine cells remain raised.215 Failure of resolution of inflammation has also been documented in several studies showing persistent elevation of interleukin-1b mRNA expression, implying impairment of downregulation of inflammation.234 239 Increased enterochromaffin cell numbers are associated with an increase in postprandial 5-HT release, an abnormality shown both in postinfective IBS240 and in diarrhoea predominant IBS without an obvious postinfective origin.169 Immediately after gastroenteritis affecting the small bowel there may be transient lactose intolerance which is particularly obvious in young children. However, in adults with postinfective IBS, who by definition have had symptoms for over six months, the incidence of lactose malabsorption is no different from uninfected controls.241

4.4.4 Imaging the stress response

An additional way to study the stress response in IBS has been to employ functional brain imaging techniques. The ventral portion of the anterior cingulate cortex and, to a lesser extent, the medial prefrontal cortex have repeatedly been shown to be differentially activated by rectal balloon distension in IBS patients compared with controls.196 This activation is heightened by acute stress.227 Taken together with established neuroanatomical knowledge, it has been proposed that the response to acute stress is coordinated by the amygdala, locus
www.gutjnl.com

4.5.3 Gut permeability

Another abnormality found in most individuals suffering from bacterial gastroenteritis is increased gut permeability.242

Guidelines on the irritable bowel syndrome

1779

Moreover, persistently increased gut permeability is seen in those who develop postinfective IBS, as was reported in the Walkerton health study.243 In that study of 105 new cases of IBS following infection with E coli and Campylobacter jejuni, a lactulose/mannitol ratio of .0.02 was seen in 35% of IBS cases compared with just 13% of non-IBS controls.243 This increased permeability, which would allow access of bacterial products to the lamina propria, could be a mechanism for perpetuating chronic inflammation.

4.5.4 Neuroimmune mechanisms

As stress and mucosal abnormalities are known to interact and contribute equally to the development of postinfective IBS,214 215 it is possible that stress, by activating mast cells, may contribute to persistently increased gut permeability and hence to immune activation. This stress effect has been demonstrated in numerous animal models.244 245 Recent studies suggest that, regardless of bowel habit subtype, IBS patients may show evidence of an ongoing immune activation.246 A genetic tendency to underproduce IL-10 might pre-dispose to this, as an abnormally small number of high IL-10 producing genotypes has been reported in IBS247 (though a recent smaller study has failed to confirm this248). 4.6 Bloating Abdominal bloating is reported by up to 96% of patients with IBS, is more common in female patients, and is often ranked as their most bothersome symptom.249 However, its presence in other functional disorderssuch as functional dyspepsia and chronic constipation, and indeed even in healthy subjects means that it is not considered a diagnostic criterion but a supportive symptom of IBS.11 Sufferers typically report a worsening of bloating as the day progresses, particularly after meals, with the symptom usually improving or disappearing overnight, which helps to distinguish if from more sinister causes of abdominal swelling such as ascites or an ovarian cyst.250 251 This increase in the sensation of bloating may or may not be associated with an increase in abdominal girth (that is, distension), which if present can reach 12 cm.251 Distension only correlates with bloating in IBS-C patients, who suffer from this more frequently (60%) than those with IBS-D (40%).251 Men do not appear to complain of bloating or distension as often as women, although this may partly reflect the fact that they often describe the symptom in different language, referring to it as tightness or hardness of the abdomen.

bloating alone have lower sensory thresholds, whereas those with bloating and distension have normal or slightly higher sensory thresholds.261 Thus bloating alonewhich tends to be commoner in IBS-Dmay be more of a sensory problem, whereas bloating with distensionwhich tends to be commoner in IBS-Cmay be more of a mechanical problem. However, computed tomography of the abdomen in distended IBS patients has shown that distension is not caused by voluntary protrusion of the abdomen or exaggerated lumbar lordosis.254 Moreover, electromyographic assessment of the anterior abdominal musculature in distended and healthy subjects revealed no differences.262 However, rectal infusion of gas was shown to be associated with paradoxical relaxation of the internal oblique muscle in patients with distension compared with an increase seen in healthy volunteers,263 suggesting an abnormality in an abdominal accommodation reflex irrespective of its strength.

5 CLINICAL HISTORY AND INVESTIGATION

Appropriate management is highly dependent on the information obtained at the time of the initial consultation and in almost all cases the diagnosis of IBS can be made on the basis of clinical history alone, integrating the many features listed below to come to a final conclusion. 5.1 History of symptoms The patient should be allowed to tell their story in their own words to ensure that they feel the doctor has understood their concerns, as previous consultations may have been unsatisfactory in this respect. The clinician should make an effort to understand the psychosocial factors which might have led the patient to seek help at this particular time. Modern medical education emphasises the benefits of optimal consultation techniques designed to elicit a therapeutic alliance between patient and physician. These include optimal eye contact, body language which conveys empathy, and open ended questioning designed to elicit the patients ideas and thus ensure their concerns and expectations are met. While much of this is based on cultural expectations, there is some evidence that such practice can reduce reconsultation rates.264 Approximately half the consulting patients believe they have serious disease such as cancer.265 Disease or death in close relatives is a frequent cause of health anxieties, and understanding the patients concerns will make it much easier to reassure them and to achieve a satisfactory consultation. It may then be appropriate to make a more specific inquiry about the chronology of key symptoms and possible precipitating factors such as gastroenteritis.

4.6.1 Mechanisms
While many patients attribute their bloating to trapped wind, studies have generally failed to show excessive intra-abdominal gas.249 252254 Indeed in studies where 10 times the normal amount of gas present in the gut was infused into the intestine, it resulted in less than half the mean increase in abdominal distension seen in IBS (that is, ,2 cm).252 Thus abnormal gas volume cannot be the sole cause of distension and bloating, although there is evidence of impaired gas transit in these patients.252 255 256 The observation that bloating only strongly correlates with distension in patients with IBS-C251 suggests that the pathophysiology is likely to be multifactorial and may differ between the bowel habit subtypes. Indeed there is evidence that small bowel transit257 may be delayed in IBS patients with bloating and subjective reports of distension. This is supported by recent objective measures of girth using the validated technique of abdominal inductance plethysmography,258 259 which showed that IBS-C patients with delayed large bowel transit distended significantly more than IBS-C patients with normal transit.260 Using this technique it has also been shown that, compared with healthy subjects, patients with

5.1.1 Features of pain

Key symptoms include the pattern of pain or discomfort, the nature of the associated bowel disturbance, and abnormalities of defecation. Pain relieved by defecation or associated with changes in stool consistency or frequency is usually intestinal in origin. Pain without these associations should lead to careful consideration of other conditions including neoplasms and inflammatory bowel, urogenital, or musculoskeletal diseases.

5.1.2 Constant pain

Constant unrelieved pain may reflect neoplastic pain or be due to functional abdominal pain syndrome.80 This is a particularly difficult syndrome to manage, commonly associated with complex psychiatric problems including possible personality disorder.
www.gutjnl.com

1780

Spiller, Aziz, Creed, et al

5.1.3 Disordered bowel habit

Clarification of exactly what the patient means by the terms diarrhoea and constipation is vital, and the Bristol stool form score is an easy way to do this without misunderstanding.266 It should be recognised that the patient may experience both loose and hard stools within a short period, and around half fit the category of mixed bowel habit rather than either diarrhoea or constipation.11 Other features that may trouble the patient are bloating (see 4.6), straining, incomplete evacuation, passage of mucus per rectum, urgency, and sometimes incontinence. In addition to inquiring about individual symptoms, their severity should be ascertained, as different patients rank different symptoms including extracolonic featuresas the most intrusive aspect of their problem. The recognition of the association of extracolonic symptoms with IBS is important as already discussed (see 3.5), as this can avoid unnecessary investigation as well as inappropriate referral to other specialties. Patients are often relieved to know about the association of these features with IBS, as they frequently feel that underlying pathology is being overlooked. Indeed it may be helpful to point out that having multiple somatic complaints makes it more likely that they have a functional rather than an organic disorder. 5.2 Psychological factors Approximately two thirds of IBS patients referred to secondary care show some form of psychological distress, most commonly anxiety. This may not necessarily be easily recognised, as some patients are reluctant to expose their feelings, whereas normal anxiety about unexplained symptoms may be mistakenly judged as abnormal. Hostility may be apparent, particularly in patients who feel dissatisfied with previous consultations with doctors, whom they felt expressed little sympathy. It is vital that any ongoing severe stress, especially of a domestic nature, is identified, as it has been shown this impairs the response to treatment.77 Multiple unexplained physical symptoms are common in IBS19 and can be a manifestation of somatisation disorder. This complicates the interpretation of symptoms and response to treatment in IBS (see 5.8.2). 5.3 Family history It is also important to inquire about a family history of inflammatory bowel disease or colon cancer, particularly below the age of 50, as this will influence patients concerns and expectations and should correctly lower the threshold for investigation. 5.4 Dietary considerations Almost all patients with IBS will have tried some form of dietary manipulation and in some instances this can lead to the adoption of bizarre diets that may be nutritionally inadequate. It should be remembered that favourite foods or foods that are taken regularly without the chance of observing the effects of withdrawal are more likely to be causing trouble, so a careful history is worthwhile to identify ingestion of abnormal amounts of fruit, caffeine, dairy products, and dietary fibre, particularly bran. It has been shown that a tendency to an eating disorder is quite common in female IBS patients and the two conditions can therefore exacerbate each other (the role of dietary manipulations is dealt with in section 7.1). 5.5 Precipitating and exacerbating factors A small proportion of patients, varying from 17% in primary care in the United Kingdom to 6% in a university outpatient clinic in the USA,192 will date their IBS to an episode of gastroenteritis or food poisoning. Other events that might
www.gutjnl.com

cause problems, even in normal individuals, tend to cause an exaggerated response in IBS. Thus menstruation or the administration of drugs such as antibiotics,267 non-steroidal anti-inflammatory drugs (NSAIDs), or statins may exacerbate symptoms. IBS symptoms can also be exacerbated by stress. Smoking or alcohol in moderation do not seem to affect the course of IBS. If an analgesic is required, paracetamol is preferred to opiates or NSAIDs as it is less likely to disturb bowel function.

5.6 Physical examination Physical examination usually reveals no relevant abnormality. General examination for signs of systemic disease should be followed by abdominal examination. This includes asking the patient to demonstrate the area of pain. Note should be made of whether pain is diffuse (expressed by an outstretched hand) or localised (pointing with a finger). Visceral pain is poorly localised, so pain which is well localised is atypical and should suggest possible alternative diagnoses. Abdominal wall pain originating from hernia, local muscle injury, or trapped nerves can be readily identified by Carnetts test. This involves asking the patient to fold their arms across their chest and raise their head off the pillow against gentle resistance from the physicians hand. Exacerbation of the pain is a positive Carnetts test. A recent study showed that abdominal wall pain is a secure diagnosis which rarely needs to be revised.268 Pain localised to the rib cage can also be a source of confusion. The painful rib syndrome, characterised by point tenderness and pain on springing the rib cage, has a benign course and its recognition can save much unnecessary and futile testing.269 270 Examination of the perianal region and rectum will be appropriate in most cases, especially those with diarrhoea, rectal bleeding, or disordered defecation. Those with rectal bleeding or diarrhoea should also have an endoscopic examination to exclude local pathology including colitis, haemorrhoids, or rectal cancer. This can either be a limited sigmoidoscopy in the clinic or as a planned procedure soon after. Those with a family history of colorectal cancer or those over 50 with recent onset of symptoms (less than six months), including a change in bowel habit, should also be considered for colonoscopy (see 5.8.3). 5.7 Alarm features (see box 5) Rectal bleeding, anaemia, weight loss, nocturnal symptoms, a family history of colon cancer, abnormal physical examination, recent antibiotic use, age of onset more than 50 years, and a short history of symptoms should all lead to careful evaluation before a diagnosis of IBS is made108 271 because of the possibility of an inflammatory or neoplastic cause. However, it should be recognised that minor bleeding from the anus, usually combined with anal discomfort, is extremely common and should not exclude an IBS diagnosis, even though an examination may be needed to reassure the patient and clinician. The Association of Coloproctologists of Great Britain and Ireland guidelines on management of colorectal cancer recommend that rectal bleeding combined with a change in bowel habit and in the absence of anal symptoms should be fully investigated, as a significant number will have colorectal cancer (www.acpgbi.org.uk/download/GUIDELINES-bowelcancer.pdf). A large recent study in an unselected gastroenterology outpatient clinic in Australia indicated that age over 50 years and rectal bleeding of any type were significantly commoner in those with a final diagnosis of organic disease, and should therefore lead to full evaluation before a final diagnosis of IBS is made (see 5.6).108

Guidelines on the irritable bowel syndrome

1781

5.8 Investigations

5.8.1 Initial laboratory investigations

The concept that IBS is a diagnosis of exclusion is no longer tenable and in a straightforward case of IBS in a young person, investigationsparticularly those involving irradiation should be kept to a minimum. The yield in those with established IBS is low but not zero.272 The patients should be warned therefore from the outset that investigations are likely to be normal, thus avoiding the possibility that negative results will lead to the demand for ever more invasive and unnecessary tests. A full blood count (FBC) should be ordered in all older patients at first presentation, and an FBC plus erythrocyte sedimentation rate (ESR) and C reactive protein in all those with recent onset D-IBS. Endomysial or tissue transglutaminase antibodies show high sensitivity and specificity in distinguishing patients with coeliac disease from healthy controls, but in IBSwhere the incidence is low (0 3%)273 274sensitivity is lower at 79%, with a specificity of 98%.274 However, many clinicians working in areas of high incidence such as the United Kingdom undertake these tests because the diagnosis of coeliac disease radically alters treatment over a lifetime and may otherwise easily be missed. It should be emphasised that this section deals with IBS and not painless diarrhoea, for which there are separate guidelines (see guidelines for the investigation of chronic diarrhoea on the BSG website at http://www.bsg.org.uk).

5.8.2 Psychological investigation

Given the frequency of anxiety and depression it is useful to assess these features objectively. The hospital anxiety and depression scale (HADS) is a simple 14 item questionnaire that can be used even in a busy outpatient clinic to provide an objective measure of anxiety and depression. The 15 item patient health questionnaire (PHQ 15)275 may also be helpful in difficult cases, as it clearly identifies the presence of multiple somatic symptoms (somatisation) which may otherwise be missed in a busy consultation. While there are no randomised studies showing benefit, there are several studies showing that somatisation is common in IBS outpatients,276 correlates with impaired quality of life,276 and predicts dissatisfaction106 with treatment and increased health care use (see 7.2.2).

5.8.3 Second level investigations including endoscopy and imaging

Second level investigations are based on the likely differential diagnosis (box 6). Given the high frequency of colonic cancer in the population at large, an examination of the colon is advisable for a change in bowel habit over the age of 50 (earlier if there is a first degree relative affected by colorectal cancer when aged less than 45 years, or two affected first

degree relatives277). As IBS patients have no increased risk of colon cancer, advice on screening for this is no different from the general population. Patients with IBS-D tend to require more in the way of investigation than IBS-C, because of the overlap with other diarrhoeal diseases including coeliac and inflammatory bowel disease. It needs to be recalled that microscopic colitis now accounts for 20% of unexplained diarrhoea in the over 70s age group in countries where colonoscopy is freely available.278 Tests for malabsorption or small bowel bacterial overgrowth are not undertaken in straightforward cases of IBS but those with difficult diarrhoeaparticularly if associated with defecation which disturbs sleepmay warrant further tests (see guidelines for the investigation of chronic diarrhoea on the BSG website at http://www.bsg.org.uk). Giardiasis should be excluded by stool examination or duodenal biopsy in those with acute onset of diarrhoea as symptoms can be long lasting. Adult acquired lactose intolerance, which can be identified by a lactose breath hydrogen test, can cause IBS-type symptoms and should be considered, especially in racial groups with a high incidence of this feature, which worldwide is the norm rather than the exception.279 A simple screen for this is to ask the patient to undertake a milk challenge of one pint of skimmed milk which contains approximately 25 g of lactose. If no symptoms result then lactose intolerance is unlikely. A positive result should be followed by objective confirmation using a formal lactose breath hydrogen test, as the milk challenge lacks specificity. It should be noted that these recommendations are based on expert opinion and experience as there are no published data. Sudden onset of severe diarrhoea, especially if it is of large volume with nocturnal disturbance, should suggest bile acid malabsorption, which can be diagnosed by the SeCHAT test.280 It should be noted that only those with severe malabsorption (less than 5% of labelled bile acid retained at seven days) respond predictably to cholestyramine.281 Constant upper abdominal pain, particularly if it radiates to the back, should lead one to consider pancreatic disease, best investigated by means of abdominal spiral computed tomography. Right upper quadrant pain with biliary features may indicate the need for ultrasound investigation and, rarely, consideration of sphincter of Oddi dysfunction, especially if pain is associated with a rise in liver enzymes or amylase.282 These investigations should be restricted to those with typical meal provoked symptoms, as IBS patients with asymptomatic gall stones are in danger of being subjected to an unnecessary cholecystectomy without benefit to their pain.

Box 6
Differential diagnosis of diarrhoea predominant irritable bowel syndrome

Table 2 Summary of the recommendations for investigating irritable bowel syndrome

Intervention N N N N N Quality of evidence Benefit/ harm Net Net Net Net benefit benefit benefit benefit Strength of recommendation Definitive Definitive Definitive Definitive Definitive Qualified Qualified Qualified Qualified

N N N N N N N N

Microscopic colitis Coeliac disease Giardiasis Lactose malabsorption Tropical sprue Small bowel bacterial overgrowth Bile salt malabsorption Colon cancer

Take a symptom history Low Assess psychosocial factors Low Physical examination Low Check for alarm symptoms Moderate Investigations FBC Moderate EMA Moderate Lactose breath hydrogen test Moderate Colonoscopy Moderate Abdominal ultrasound Low

Net benefit Trade-offs Net benefit Trade-offs Trade-offs

EMA, endomysial antibodies; FBC, full blood count.

www.gutjnl.com

1782

Spiller, Aziz, Creed, et al

5.9 Recommendations A summary of the recommendations for investigating IBS is given in table 2.

6 DIAGNOSIS AND INITIAL MANAGEMENT OF IBS IN PRIMARY CARE

Adult patients who present to their general practitioner with lower gastrointestinal tract disorders often pose a difficult diagnostic problem. They account for one in 20 of all general practice consultations19 and yet their symptoms are frequently ill defined. Although functional disorders such as IBS are the most prevalent, the possibility of colorectal cancer or inflammatory bowel disease may create diagnostic uncertainty and reluctance on the part of the doctor to attribute the symptoms to a specific diagnosis.283 6.1 Differences between primary and secondary care Primary care differs from specialist care because the general practitioners greater familiarity with the patient, and their previous consultations and behaviours, enable current complaints to be seen in context rather than in isolation. Furthermore, it involves the first contact for care of problems and diseases at a stage when they are likely to be poorly differentiated. Lastly, it is characterised by a model of patient care that is longitudinal and comprehensive, and takes account of the biopsychosocial context of the persons problem. These characteristics become particularly important when considering chronic disorders, such as IBS, where patients place high priority on continuity of care19 and where the doctors relationship with the patient can be therapeutic in itself. Time is frequently used as both a diagnostic and a therapeutic tool in primary care.

as characteristics essential for the diagnosis of IBS.286 Abdominal pain per se was not an essential characteristic, though participants described as essential a feature of disordered abdominal sensation, which included pain, discomfort, and annoyance. This reflected differences in expression according to culture and language. Symptom characteristics and interrelationshipssuch as relief of abdominal pain/discomfort/annoyance with defecationwere considered supportive of the diagnosis. Measures of frequency and persistence of symptoms were considered relevant but without consensus on specific figures.286 Consultation style, notably frequent consultation, somatisation, and abnormal illness behaviours in response to stress are key contextual features supporting the diagnosis of IBS in general practice. Inappropriate consultations for minor illness and multiple somatic complaints have been described for IBS by Whitehead and Bosmajian.287 Extracolonic symptoms, however, have less prominence in making the diagnosis, and in most instances there was no consensus on their significance among GPs. Apart from being associated with IBS, symptoms such as tiredness, urinary frequency, and backache are commonly encountered in general practice and may be perceived as lacking specificity, while others such as history of abuse lack sensitivity Mood assessment can be done rapidly using three questions288 (box 7). In general practice the diagnosis of depression after these three questions have been answered has a sensitivity of 79% and a specificity of 94%.288

6.1.4 Investigations in primary care

The consensus group considered only a limited number of investigations to be essential for the diagnosis of IBS. Rectal examination confirms the consistency of the stool and identifies anal conditions and low rectal masses, but has a low sensitivity as a diagnostic test for rectal cancer.289 A full blood count should be ordered in all older patients at first presentation and an FBC and ESR/CRP in all those with new IBS-D. Faecal occult blood testing cannot be recommended as it lacks the required sensitivity and specificity. The value of serological tests for coeliac disease (endomysial antibodies (EMA) or tissue transglutaminase (TTG) antibodies) in patients with IBS-D depends on the population and is generally considered cost-effective if the incidence of coeliac disease is above 1%.290 It may therefore be worthwhile in the United Kingdom, where up to 3% of cases of IBS-D in primary care have coeliac disease.291

6.1.1 Diagnosis in primary care

Existing diagnostic criteria for IBS are based on specific symptoms of defined duration and frequency and have been derived from the characteristics of patients in secondary care. Their applicability to clinical practice has been challenged as unnecessarily restrictive,32 with one study finding that only a minority of those diagnosed with IBS in primary care fulfilled the Rome II criteria.35 This may be because their restrictive approach is at odds with the diagnostic process used in primary care. Here the diagnosis is based on risk estimations that start from the prevalence of symptoms in primary care, balancing the perceived relative risks of serious (notably cancer) and nonserious disease, and combining this with a limited number of investigations. In this diagnostic process, symptoms, history, psychosocial background, disease patterns, previous disease history, and consultation behaviour play important roles. At the same time, the patients ideas, concerns (notably about cancer, see 5.1), and expectations are also addressed.

6.1.5 When to refer

Patients with alarm symptoms (see Box 5), those in whom there is genuine uncertainty about the diagnosis, and those whose concerns have not been successfully allayed in their consultations with the GP should be referred for a specialist opinion. Twenty per cent of patients with non-specific abdominal complaints present over a 12 month period were referred to secondary care in one Dutch study.74

6.1.2 Diagnostic decision making in primary care

GPs (primary care physicians) tend to make a positive diagnosis of IBS when the risk profile for that condition is high, the characteristics of the patient fit the profile for functional disease, and the risk of serious bowel disease is low.284 This profiling approach to diagnosis is quite distinct from a criterion based approach, though its key features and their relative importance are unknown. Most surveys suggest that similar strategies are used in secondary care, as very few specialists use formal diagnostic criteria for IBS.

Box 7
Questions for assessing mood in primary care

6.1.3 Diagnosing IBS in primary care

In a rigorous consensus development exercise using a nominal group technique,285 European GPs identified alteration in bowel habit and bloating or distension, with symptom-free intervals,
www.gutjnl.com

N N N

During the past month have you often been bothered by feeling down, depressed, or hopeless? During the past month have you often been bothered by little interest or pleasure in doing things? Is this something you would like help with?

Guidelines on the irritable bowel syndrome

1783

Table 3 Recommendations for diagnosing irritable bowel syndrome in primary care

Intervention N Take a symptom history N Assess previous consultations N Screening questions for depression N Assess psychosocial factors N Check for alarm symptoms N Investigations FBC EMA/TTG Quality of evidence Moderate Low Good Moderate Moderate Moderate Good Benefit/ harm Net benefit Net benefit Net benefit Net benefit Net benefit Net benefit Trade-offs Strength of recommendation Definitive Definitive Definitive Definitive Definitive Definitive Qualified

EMA, endomysial antibodies; FBC, full blood count; TTG, tissue transglutaminase.

6.2 Recommendations A summary of the recommendations for diagnosing IBS in primary care is given in table 3.

7 TREATMENT OF IBS
Treatments should be safe and proportionate. Safety is a high priority as IBS is non-fatal, though it should be recognised that for some patients symptoms markedly reduce the quality of life. Furthermore, as IBS is very common, cost-effectiveness is also important for health care providers. 7.1 Dietary treatment

7.1.1 Alterations in fibre intake

Fruit and vegetable contain substantial amounts of both soluble (pectins, hemicelluloses) and insoluble (cellulose, lignin) nonstarch polysaccharide commonly referred to under the umbrella term fibre, while cereals and especially bran contains mainly insoluble fibre. Although the commonest dietary recommendation made to patients with IBS is to increase the intake of dietary fibre, with particular emphasis on cereal bran, there are few data to support this approach. A survey based on secondary care patients actually suggested that cereal fibre makes the symptoms worse in around 55% of cases, with only 11% reporting any benefit.292 Other forms of fibre, especially the soluble varieties, were not so detrimental. Psyllium and ispaghulathough they are soluble gum-forming mucilages are relatively poorly fermented, which may give them unique advantages. These have been demonstrated in RCTs.293 294 It is also interesting to note that the majority of therapeutic trials examining the effect of fibre in IBS have failed to show much benefit, and have suffered from the flaw that they were not designed to detect a negative effect. A recent systematic review of 17 clinical trials concluded that the benefits of fibre in IBS were marginal and that insoluble fibre can make the condition worse.294 It is important to point out that none of these studies was undertaken in primary care, where, it could be argued, response to alteration of fibre intake may be more encouraging. It is therefore worthwhile trying a period of cereal fibre exclusion, especially in those patients in whom consumption is excessive. However, if it is felt that fibre supplementation is needed and this cannot be achieved by diet alone, then the soluble varieties (ispaghula, sterculia, or methyl cellulose) are probably the best choice.

suggest that immediate type IgE mediated reactions are particularly important in IBS as a whole, although in those who suffer from diarrhoea and also exhibit atopy, this mechanism may be more important295 and oral sodium cromoglycate has been recommended.296298 However, it should be noted that the trials that support thiswhich were completed a decade ago within a single countrydid not use the standard randomised placebo controlled design. In clinical practice this treatment is rarely used, indicating that these studies need to be repeated with more rigorous study designs before any definite conclusions can be drawn. There seems little doubt, however, that some patients do show some form of food intolerance, but the mechanisms involved in such reactions are not known. Currently the most robust way of identifying food intolerance is by double blind food challenge, although this is time consuming and labour intensive. In a study involving 21 patients with diarrhoea predominant IBS, it was shown that in approximately 66% of cases food intolerance could be identified by using an exclusion diet followed serial reintroduction of individual foods.299 In some of these patients the validity of the intolerance was confirmed by a double blind challenge.299 There has been a systematic review of seven studies attempting to reproduce these results, which showed response rates varying from 15% to 71%, and it was concluded that there is insufficient evidence to recommend this approach routinely.300 Nevertheless, there is no doubt that some patients do respond to dietary exclusion, and this may be worth trying in the more refractory patients. It is important to realise that dietary exclusion can become problematic if the diet becomes so restricted as to be nutritionally inadequate, so it is best if this process can be supervised by a dietician. Dietary exclusion would be much easier if there was a simple test that could be used to predict which food, or foods, are likely to be causing problems. A wide variety of food intolerance tests is available over the counter but none of these has any evidence base and they are therefore of dubious value. However, there is some preliminary evidence that the measurement of circulating IgG antibodies to food may be successfully used as a guide to which foods should be eliminated from the diet in order to improve symptoms.301303 Interestingly, the foods identified by using IgG antibodies or an exclusion diet differ somewhat, suggesting that the two approaches might be detecting different mechanisms of intolerance.

7.1.3 Carbohydrate intolerance

This has been extensively investigated in IBS,304313 with varying levels of lactose, fructose, and sorbitol intolerance being reported. However, the prevalence of lactose intolerance shows considerable geographical fluctuation, which partly reflects racial differences in the incidence of the mutant gene that causes lactase persistence, which appears to have originated in NW Europe. Thus the incidence of adult hypolactasia is just 10% in people of north western European origin but approximately 40% in those of Mediterranean origin, 60% in Asians, and 90% in Chinese.279 In addition, in some studies the prevalence of malabsorption of carbohydrates in IBS does not greatly exceed that observed in controls, although their exclusion from the diet undoubtedly benefits some patients. It is also worth remembering that IBS patients often show fat intolerance and it has been shown that lipid can induce greater gas retention256 and increase visceral hypersensitivity314 in patients with IBS than in healthy controls. In the absence of a specific test on which dietary advice can be based, an empirical approach is still necessary. Adjusting the intake of fibre, carbohydrate, and fat is relatively easy before embarking on more complex strategies which involve excluding a wide range of foods and then systematically reintroducing
www.gutjnl.com

7.1.2 Role of food allergy

The symptoms of IBS are often made worse by eating, and this leads many patients to conclude that they are suffering from some form of dietary allergy. There is little evidence to

1784

Spiller, Aziz, Creed, et al

them one by one until intolerances can be identified.315 When this has been done, 3841% showed specific benefit,315 316 the commonest intolerances being to dairy and wheat products. It should also be remembered that even normal individuals often have one or two foods that upset them, and IBS subjects are no exception to this rule. When undertaking a trial of dietary manipulation patients should be warned that the effect of this may take a few days to become apparent, because whole gut transit may range from one to five days in normal individuals and possibly much longer when there is constipation. Likewise, responses to offending foods may also be delayed by many hours.

7.1.4 Recommendations
A summary of the recommendations for the dietary treatment of IBS is given in table 4. 7.2 Psychological treatment

marked fears of serious illness do not appear to be allayed by numerous investigations or consultations, whereas seeing the same doctor at different consultations does seem to be important.318 A 30 minute standardised gastroenterology consultation, which includes a positive diagnosis, patient education using a leaflet, and explicit reassurance about the absence of serious illness, may be followed by a reduced number of consultations for gastrointestinal symptoms and less pain.319 Such management does not, however, appear to be followed by improvement in health related quality of life or reduced anxiety about numerous bodily symptoms.319 This is important, because when anxiety, depression, or somatisation disorder are present, patients are not reassured by normal investigations,320 they consult more frequently, and have an impaired quality of life.321 323 It is important that psychological co-morbidity is detected and effectively treated in IBS, as discussed later.

7.2.1 Introduction
The role of psychological factors in the onset and progress of irritable bowel syndrome (IBS) is complex, and remains controversial, ranging from subtle modulations of enteric nervous system function and maladaptive behaviour to overt co-morbidity with anxiety, depression, or somatisation disorder. Unsurprisingly a range of psychological approaches to managing IBS has been developed andbecause of significant challenges in terms of study design, patient selection, and the interpretation of resultssome uncertainty still remains about the roles of psychological therapies in management.

7.2.3 Evidence for psychological therapies

Two recent systematic reviews of psychological treatment in IBS provide a useful summary of most relevant studies.324 325 One is guarded in its support for psychological treatments,324 pointing to major design issues with many trials, including the robustness of the control groups and the blindness of assessments. Eight studies326333 were identified as being of acceptable methodological quality in both reviews, and four of these showed a clear benefit to patients in terms of IBS symptoms and included studies of cognitive behavioural therapy (CBT), psychotherapy, and multicomponent behaviour therapy.307 308 312 333 The second review, adopting careful and innovative methodology to select and analyse the studies, found that psychological treatments were significantly superior to controls in terms of improvement in abdominal pain, bowel dysfunction, depression, and anxiety.334 The meta-analyses were not entirely satisfactory because two thirds of the trials had been undertaken at the same centre in the USA, at which a waiting list control was used rather than a true attention control. This review concluded that there was overall evidence of efficacy for psychological treatments, with little to choose between the various forms. Three larger trials employing more rigorous methodology have subsequently been published,112 335 336 adding further support for the efficacy of CBT and psychotherapy, either alone or in conjunction with antidepressant drug treatment. Interpretation of these trials is made difficult by the fact that they have been conducted in different settings, including the general population,326 primary care,112 gastroenterology clinics,335 and in patients with chronic or treatment resistant IBS.336 It is likely that patients recruited after failure of short term treatment in primary care112 have less severe IBS than those recruited from gastroenterology clinics, who have failed to respond to the usual treatments.336 In spite of this there is some evidence that psychological treatment for different types of somatic complaints (including IBS) is more effective when delivered to patients in tertiary care than in community settings.337

7.2.2 Psychological approach to management

Most patients with IBS are managed in primary care, where the mainstay of treatment is explanation and reassurance in terms understandable to the patient, coupled with sensible advice about lifestyle, including diet and stresses and, when possible, symptom control. A psychological approach to management should be integrated into the first consultation. Eliciting the patients reason for consulting and their views on the causes of their symptoms is essential. Fears of cancer or other serious illnesses are common, and are important reasons for seeking medical attention.59 Patients who attribute their symptoms to physical illness rather than to stress are more likely to be referred from primary to secondary care and consult their general practitioner more often.19 317 In secondary care the patient who fears serious illness is more likely to be reassured if the doctor has correctly determined, at the first interview, whether the symptoms are attributed to stress or to physical illness.318 Interestingly,

Table 4 Summary of recommendations for the dietary treatment of irritable bowel syndrome
Intervention Quality of Benefit/ evidence harm Strength of recommendation

1. Take a careful dietary history to identify potential causes of symptoms Very low 2. Assess dietary fibre intake and consider recommending an increase or decrease accordingly Low 3. Trial of exclusion of wheat bran or lactose Low 4. Consider systematic modification of diet to identify intolerances Low

Net benefit

Qualified

7.3.4 The psychological therapies

Anxiety and depression are common in IBS,105 and patients report a close relation between stress and hassles and their gut symptoms,338 providing a pragmatic rationale for psychological therapy.
7.3.4.1 Relaxation training

Net benefit Trade-offs

Qualified Qualified

Trade-offs

Qualified

This is useful when stress causes exacerbation of symptoms, which can be relieved by progressive muscle relaxation, biofeedback, and transcendental or yoga meditations,339 340

www.gutjnl.com

Guidelines on the irritable bowel syndrome

1785

although it is unclear how much of the benefit is the result of the non-specific factor of increased attention from a therapist.341343
7.3.4.2 Cognitive behavioural therapy

7.3.6 Recommendations
All approaches to managing IBS should be informed by psychological understanding, recognising that the most important aspect of management is the relation between the patient and the physician. Empathic listening, respecting patients views of symptom causation, and giving honest, clear explanations of the interplay between psychological and physical symptoms are essential. Conversely, collusion in seeking a physical cause and undertaking endless investigations must be resisted. Referral for a psychological treatment in primary care should be considered if the patient wishes this or if there are marked anxiety or depressive symptoms. There has recently been a general increase in the availability of talking therapies in primary care. In secondary care, more specialised psychological treatment, focused on IBS, is preferable if it is available. Gastroenterologists are encouraged to develop close links with a particular psychotherapist or hypnotherapist as this facilitates referral of patients, who may express reservations about such treatments unless they are made to seem part of the entire process and not as a rejection by the gastroenterologist. A summary of the recommendations for the psychological treatment of IBS is given in table 5. 7.4 Hypnotherapy

CBT is also based on the assumption that IBS symptoms are a response to stressful life events or daily hassles, producing maladaptive behaviour and inappropriate symptom attributions. Treatment involves identifying the triggers for symptom exacerbation, understanding the patients response to symptoms, and teaching more adaptive ways of responding. The evidence for the efficacy of CBT remains controversial,112 327 335 344 with the most recent study in primary carein which CBT was combined with mebeverineshowing symptom improvement at up to three months, and improved work and social adjustment up to one year. A larger study in secondary care found little effect on abdominal pain or IBSspecific quality of life, although satisfaction and global wellbeing were improved.335 Both studies suggest that CBT may help patients cope with their symptoms without necessarily abolishing them.
7.3.4.3 Psychodynamic interpersonal therapy

Psychodynamic interpersonal therapy (PIT) attempts to provide the patient with insights into why symptoms developed in the context of difficulties or changes in key relationships. As well as helping the patient understand how emotional state is related to stress, the link between emotions and bowel symptoms may also become clearer.345 When successful, this treatment may lead to significant life changes as well as to an improvement in emotional state and IBS symptoms.328 333 345 Two studies of PIT compared with supportive listening with the same therapist, showed significant improvements compared with the comparison groups, and a large costeffectiveness trial has shown that short term PIT is widely acceptable and leads to a significant improvement in health related quality of life and a reduction in health care costs.336 Hypnotherapy, which is an important psychological treatment, is described later (7.4).

7.4.1 Evidence of benefit

The first controlled trial assessing the value of hypnotherapy in IBS patients refractory to other treatments was reported in 1984.347 In that study hypnotherapy was shown to produce a significantly greater improvement over a three month period than supportive therapy combined with the administration of a placebo drug. Since that time continuing evidence for its value has accrued,348 349 and there has recently been a systematic review of published reports assessing the efficacy of hypnotherapy in IBS.350 In the 14 studies identified, of which only six included a control group, 599 patients were treated with hypnotherapy and 100 received some form of control treatment. It was concluded that, according to the clinical psychology division of the American Psychological Association guidelines, hypnotherapy qualified for the highest level of acceptance as being both effective and specific.350 There is also some preliminary evidence that a home hypnosis programme might be useful, although the response rate is not so high as that in therapist led treatment,351 and it is therefore probably not suitable for the more severe cases seen in referral centres. One particular advantage of hypnotherapy is that, rather than just relieving a single symptom, it has been shown that it improves many of the features of the condition, including quality of life and psychological status.111 Furthermore, the beneficial effects appear to be sustained over time, with patients reporting continued relief from symptoms for at least five years.352

7.3.5 Choosing patients for psychotherapy

Patients with constant as opposed to intermittent abdominal pain and constipation tend to do poorly with PITthe large trials of CBT and PIT in secondary care reported no improvement in patients with depression.323 335 PIT was particularly successful in patients who reported a history of sexual abuse.336 346 In the primary care CBT trial,112 a poor response to therapy was found in men who believed in a physical cause for their symptoms. Few data are available, however, to guide the timing of psychological therapies, although the temptation to withhold them for refractory patients should, perhaps, be tempered by the recognition that they may provide effective alternatives or adjuncts to existing drug treatments, although there are few comparative trials. The choice of psychological treatment will depend on what type of therapy is available locally and on patient preference. Some patients are very reluctant to accept that psychological therapy is necessary, but may be prepared to take a small dose of an antidepressant to see if it helps the pain or other symptoms. Many more patients are prepared to accept that psychological factors could be important and would prefer a psychological, or talking, therapy to drug treatment. As patients who do not wish to take antidepressants gain no benefit from them.335 336 it is important to elicit and respect patients preference for type of treatment.

7.4.2 Mechanisms
There has been some research into establishing how hypnotherapy might mediate its beneficial effects. There is evidence to suggest that in patients with IBS, it normalises visceral sensation,353 reduces colonic phasic contractions,354 and reverses the patients negative thoughts about their condition.355 As has already been discussed above, the activation of the certain areas of the brain, especially the anterior cingulate cortex, in response to a painful rectal stimulus appears to be exaggerated in IBS compared with controls. It is therefore of interest that hypnotic reduction of somatic pain is associated with a reduction in activation of this particular region,356 suggesting that hypnotherapy might enable IBS subjects to modify their central response to pain.
www.gutjnl.com

1786

Spiller, Aziz, Creed, et al

Table 5 Summary of recommendations for the psychological treatment of irritable bowel syndrome
Intervention N Make a positive diagnosis and provide a clear explanation of the cause and nature of symptoms and an honest appraisal of prognosis and treatment options Psychological approaches to treatment N Relaxation therapy N Patients with moderate anxiety, not amounting to psychiatric disorder, who do not respond satisfactorily to standard treatment may benefit from relaxation therapy N Cognitive behavioural therapy N Psychodynamic interpersonal therapy N Specific psychological treatment for coexisting psychopathology Quality of evidence Benefit/ harm Strength of recommendation

Medium

Net benefit

Qualified

Moderate

Trade-offs

Qualified

Moderate Moderate Moderate High

Trade-offs Trade-offs Trade-offs Net benefit

Qualified Qualified Qualified Definitive

7.4.3 Problems with application

Hypnotherapy, like all behavioural treatments, suffers from several disadvantages, especially in terms of its lack of availability and lack of therapists adequately qualified to provide it. It is labour intensive, requiring as many as 12 onehour sessions of treatment, as well as being extremely operator dependent and therefore subject to variation in the quality of provision. Although most individuals can be hypnotised, for a successful therapeutic application there must be regular practice and commitment on the part of the patient, without which it is likely to fail. The best evidence for effectiveness is in patients refractory to standard treatments, so its efficacy as first line treatment is uncertain. Thus this form of treatment is probably best reserved for the more refractory patients, who could then be treated in a limited number of specialist centres where hypnotherapy can be integrated into an overall care package.357 A summary of the recommendations for hypnotherapy in the treatment of IBS is given in table 6. 7.5 Pharmacological treatments for IBS

Meta-analyses have shown that the placebo response is increased by more frequent dosing and by doctor/patient interactions. Several investigators have pointed out that rather than regarding this as a problem physicians should be harnessing the effect.360 361

7.5.2 Antispasmodic agents

The rationale for using antispasmodic agents is to attenuate the heightened baseline and postprandial contractility seen in patients with IBS (particularly when diarrhoea predominant).151 The efficacy of antispasmodic agents has been the subject of several meta-analyses.362366 Of the various agents shown to have some efficacy in these studies, only two are licensed in the United Kingdommebeverine (135150 mg three times a day) and hyoscine (1020 mg four times a day). Comparisons between these and more recently developed drugs are difficult because at the time when the earlier drugs were developed the trials were much smaller than they are now, and by comparison underpowered. There may also have been a publication bias. A recent meta-analysis364 366 give an odds ratio for benefit of 2.1 and global improvement of 56% for active drug vs 38% for placebo, and a number needed to treat (NNT) of 5.5. Relief of pain was seen in 53% and 41%, respectively, giving an NNT of 8.3. The odds ratio for benefit must be interpreted with caution as in a much larger modern trial of mebeverine vs alosetron (see below), alosetron was shown to be more effective than antispasmodic agents, with an odds ratio of benefit of only 1.7,367 which is not much different from its benefit over placebo in other trials. Furthermore, these drugs do not seem to have any beneficial effect on the symptoms of diarrhoea or constipation.365 Other antimuscarinic agents licensed in the United Kingdom lack RCT evidence of effectiveness (alverine citrate368) or are associated with significant side effects (dicycloverine).364 Mebeverine is generally well tolerated and can be used on an as required basis (before meals) and hence is sometimes employed when simple reassurance fails to improve symptoms. Other classes of antispasmodicfor example calcium channel blockers369 and opioid antagonists such as trimebutine370have been shown to produce inconsistent benefit in IBS and have been made available in only a few countries worldwide.

7.5.1 Overview
Various pharmacological agents have been tried in the management of IBS, but these have proved of limited efficacy for the cardinal symptoms of abdominal pain and bloating. Therapeutic targets for these symptoms have changed over the years, initially focusing on relaxing the smooth muscle of the gut, latterly evolving into attempts to alter gut transit and to modulate the perception of visceral afferent information in the CNS. Treatment of bowel dysfunction is comparatively more straightforward, aimed at accelerating or slowing transit as required. The placebo response of up to 4050% in IBS trials358 359 confounds interpretation of many drug studies.

Table 6 Summary of recommendations for hypnotherapy in the treatment of irritable bowel syndrome
Intervention Quality of evidence Benefit/ harm Strength of recommendation

N Hypnotherapy for patients refractory to standard treatment Moderate N Hypnotherapy works best for Those without major psychiatric disease Low

Trade-offs

Qualified

7.5.3 Antidepressants
It is important that patients preferences are taken into account when deciding whether to recommend antidepressants or psychological treatment, as both require good patient compliance to be effective.

Trade-offs

Qualified

www.gutjnl.com

Guidelines on the irritable bowel syndrome

1787

7.5.3.1 Tricyclic antidepressants

7.5.4 Fibre and laxatives

Constipation is a common complaint in patients with IBS. Fibre supplementation with naturally derived concentrated nonstarch polysaccharides such as bran, ispaghula husk, methylcellulose, and sterculia increases faecal mass and may accelerate transit. The odds ratio for benefit in global symptom relief with fibre is 1.33, but although constipation symptoms may improve there is no benefit for abdominal pain.294 As already mentioned above, overall only 10% of patients are improved by such bulking agents, and insoluble fibre (such as bran) has been shown in randomised placebo controlled trials to have no effect on pain and to exacerbate flatulence and bloating.383 This is recognised by IBS patients, of whom around half report that bran aggravates their symptoms.292 Inorganic salts (for example, magnesium salts and polyethylene glycol based laxatives) act as an osmotic laxative and are effective and well tolerated in chronic constipation,384 though data are lacking in IBS-C. These inorganic salts are preferred to organic alcohols and sugars, which are more expensive and may promote flatulence. One of the few randomised controlled trials in chronic constipation showed that polyethylene glycol was superior in efficacy and tolerability to lactulose, with less flatulence.384 Stimulant laxatives act erratically and are associated with tachyphylaxis and dependency. Stimulants are therefore generally recommended only for occasional use.

The tricyclic antidepressants are drugs with anticholinergic and non-selective serotonin reuptake inhibitor effects. Tricyclic antidepressants are widely used in other specialties for their ability to potentiate analgesics, with NNT ranging from 2.3 to 3.6.371 The drugs may alter pain perception,372 especially during acute stress,227 independent of their antidepressant or antianxiety effect (for a review, see Clouse and Lustman373). Approximately 10% of IBS patients, usually those with refractory symptoms, are tried on the tricyclic antidepressants.105 Several randomised placebo controlled studies have shown that low dose tricyclic agents effectively decrease symptoms. Although a meta-analysis has suggested a beneficial odds ratio of 4.0 compared with placebo, with an NNT of 3,374 this metaanalysis was strongly influenced by a single trial that appeared to be a clear outlier.362 375 If that study is excluded then no benefit remains, in keeping with the largest and most recent study in which no benefit was seen when analysed on an intention to treat basis (though benefit was seen in those able to tolerate the drug, with an NNT of 5.2).335 Five tricyclic agents have been studied formally (amitriptyline, trimipramine, desipramine, clomipramine, and doxepin), in addition to the anti-serotonin agent mianserin. The effect of these agents primarily relates to pain, and it has been suggested that patients with diarrhoea predominant IBS obtain the greatest benefit.335 Even with low doses, side effects of constipation, dry mouth, drowsiness, and fatigue occur in over one third of patients treated with tricyclic agents. The number needed to harm with these drugs is 22.371 These side effects often preclude good compliance, and so it is essential that the prescriber counsels the patient adequately about the potential for developing these problems, in addition to explaining the nature of the drug and the need to try it for at least four weeks (though effects may be seen as soon as one week335 376). The hypnotic side effect can be minimised or taken advantage of by night time dosing, and daily administrationstarting at a dose of 10 mg for any of the tricyclic antidepressants, with a gradual increase to 25 to 100 mghas been suggested.377 The drug should be continued for 6 to 12 months, after which dose tapering may be attempted.377 It should be noted that IBS patients, who show hypersensitivity to many stimuli, are often hypersensitive to drug side effects. Many practitioners therefore find the lower dose range (initially 10 mg increasing as tolerated up to 30 mg at night) is the most useful.
7.5.3.2 Selective serotonin reuptake inhibitors

7.5.5 Antidiarrhoeal agents

The opioid analogues loperamide and diphenoxylate stimulate inhibitory presynaptic receptors in the enteric nervous system resulting in inhibition of peristalsis and secretion. Loperamide reduces diarrhoea in patients with IBS385 but has little effect on abdominal pain.386 No such studies have been undertaken with cophenotrope (diphenoxylateatropine) but loperamide is preferred as it causes neither confusion nor anticholinergic side effects. Codeine phosphate is also not favoured because of its potential for dependence and its tendency to induce nausea and dysphoria.387 Loperamide and cophenotrope can be used both as regular medication and also on an as required basis. Tachyphylaxis does not develop with chronic dosing. Loperamide has particular potential value in that it is available in syrup formulation for fine tuning of dose to minimise the adverse effect of constipation. Bile acid malabsorption has been variably reported in diarrhoea predominant IBS.388 However, this has to be severe, with less than 5% of bile acid retained at seven days, before a reliable response to treatment can be expected.281 Such patients made up approximately 10% of Williams series of unexplained bile acid malabsorbers. Responders are often those with an acute, presumed infective onset389 and nocturnal diarrhoea.280 390

Selective serotonin reuptake inhibitors (SSRIs) are widely prescribed and well tolerated in the treatment of anxiety, depression, and somatisation disorders.378 There have been four randomised controlled trials of SSRIs in IBS, but only one of reasonable size. This large cost-effectiveness trial showed that a standard dose of an SSRI antidepressant leads to a significant improvement in health related quality of life at no extra cost in patients with chronic or treatment resistant IBS.309 All four studies showed global benefit without significant change in bowel symptoms or pain.336 379381 After the trial, patients on SSRIs were more likely to want to continue with the drug (84% vs 37% on placebo) so plainly they are providing benefit even if they do not change bowel symptoms. SSRIs have been shown to benefit patients with somatisation,382 a common feature of more severe IBS. Treatment of this aspect may underlie the global improvement and why patients wish to continue with treatment.

7.5.6 Serotonin receptor agonists/antagonists

Serotonin (5-HT), acting particularly through the 5-HT3 and 5HT4 receptors, plays a significant role in the control of gastrointestinal motility, sensation, and secretion.391393 Furthermore, recent observations that plasma 5-HT concentrations are reduced in IBS patients with constipation,169 240 but raised in those with diarrhoea,169 394 especially those showing postprandial symptoms,394 provide further support for its involvement in the motor and sensory dysfunction associated with this condition. Thus there has been considerable interest in these receptors as possible therapeutic targets for IBS, with agonists at the 5-HT4 receptor predicted to enhance gastrointestinal propulsion (that is, to be prokinetics)379 395 396 and antagonists at the 5-HT3 receptor to slow gastrointestinal transit and reduce visceral sensation.379 397399
www.gutjnl.com

1788

Spiller, Aziz, Creed, et al

7.5.6.1 5-HT 4 receptor agonists

7.5.7 Alternative pharmacological strategies

7.5.7.1 Antibiotics and probiotics

8Tegaserod is a selective partial agonist at the 5-HT4 receptor, available in the USA since 2002 and in many other countries, though not in Europe, for the treatment of IBS with constipation. Tegaserod has been assessed in multiple, large, and well designed clinical trials379 395 400 401 and has also been shown to have promotility effects in both the small and the large bowel.396 A Cochrane review identified seven high quality placebo controlled trials of tegaserod in IBS-C, which included 4040 patients treated for up to a maximum of 20 weeks, and a small study in IBS-D.401 Again, a small benefit was identified, with a relative risk (RR) of global relief of gut symptoms with tegaserod at 6 mg twice daily of 1.19 (95% confidence interval (CI), 1.09 to 1.29; NNT = 14) and at 2 mg twice daily of 1.15 (1.02 to 1.31; NNT = 20). The most improved symptoms were those related to defecatory frequency. A more recent randomised controlled trial conducted in 2660 female patients, with 1191 entering a repeat treatment phase, showed that global and individual symptoms were significantly improved by tegaserod in both phases (33.7 vs 24.2% and 44.9 vs 28.7%, respectively).69 Extended use studies suggest that benefit continues to be experienced (Am J Gastroenterol 2006;101: 255869). In addition, quality of life was also significantly improved.69 Other recent studies have similarly shown a positive effect on quality of life,402 403 and a decrease, although small, in absenteeism from work (2.6%) and activity impairment (5.8%).404 It should be noted that, as there have been no direct comparisons, it is unknown whether this agent superior to older stimulant laxatives. The commonest side effect of tegaserod 6 mg twice daily is predictably diarrhoea (RR = 2.75 (95% CI, 1.90 to 3.97)), with the number needed to harm = 20.401 Despite initial good experience concerning safety, the use of tegaserod has recently been restricted owing to concerns about an apparent small excess of cases of myocardial ischaemia and stroke (13 events per 11 614 patients treated) (see www.fda.gov/cder/drug/advisory/tegaserod.htm). Whether this will prove to be a problem with other 5-HT4 agonists under development remains uncertain.
7.5.6.2 5-HT 3 receptor antagonists

Approximately three quarters of IBS patients have been found to have a positive lactulose hydrogen breath test, defined as a double peak in breath hydrogen, the first occurring less than 90 minutes after ingestion, with a rise of more than 20 parts per million.411 The significance of this is disputed, as double peaks can be seen once lactulose reaches the colon and do not usually represent fermentation within the small bowel.412 However, the investigators interpreted this finding as suggestive of the presence of small intestinal bacterial overgrowth,411 providing the rationale for antibiotic treatment. When given a 10 day course of broad spectrum antibiotics (neomycin, ciprofloxacin, metronidazole, or doxycycline), one third of these patients became asymptomatic, at least in the short term.413 A similar result has been seen in an RCT of rifamixin which showed benefit lasting up to 10 weeks after treatment.414. No other group has adopted this treatment, which cannot be recommended until replicated in well designed studies by others. An elemental diet has been shown to normalise the lactulose hydrogen breath test, possibly because of alteration in gut microflora.415 Again, the durability of this response is unknown. Probiotics are a more attractive though possibly less effective way of altering bowel flora, and five randomised placebo controlled trials of probiotics have shown benefit for some symptoms, notably bloating and flatulence, using a variety of probiotic agents including Lactobacillus rhamnosus plantarum and VSL#3, a mixture of lactobacilli, bifidobacteria, and a streptococcus.416420 A more recent study using Bifidobacterium infantis suggested benefit and linked this to a downregulation of immune response,246 but this finding also needs to be replicated. A subsequent larger study421 has confirmed the benefit of B infantis, though problems with formulation mean that further studies are needed before this can be firmly recommended.
7.5.7.2 Miscellaneous agents

Alosetron, a selective 5-HT3 receptor antagonist used for the treatment of female IBS patients with diarrhoea, has recently been reapproved by the US Food and Drug Administration after being withdrawn in the USA in 2000 because of side effects of constipation and ischaemic colitis.405 It is unavailable for use in any country other than the USA. Meta-analyses have shown it to be helpful in women with IBS-D (odds ratio = 2.2 (95% CI, 1.9 to 2.6)),400 406 being more effective than placebo at inducing adequate relief of abdominal pain and discomfort, and improvement in bowel frequency, consistency, and urgency of bowel movement,379 400 with NNT = 7.406 Again extended use studies suggest that the benefit continues as long as the drug is taken.407
7.5.6.3 Developmental 5-HT drugs

Cilansetron, another 5-HT3 receptor antagonist for the treatment of IBS-D, has been reported in two RCTs published in abstract form to relieve abdominal pain or discomfort and abnormal bowel habit in both male and female patients at three and six months.408 409 Renzapridea mixed 5-HT4 receptor agonist/5-HT3 receptor antagonisthas been shown to accelerate colonic transit in a small, randomised placebo controlled trial for two weeks in patients with IBS-C but to be without effect on symptoms.410
www.gutjnl.com

An alternative approach to modifying neuroimmunology of the gut is to use an immunosuppressive agent. There has been only one small placebo controlled trial of prednisolone 30 mg which failed to show a beneficial effect after three weeks.422 Similar disappointing results with leuprolidea gonadotrophin releasing hormone antagonist that induces a medical menopause mean that this approach cannot be recommended either.423 Three underpowered placebo controlled studies looked at the D2 antagonist domperidone: two found no effect424 425 but the third reported significant improvement in flatulence, pain, and altered bowel habit compared with placebo.426 Herbal preparations have also been the subject of several trials. The plant preparations (STW-5 containing bitter candytuft, chamomile flower, peppermint leaves, caraway fruit, liquorice root, lemon balm leaves, celandine herbs, angelica root, and milk thistle fruit) have been shown to improve overall IBS scores and abdominal pain but it is unclear which is the active ingredient.427 A longer study of 16 weeks with Chinese herbal preparations reported significant symptom alleviation.428 Herbal mixtures individualised for each patient by Chinese medical practitioners were compared with a standardised mixture of 20 herbs and found to offer no advantage. As with probiotics, this area of treatment is attractive to patients and needs further studies with well characterised preparations to help elucidate which formulations will benefit which patient groups. A summary giving details of all the studies cited here is provided in appendix 2, which is available online at the journal website (http://www.gutjnl.com/supplemental).

Guidelines on the irritable bowel syndrome

1789

7.5.8 Sequence of treatments

Given that most treatments benefit only a minority, it will often be logical to try a sequence of treatments, starting with the safest and least expensive drugs. However, the reader should be aware that the sequences shown in table 7 are based on expert opinion only and the effectiveness of such strategies needs to be tested in controlled trials. The evidence for bloating is particularly weak; however, recent studies suggest that it is important to distinguish between the perception of bloating and visible distension. Both symptoms together are associated with constipation and may respond to laxatives.251 Another approach in non-constipated subjects might be to try reducing dietary fibre, particularly excluding wheat bran. By contrast, bloating without distension may be caused by visceral hypersensitivity429 for which tricyclic agents may be a more logical treatment. Some probiotics have been shown to benefit bloating, but more experience is needed before definitive recommendations can be made. A summary of the recommendations for the pharmacological treatment of IBS is provided in table 8.

there was a substantial mismatch between categorisation based on the Rome II criteria and the patients own classification.38

8 TREATMENT IN PRIMARY AND SECONDARY CARE

8.1 Spectrum of severity in primary care Patients with IBS managed in primary care comprise the entire spectrum, from those with mild or ill defined symptoms to those with severe or persistent problems. In contrast, those referred to a specialist are more likely to be at the more severe end of the spectrumin terms of both physical symptoms and psychopathologyand primary care management has proved to be difficult or ineffective. In the United Kingdom up to 29% of patients with IBS are referred to a specialist19 but the majority of these will return to their general practitioners for long term management. Treatment approaches in primary care are influenced by the awareness that functional diseases present with a variable combination of undifferentiated symptoms, many of which such as tiredness or backacheare non-gastrointestinal and non-specific. The specialist led diagnostic criteria for IBS, such as the Manning or Rome criteria, are not commonly known or applied in primary care, where the management approach is more likely to reflect the presenting problem. A formal diagnosis of IBS is not necessarily made, even though treatments which are recognised as being associated with IBS might be used.430 For example, constipation is often diagnosed as a problem in its own right and managed as such rather than identified as a possible symptom of IBS. In contrast, patients with loose motions are more likely to be asked about other symptoms such as bloating and to receive a formal label of IBS. A rigid distinction between the different subtypes of IBS (constipation or diarrhoea predominant or alternating) is often difficult to achieve in practice, and in a large community survey Table 7 Suggested sequence of pharmacological treatment for irritable bowel syndrome
Predominant symptom First line Pain Antispasmodic agents Second line

8.2 Nature of the relation between the patient and the primary care doctor Various other factors are specific to primary care, influencing the management and distinguishing it from secondary care. First, patients tend to have a long term, longitudinal consultation pattern with their general practitioners, and time plays an important role in the understanding of the problem by the patient and the evolution of its management. This enables treatment to take place through a series of steps which may be characterised by the use of different treatments or types of management, including drugs and psychological interventions. Second, the recurrent, relapsing, and non-lethal nature of IBSincluding a change in the pattern of symptoms to involve other systems29enables both the patient and the clinician to come to terms with the problem using remedies that appear effective. Finally, it is known that only a minority of IBS sufferers consult a doctor. While those doing so probably have more severe symptoms and are seeking an explanation, they do not necessarily want a prescription medication. 8.3 Use of self management Most patients will have tried various approaches to self management of their IBS. In two large community studies,29 430 37% of IBS sufferers had not consulted a health professional at all, 60% had tried an over-the-counter remedy, 47% had altered their diet, and a large number of complementary health carers had been consulted. Substances used included laxatives, supplements, and various natural remedies. A range of self help organisations offers advice and information which may assist patients to manage and come to terms with their condition (for example, the IBS Network, available at www.ibsnetwork.org.uk). 8.4 Prescribed drugs in primary care Prescribed drugs in primary care do not differ substantially from those in secondary care. Commonly used medicines, irrespective of their actual effectiveness, are the bulking agents (ispaghula), laxatives (osmotic or stimulant), antispasmodics, and antidepressants.74 With regard to antidepressants, general practitioners have considerable experience in their use because psychological problems are commonly managed in primary care. As general practitioners tend to take a holistic approach they are comfortable with exploring psychological factors associated with IBS; indeed, a consideration of psychological factors is often prominent in making the diagnosis and in influencing treatment. 8.5 Psychological approaches in primary care Recent research suggests that many IBS patients are not committed to seeking a somatic explanation for their symptoms and they readily accept the possibility of a psychological contribution to their gut problems.431 Allied with the use of the drug treatment, GPs commonly use counselling and other psychological therapies. Many general practices have in-house counsellors; while these are not trained to deal specifically with IBS, most have strategies for the management of anxiety and somatisation. Research has supported the use of cognitive behaviour therapy.112 Though this not routinely available in primary care, it can be accessed in some localities without referral to a gastroenterologist. Hypnotherapy for IBS has been shown to be effective in specialist centres (see 7.4) and new data from general practice suggests that this is effective during the first three months, although the effect is less marked after that.432 A recent report has also highlighted the success of a
www.gutjnl.com

Tricyclic antidepressives Hypnosis Psychological treatments Diarrhoea Loperamide 5-HT3 antagonist* Constipation Ispaghula 5-HT4 agonist* Bloating with distension Dietary manipulation Probiotics Polyethylene glycols 5-HT4 agonist* Bloating without Antispasmodic agents Probiotics distension Tricyclics *No representative of this class of drugs is currently licensed for IBS in Europe but there are other related drugs in development.

1790

Spiller, Aziz, Creed, et al

Table 8 Summary of recommendations for pharmacological treatment of irritable bowel syndrome

Intervention Antispasmodics Mebeverine Alverine citrate Dicyclomine Fibre supplements Ispaghula Bran Opioids Loperamide Quality of evidence Low Very low Very low Benefit/ harm Net benefit Uncertain trade-offs Uncertain trade-offs Strength of recommendation Qualified Definitive Definitive Comments

High High High

Net benefit No net benefit Net benefit

Definitive Definitive Definitive

Half are made worse Helps diarrhoea but less effect on pain/discomfort

Tricyclic antidepressants Desimipramine Moderate

Trade-offs

Qualified

Amitriptyline Nortriptyline SSRIs Paroxetine Fluoxetine 5-HT4 agonists Tegaserod 5-HT3 antagonists Alosetron

Low

Trade-offs

Qualified

Ineffective on intention to treat analysis Poorly tolerated at full dose Poorly tolerated at full dose

High High

Net benefit Net benefit

Qualified Qualified

Better tolerated than TCAs Global benefit without benefit to specific bowel symptoms Global benefit Prokinetic; benefit IBS-C NNT = 14 Antidiarrhoeal; benefit IBS-D NNT = 7 Ischaemic colitis, 1/700

High

Net benefit

Definitive

High

Trade-offs

Definitive

Probiotics Antibiotics

Moderate Low

Trade-offs Trade-offs

Qualified Qualified

Controversial; needs replicating

IBS-C, constipation predominant irritable bowel syndrome; IBS-D, diarrhoea predominant irritable bowel syndrome; NNT, number needed to treat; TCA, tricyclic antidepressant.

patient derived information and explanation booklet in primary care, although this has not been used widely.433 434

9.1 Organisational barriers in implementing the recommendations

9.1.1 Consultation time

8.6 Patients perspective These guidelines were reviewed by some members of the IBS Network, who created 10 top requests in answer to the question When I visit my health professional about my IBS, I would like them to give me.? IBS is a complicated condition which requires identification of important psychosocial factors for optimal management. Such patients often need longer consultations than normal in order to determine the role of psychological and social factors in exacerbating the symptoms and to offer the full explanation and reassurance that may be required. This is likely to prove a problem within fixed timed appointments. Dedicated longer time slots may be an appropriate way to manage the disorder rather than repeated brief consultationsoften with different doctors which usually lead to numerous negative investigations, more frequent attendances, and a poorer long term outcome. Educational booklets should be freely available, but patients may need the opportunity to discuss their concerns again once they have read such material. A suitably trained specialist nurse may be best suited to this task, but may not be available in many centres.

N N N N N N N N N N

A clear knowledgeable explanation of what IBS is. A statement that there is no miracle cure. A clear indication that it is my body, my illness, and that it is up to me to take control. A clear explanation that there will be good days and bad days, but that there will be light at the end of the tunnel. An explanation of the different treatment options. Recognition that IBS is an illness. Consider and discuss complementary/alternative therapies. Offer at least one complementary/alternative therapy. Offer support and understanding. Be aware of conflicting emotions in someone who is newly diagnosed.

9.1.2 Provision of hypnotherapy, cognitive behavioural therapy, or other psychological treatments

This is limited by lack of trained practitioners and the reluctance of some providers to budget for it.

9 APPLICABILITY OF GUIDELINES
These guidelines are relevant to adult patients with IBS in both primary and secondary care.
www.gutjnl.com

9.1.3 Availability of certain drugs

Some drugs which are of proven benefit have not been licensed in the United Kingdom and at present patients are left to try to obtain drugs themselves over the internet at their own expense.

Guidelines on the irritable bowel syndrome

1791

9.1.4 Training in functional gastrointestinal diseases

Lack of adequate training leaves some gastroenterologists feeling uncomfortable managing such patients. Most primary care physicians are not aware of diagnostic criteria for IBS and about one third of secondary care doctors do not use them in practice.261 Recent advances in knowledge and treatments mean that much needs to be done during training to ensure that best practice becomes the norm. Trainee or practising gastroenterologists and associated staff (for example, specialist nurses or other therapists) may require further training in the techniques of consultation suitable for IBS patients. The training of general practitioners usually includes generic consultation skills, but training in more specialised techniques of reassurance, explanation, and exploration of psychological factors in patients who prefer to speak of bodily symptoms may be helpful. 9.2 Costs of applying the recommendations Costs of any condition and the costbenefit ratio depend critically on whether indirect costs are included. Currently available drugs are cheap, though consultation time is not. Indirect costs can, however, be much greater.435 These derive from time lost from work, which is increased by 21%,3 and costs of investigations and procedures which were increased by 69% in one study.3 436 These costs were based on the average IBS patient, but costs for the more severely affected cases can be much greater.322 Annual total costs (health care and loss of productivity) are approximately 1000 in patients with severe IBS which has not responded to usual treatment, but this is nearly doubled in those patients who also have a depressive or panic disorder.323 Both psychotherapy and an SSRI have been shown to improve health related quality of life in these patients at no extra cost.336 Psychotherapy, but not antidepressant use, has been shown to reduce the direct health care costs significantly in patients with severe and persistent IBS, and psychotherapy appears also to reduce the chances of patients being on disability benefits.336 However, local health authorities are unlikely to see the wider picture and will focus on costs generated within their own budget, namely the costs of investigations and prescribing. There is evidence that IBS patients undergo more unnecessary surgery18 437 and consult more frequently than the normal population.438 Whether optimum management will be able to show reduction in consultation rates and procedures is a question that requires urgent study. Increased consultation time costs money but may be costeffective if it saves further investigations and unnecessary operations. However, demonstrating that this is the case requires further cost-effectiveness studies. Better training in managing functional gastrointestinal diseases may involve some reorganisation of training programmes but should not be expected to incur much extra cost. 9.3 Criteria for audit Suggested criteria for audit are as follows: improvement in patient satisfaction with management in primary care after initial diagnosis (demonstrating this would require systematic patient surveys using validated questionnaires); improvement in patient understanding of their disorder; increase in confidence of gastroenterologists in dealing with IBS; increase in the proportion of referrals to secondary care which meet these guidelines; reduction in the number of negative investigations initiated in primary care after initial diagnosis of IBS has been confirmed in secondary care; reduction in number of elective cholecystectomies in IBS patients in whom no gall stones are found; and reduction in number of acute appendectomies with normal appendices in patients subsequently diagnosed as IBS.

10 SUGGESTIONS FOR FURTHER RESEARCH

As brief perusal of our recommendations will show much of the available evidence is poor. Major limitations include small patient numbers and lack of adequate characterisation in terms of the variables known to affect outcomes, particularly psychological factors. There is therefore an urgent need for better research in many areas. The following list provides some examples:

N N N N N N N N N N N

Large community based follow up studies to enable a better definition of the natural history, in particular its relation to life events. Improved ability to recognise food intolerances and response to food challenge using objective measures including genetic, blood, urine, and stool tests. Large high quality randomised controlled trials of dietary manipulation in hospital-naive patients. Studies of mechanisms underlying gut sensory, motor, and reflex changes in response to stress to identify potential novel pharmacological targets. Improvement in behavioural assessment of visceral sensation, to move from current subjective measures to a combination of behavioural assessments, with objective measures such as cortical evoked potentials and autonomic function tests. PET studies using ligands for various receptors known to be relevant in visceral pain may be helpful in understanding the neuropharmacology of visceral pain. Large high quality randomised, double blind, placebo controlled trials to evaluate psychological therapies. Large community based clinical trials comparing tricyclic antidepressants with SSRIs. Mechanistic studies to define putative mechanisms and hence possible targets for treatment. Community studies of behavioural interventions, including patient education and empowerment, should be further evaluated for cost-benefit. Long term intervention studies are needed to determine whether changes in management can reduce excess surgery rates associated with IBS.

A summary form of this document and appendixes 1 and 2 are available on the journal website (http// www.gutjnl.com/supplemental).

.......................

Authors affiliations

R Spiller, Wolfson Digestive Diseases Centre, University of Nottingham, Nottingham, UK Q Aziz, Department of Gastroenterology, St Barts and Royal London Hospital, London, UK F Creed, University Department of Psychiatry, Manchester Royal Infirmary, Manchester, UK A Emmanuel, Digestive Disorders Institute, University College Hospital, London, UK L Houghton, Neurogastroenterology Unit, Wythenshawe Hospital, Manchester, UK P Hungin, Centre for Integrated Research, University of Durham, Durham, UK R Jones, Department of General Practice and Primary Care, Kings College London, London, UK D Kumar, Department of Surgery, St Georges Hospital, Tooting, London, UK G Rubin, University of Sunderland, Sunderland, UK N Trudgill, Sandwell General Hospital, West Bromwich, UK P Whorwell, University Hospital of South Manchester, Manchester, UK www.gutjnl.com

1792 Conflicts of interest: Professor Aziz has received remuneration for consultancy advice to Novartis and Mundi Pharma, and has received research funding from GlaxoSmithKline (GSK) and Pfizer Pharmaceuticals. Professor Creed has received remuneration for consultancy advice to Eli Lilley and Company. Dr Emmanuel has been reimbursed for travelling and conferences by GSK and Novartis and has received research funding from GSK. Dr Houghton has received remuneration for advice and speaking (Novartis, Solvay, Clasado), together with financial support for the conduct of physiological research from Novartis, GSK, and Pfizer. Professor Hungin has received remuneration for speaking and consulting from GSK, Novartis, and AstraZeneca, and research funding from Novartis. Professor Jones has received remuneration for speaking and consulting from Novartis, Solvay, Astra-Zeneca, and GSK. Professor Rubin has received remuneration for consultancy advice to Novartis and Tillots Pharma, and has received research funding from Novartis. He has shares in GSK. Professor Spiller has received remuneration for consultancy advice and received research support from Novartis Pharmaceuticals and GSK. He has also acted on an advisory board for Solvay Pharmaceuticals. Dr Trudgill has received remuneration for consultancy advice to Astra-Zeneca and Ferring. Professor Whorwell has received remuneration for advice and his department has received financial support from Novartis, GSK, Pfizer, Solvay, Rotta Research, Proctor and Gamble, Astellas, and Tillots.

Spiller, Aziz, Creed, et al

24 Talley NJ, OKeefe EA, Zinsmeister AR, et al. Prevalence of gastrointestinal symptoms in the elderly: a population-based study. Gastroenterology 1992;102:895901. 25 Drossman DA, Li Z, Andruzzi E, et al. US householder survey of functional gastrointestinal disorders. Prevalence, sociodemography, and health impact. Dig Dis Sci 1993;38:156980. 26 Talley NJ, Zinsmeister AR, Melton IIL. Irritable bowel syndrome in a community: symptom subgroups, risk factors, and health care utilization. Am J Epidemiol 1995;142:7683. 27 Saito YA, Locke GR, Talley NJ, et al. A comparison of the Rome and Manning criteria for case identification in epidemiological investigations of irritable bowel syndrome. Am J Gastroenterol 2000;95:281624. 28 Saito YA, Talley NJ, Melton J, et al. The effect of new diagnostic criteria for irritable bowel syndrome on community prevalence estimates. Neurogastroenterol Motil 2003;15:68794. 29 Hungin AP, Chang L, Locke GR, et al. Irritable bowel syndrome in the United States: prevalence, symptom patterns and impact. Aliment Pharmacol Ther 2005;21:136575. 30 Thompson WG, Irvine EJ, Pare P, et al. Functional gastrointestinal disorders in Canada: first population-based survey using Rome II criteria with suggestions for improving the questionnaire. Dig Dis Sci 2002;47:22535. 31 Li FX, Patten SB, Hilsden RJ, et al. Irritable bowel syndrome and health-related quality of life: a population-based study in Calgary, Alberta. Can J Gastroenterol 2003;17:25963. 32 Boyce PM, Koloski NA, Talley NJ. Irritable bowel syndrome according to varying diagnostic criteria: are the new Rome II criteria unnecessarily restrictive for research and practice? Am J Gastroenterol 2000;95:317683. 33 Barbezat G, Poulton R, Milne B, et al. Prevalence and correlates of irritable bowel symptoms in a New Zealand birth cohort. NZ Med J 2002;115:U220. 34 Boekema PJ, van Dam van Isselt EF, Bots ML, et al. Functional bowel symptoms in a general Dutch population and associations with common stimulants. Neth J Med 2001;59:2330. 35 Mearin F, Badia X, Balboa A, et al. Irritable bowel syndrome prevalence varies enormously depending on the employed diagnostic criteria: comparison of Rome II versus previous criteria in a general population. Scand J Gastroenterol 2001;36:115561. 36 Gaburri M, Bassotti G, Bacci G, et al. Functional gut disorders and health care seeking behavior in an Italian non-patient population. Recenti Prog Med 1989;80:2414. 37 Coffin B, Dapoigny M, Cloarec D, et al. Relationship between severity of symptoms and quality of life in 858 patients with irritable bowel syndrome. Gastroenterol Clin Biol 2004;28:1115. 38 Agreus L, Svardsudd K, Nyren O, et al. Irritable bowel syndrome and dyspepsia in the general population: overlap and lack of stability over time. Gastroenterology 1995;109:67180. 39 Hillila MT, Farkkila MA. Prevalence of irritable bowel syndrome according to different diagnostic criteria in a non-selected adult population. Aliment Pharmacol Ther 2004;20:33945. 40 Kay L, Jorgensen T, Jensen KH. The epidemiology of irritable bowel syndrome in a random population: prevalence, incidence, natural history and risk factors. J Intern Med 1994;236:2330. 41 Hoseini-Asl MK, Amra B. Prevalence of irritable bowel syndrome in Shahrekord, Iran. Indian J Gastroenterol 2003;22:21516. 42 Karaman N, Turkay C, Yonem O. Irritable bowel syndrome prevalence in city center of Sivas. Turk J Gastroenterol 2003;14:12831. 43 Celebi S, Acik Y, Deveci SE, et al. Epidemiological features of irritable bowel syndrome in a Turkish urban society. J Gastroenterol Hepatol 2004;19:73843. 44 Masud MA, Hasan M, Khan AK. Irritable bowel syndrome in a rural community in Bangladesh: prevalence, symptoms pattern, and health care seeking behavior. Am J Gastroenterol 2001;96:154752. 45 Huerta I, Valdovinos MA, Schmulson M. Irritable bowel syndrome in Mexico. Dig Dis 2001;19:2517. 46 Kwan AC, Hu WH, Chan YK, et al. Prevalence of irritable bowel syndrome in Hong Kong. J Gastroenterol Hepatol 2002;17:11806. 47 Lau EM, Chan FK, Ziea ET, et al. Epidemiology of irritable bowel syndrome in Chinese. Dig Dis Sci 2002;47:26214. 48 Schlemper R, Van der Werf SJ, Vandenbroucke JP, et al. Peptic ulcer, non-ulcer dyspepsia and irritable bowel syndrome in The Netherlands and Japan. Scand J Gastroenterol Suppl 1993;28:3341. 49 Ho KY, Kang JY, Seow A. Prevalence of gastrointestinal symptoms in a multiracial Asian population, with particular reference to reflux-type symptoms. Am J Gastroenterol 1998;93:181622. 50 Xiong LS, Chen MH, Chen HX, et al. A population-based epidemiologic study of irritable bowel syndrome in South China: stratified randomized study by cluster sampling. Aliment Pharmacol Ther 2004;19:121724. 51 Gwee KA, Wee S, Wong ML, et al. The prevalence, symptom characteristics, and impact of irritable bowel syndrome in an asian urban community. Am J Gastroenterol 2004;99:92431. 52 Rajendra S, Alahuddin S. Prevalence of irritable bowel syndrome in a multiethnic Asian population. Aliment Pharmacol Ther 2004;19:7046. 53 Drossman DA, McKee DC, Sandler RS, et al. Psychosocial factors in the irritable bowel syndrome. A multivariate study of patients and nonpatients with irritable bowel syndrome. Gastroenterology 1988;95:7018. 54 Smith RC, Greenbaum DS, Vancouver JB, et al. Psychosocial factors are associated with health care seeking rather than diagnosis in irritable bowel syndrome. Gastroenterology 1990;98:293301. 55 Drossman DA. Do psychosocial factors define symptom severity and patient status in irritable bowel syndrome? Am J Med 1999;107:4150S.

REFERENCES
1 Atkins D, Best D, Briss PA, et al. Grading quality of evidence and strength of recommendations. BMJ 2004;328:1490. 2 Andrews EB, Eaton SC, Hollis KA, et al. Prevalence and demographics of irritable bowel syndrome: results from a large web-based survey. Aliment Pharmacol Ther 2005;22:93542. 3 Dean BB, Aguilar D, Barghout V, et al. Impairment in work productivity and health-related quality of life in patients with IBS. Am J Manag Care 2005;11:S1726. 4 Longstreth GF, Bolus R, Naliboff B, et al. Impact of irritable bowel syndrome on patients lives: development and psychometric documentation of a diseasespecific measure for use in clinical trials. Eur J Gastroenterol Hepatol 2005;17:41120. 5 Chang L. Epidemiology and quality of life in functional gastrointestinal disorders. Aliment Pharmacol Ther 2004;20(suppl 7):319. 6 Manning AP, Thompson WG, Heaton KW, et al. Towards positive diagnosis of the irritable bowel. BMJ 1978;ii:6534. 7 Drossman DA, Thompson WG, Talley NJ, et al. Identification of subgroups of functional gastrointestinal disorders. Gastroenterol Int 1990;3:15972. 8 Whitehead WE, Crowell MD, Bosmajian L, et al. Existence of irritable bowel syndrome supported by factor analysis of symptoms in two community samples. Gastroenterology 1990;98:33640. 9 Talley NJ, Boyce P, Jones M. Identification of distinct upper and lower gastrointestinal symptom groupings in an urban population. Gut 1998;42:6905. 10 Thompson WG, Longstreth GF, Drossman DA, et al. Functional bowel disorders and functional abdominal pain. Gut 1999;45(suppl 2):II437. 11 Longstreth GF, Thompson WG, Chey WD, et al. Functional bowel disorders. Gastroenterology 2006;130:148091. 12 Tillisch K, Labus JS, Naliboff BD, et al. Characterization of the alternating bowel habit subtype in patients with irritable bowel syndrome. Am J Gastroenterol 2005;100:896904. 13 Mearin F, Balboa A, Badia X, et al. Irritable bowel syndrome subtypes according to bowel habit: revisiting the alternating subtype. Eur J Gastroenterol Hepatol 2003;15:16572. 14 Drossman DA, Morris CB, Hu YM, et al. A prospective assessment of bowel habit in irritable bowel syndrome in women: defining an alternator. Gastroenterology 2005;128:5809. 15 Thompson WG, Heaton KW. Functional bowel disorders in apparently healthy people. Gastroenterology 1980;79:2838. 16 Jones R, Lydeard S. Irritable bowel syndrome in the general population. BMJ 1992;304:8790. 17 Heaton KW, ODonnell LJ, Braddon FE, et al. Symptoms of irritable bowel syndrome in a British urban community: consulters and nonconsulters. Gastroenterology 1992;102:19627. 18 Kennedy TM, Jones RH. Epidemiology of cholecystectomy and irritable bowel syndrome in a UK population. Br J Surg 2000;87:165863. 19 Thompson WG, Heaton KW, Smyth GT, et al. Irritable bowel syndrome in general practice: prevalence, characteristics, and referral. Gut 2000;46:7882. 20 Wilson S, Roberts L, Roalfe A, et al. Prevalence of irritable bowel syndrome: a community survey. Br J Gen Pract 2004;54:495502. 21 Drossman DA, Sandler RS, McKee DC, et al. Bowel patterns among subjects not seeking health care. Use of a questionnaire to identify a population with bowel dysfunction. Gastroenterology 1982;83:52934. 22 Sandler RS, Drossman DA, Nathan HP, et al. Symptom complaints and health care seeking behavior in subjects with bowel dysfunction. Gastroenterology 1984;87:31418. 23 Talley NJ, Zinsmeister AR, Van Dyke C, et al. Epidemiology of colonic symptoms and the irritable bowel syndrome. Gastroenterology 1991;101:92734.

www.gutjnl.com

Guidelines on the irritable bowel syndrome

56 Koloski NA, Talley NJ, Boyce PM. Predictors of health care seeking for irritable bowel syndrome and nonulcer dyspepsia: a critical review of the literature on symptom and psychosocial factors. Am J Gastroenterol 2001;96:13409. 57 Locke GR, Weaver AL, Melton LJ, et al. Psychosocial factors are linked to functional gastrointestinal disorders: a population based nested case-control study. Am J Gastroenterol 2004;99:3507. 58 Mardini HE, Kip KE, Wilson JW. Crohns disease: a two-year prospective study of the association between psychological distress and disease activity. Dig Dis Sci 2004;49:4927. 59 Kettell J, Jones R, Lydeard S. Reasons for consultation in irritable bowel syndrome: symptoms and patient characteristics. Br J Gen Pract 1992;42:45961. 60 Donker GA, Foets M, Spreeuwenberg P. Patients with irritable bowel syndrome: health status and use of health care services. Br J Gen Pract 1999;49:78792. 61 Icks A, Haastert B, Enck P, et al. Prevalence of functional bowel disorders and related health care seeking: a population-based study. Z Gastroenterol 2002;40:17783. 62 Badia X, Mearin F, Balboa A, et al. Burden of illness in irritable bowel syndrome comparing Rome I and Rome II criteria. Pharmacoeconomics 2002;20:74958. 63 Kumano H, Kaiya H, Yoshiuchi K, et al. Comorbidity of irritable bowel syndrome, panic disorder, and agoraphobia in a Japanese representative sample. Am J Gastroenterol 2004;99:3706. 64 Locke GR, Yawn BP, Wollan PC, et al. Incidence of a clinical diagnosis of the irritable bowel syndrome in a United States population. Aliment Pharmacol Ther 2004;19:102531. 65 Agreus L, Svardsudd K, Talley NJ, et al. Natural history of gastroesophageal reflux disease and functional abdominal disorders: a population-based study. Am J Gastroenterol 2001;96:290514. 66 Saito YA, Schoenfeld P, Locke GR. The epidemiology of irritable bowel syndrome in North America: a systematic review. Am J Gastroenterol 2002;97:191015. 67 Bardhan KD, Bodemar G, Geldof H, et al. A double-blind, randomized, placebo-controlled dose-ranging study to evaluate the efficacy of alosetron in the treatment of irritable bowel syndrome. Aliment Pharmacol Ther 2000;14:2334. 68 Camilleri M, Mayer EA, Drossman DA, et al. Improvement in pain and bowel function in female irritable bowel patients with alosetron, a 5-HT3 receptor antagonist. Aliment Pharmacol Ther 1999;13:114959. 69 Tack J, Muller-Lissner S, Bytzer P, et al. A randomised controlled trial assessing the efficacy and safety of repeated tegaserod therapy in women with irritable bowel syndrome with constipation. Gut 2005;54:170713. 70 Svendsen JH, Munck LK, Andersen JR. Irritable bowel syndrome prognosis and diagnostic safety. A 5-year follow-up study. Scand J Gastroenterol 1985;20:41518. 71 Sloth H, Jorgensen LS. Chronic non-organic upper abdominal pain: diagnostic safety and prognosis of gastrointestinal and non-intestinal symptoms. A 5- to 7year follow-up study. Scand J Gastroenterol 1988;23:127580. 72 Harvey RF, Mauad EC, Brown AM. Prognosis in the irritable bowel syndrome: a 5-year prospective study. Lancet 1987;i:9635. 73 Lembo T, Fullerton S, Diehl D, et al. Symptom duration in patients with irritable bowel syndrome. Am J Gastroenterol 1996;91:898905. 74 Janssen HA, Borghouts JA, Muris JW, et al. Health status and management of chronic non-specific abdominal complaints in general practice. Br J Gen Pract 2000;50:3759. 75 Bennett EJ, Tennant CC, Piesse C, et al. Level of chronic life stress predicts clinical outcome in irritable bowel syndrome. Gut 1998;43:25661. 76 Neal KR, Barker L, Spiller RC. Prognosis in post-infective irritable bowel syndrome: a six year follow up study. Gut 2002;51:41013. 77 Bennett EJ, Tennant CC, Piesse C, et al. Level of chronic life stress predicts clinical outcome in irritable bowel syndrome. Gut 1998;43:25661. 78 Hahn B, Watson M, Yan S, et al. Irritable bowel syndrome symptom patterns: frequency, duration, and severity. Dig Dis Sci 1998;43:271518. 79 Stevens JA, Wan CK, Blanchard EB. The short term natural history of irritable bowel syndrome: a time-series analysis. Behav Res Ther 1997;35:31926. 80 Clouse RE, Mayer EA, Aziz Q, et al. Functional abdominal pain syndrome. Gastroenterology 2006;130:14927. 81 Corsetti M, Caenepeel P, Fischler B, et al. Impact of coexisting irritable bowel syndrome on symptoms and pathophysiological mechanisms in functional dyspepsia. Am J Gastroenterol 2004;99:11529. 82 Stanghellini V, Tosetti C, Barbara G, et al. Dyspeptic symptoms and gastric emptying in the irritable bowel syndrome. Am J Gastroenterol 2002;97:273843. 83 Holtmann G, Goebell H, Talley NJ. Functional dyspepsia and irritable bowel syndrome: Is there a common pathophysiological basis? Am J Gastroenterol 1997;92:9549. 84 Locke GR, Zinsmeister AR, Fett SL, et al. Overlap of gastrointestinal symptom complexes in a US community. Neurogastroenterol Motil 2005;17:2934. 85 Ragnarsson G, Bodemar G. Pain is temporally related to eating but not to defaecation in the irritable bowel syndrome (IBS). Patients description of diarrhea, constipation and symptom variation during a prospective 6-week study. Eur J Gastroenterol Hepatol 1998;10:41521. 86 Chey WY, Jin HO, Lee MH, et al. Colonic motility abnormality in patients with irritable bowel syndrome exhibiting abdominal pain and diarrhea. Am J Gastroenterol 2001;96:1499506. 87 Clemens CH, Samsom M, Roelofs JM, et al. Association between pain episodes and high amplitude propagated pressure waves in patients with irritable bowel syndrome. Am J Gastroenterol 2003;98:183843. 88 Accarino AM, Azpiroz F, Malagelada JR. Modification of small bowel mechanosensitivity by intestinal fat. Gut 2001;48:6905.

1793
89 Lea R, Hopkins V, Hastleton J, et al. Diagnostic criteria for irritable bowel syndrome: utility and applicability in clinical practice. Digestion 2004;70:21013. 90 Whorwell PJ, McCallum M, Creed F, et al. Non-colonic features of irritable bowel syndrome. Gut 1986;27:3740. 91 Prior A, Wilson K, Whorwell PJ, et al. Irritable bowel syndrome in the gynecological clinic. Survey of 798 new referrals. Dig Dis Sci 1989;34:18204. 92 Francis CY, Duffy JN, Whorwell PJ, et al. High prevalence of irritable bowel syndrome in patients attending urological outpatient departments. Dig Dis Sci 1997;42:4047. 93 Maxton DG, Morris J, Whorwell PJ. More accurate diagnosis of irritable bowel syndrome by the use of non-colonic symptomatology. Gut 1991;32:7846. 94 Lubrano E, Iovino P, Tremolaterra F, et al. Fibromyalgia in patients with irritable bowel syndrome. An association with the severity of the intestinal disorder. Int J Colorectal Dis 2001;16:21115. 95 Sperber AD, Carmel S, Atzmon Y, et al. Use of the Functional Bowel Disorder Severity Index (FBDSI) in a study of patients with the irritable bowel syndrome and fibromyalgia. Am J Gastroenterol 2000;95:9958. 96 Whitehead WE, Palsson O, Jones KR. Systematic review of the comorbidity of irritable bowel syndrome with other disorders: what are the causes and implications? Gastroenterology 2002;122:114056. 97 Walker EA, Gefand AN, Gelfand MD, et al. Chronic pelvic pain and gynecological symptoms in women with irritable bowel syndrome. J Psychosom Obstet Gynaecol 1996;17:3946. 98 Williams RE, Hartmann KE, Sandler RS, et al. Prevalence and characteristics of irritable bowel syndrome among women with chronic pelvic pain. Obstet Gynecol 2004;104:4528. 99 Lamvu G, Williams R, Zolnoun D, et al. Long-term outcomes after surgical and nonsurgical management of chronic pelvic pain: one year after evaluation in a pelvic pain specialty clinic. Am J Obstet Gynecol 2006;195:5918. 100 Aaron LA, Burke MM, Buchwald D. Overlapping conditions among patients with chronic fatigue syndrome, fibromyalgia, and temporomandibular disorder. Arch Intern Med 2000;160:2217. 101 Vandvik PO, Wilhelmsen I, Ihlebaek C, et al. Comorbidity of irritable bowel syndrome in general practice: a striking feature with clinical implications. Aliment Pharmacol Ther 2004;20:1195203. 102 Sykes MA, Blanchard EB, Lackner J, et al. Psychopathology in irritable bowel syndrome: support for a psychophysiological model. J Behav Med 2003;26:36172. 103 Pan G, Lu S, Ke M, et al. Epidemiologic study of the irritable bowel syndrome in Beijing: stratified randomized study by cluster sampling. Chin Med J (Engl) 2000;113:359. 104 Bennett EJ, Piesse C, Palmer K, et al. Functional gastrointestinal disorders: psychological, social, and somatic features. Gut 1998;42:41420. 105 Drossman DA, Camilleri M, Mayer EA, et al. AGA technical review on irritable bowel syndrome. Gastroenterology 2002;123:210831. 106 North CS, Downs D, Clouse RE, et al. The presentation of irritable bowel syndrome in the context of somatization disorder. Clin Gastroenterol Hepatol 2004;2:78795. 107 Vanner SJ, Depew WT, Paterson WG, et al. Predictive value of the Rome criteria for diagnosing the irritable bowel syndrome. Am J Gastroenterol 1999;94:291217. 108 Hammer J, Eslick GD, Howell SC, et al. Diagnostic yield of alarm features in irritable bowel syndrome and functional dyspepsia. Gut 2004;53:66672. 109 Drossman DA, Li Z, Toner BB, et al. Functional bowel disorders. A multicenter comparison of health status and development of illness severity index. Dig Dis Sci 1995;40:98695. 110 Francis CY, Morris J, Whorwell PJ. The irritable bowel severity scoring system: a simple method of monitoring irritable bowel syndrome and its progress. Aliment Pharmacol Ther 1997;11:395402. 111 Gonsalkorale WM, Houghton LA, Whorwell PJ. Hypnotherapy in irritable bowel syndrome: a large-scale audit of a clinical service with examination of factors influencing responsiveness. Am J Gastroenterol 2002;97:95461. 112 Kennedy T, Jones R, Darnley S, et al. Cognitive behaviour therapy in addition to antispasmodic treatment for irritable bowel syndrome in primary care: randomised controlled trial. BMJ 2005;331:435. 113 Hahn BA, Yan S, Strassels S. Impact of irritable bowel syndrome on quality of life and resource use in the United States and United Kingdom. Digestion 1999;60:7781. 114 Davidson M, Waserman R. The iritable colon of childhood (chronic nonspecific diarrhea syndrome). J Pediatr 1966;69:102738. 115 Kalantar JS, Locke GR, Zinsmeister AR, et al. Familial aggregation of irritable bowel syndrome: a prospective study. Gut 2003;52:17037. 116 Morris-Yates A, Talley NJ, Boyce PM, et al. Evidence of a genetic contribution to functional bowel disorder. Am J Gastroenterol 1998;93:131117. 117 Levy RL, Jones KR, Whitehead WE, et al. Irritable bowel syndrome in twins: heredity and social learning both contribute to etiology. Gastroenterology 2001;121:799804. 118 Mohammed I, Cherkas LF, Riley SA, et al. Genetic influences in irritable bowel syndrome: a twin study. Am J Gastroenterol 2005;100:13404. 119 Levy RL, Whitehead WE, Von Korff MR, et al. Intergenerational transmission of gastrointestinal illness behavior. Am J Gastroenterol 2000;95:4516. 120 Levy RL, Whitehead WE, Walker LS, et al. Increased somatic complaints and health-care utilization in children: effects of parent IBS status and parent response to gastrointestinal symptoms. Am J Gastroenterol 2004;99:244251. 121 Whitehead WE, Busch CM, Heller BR, et al. Social learning influences on menstrual symptoms and illness behavior. Health Psychol 1986;5:1323. 122 Saito YA, Cremonini F, Talley NJ. Association of the 1438G/A and 102T/C polymorphism of the 5-HT2A receptor gene with irritable bowel syndrome 5-

www.gutjnl.com

1794
HT2A gene polymorphism in irritable bowel syndrome. J Clin Gastroenterol 2005;39:8356. Park MI, Camilleri M. Genetics and genotypes in irritable bowel syndrome: implications for diagnosis and treatment. Gastroenterol Clin North Am 2005;34:30517. Camilleri M, Atanasova E, Carlson PJ, et al. Serotonin-transporter polymorphism pharmacogenetics in diarrhea-predominant irritable bowel syndrome. Gastroenterology 2002;123:42532. Park MI, Camilleri M. Genetics and genotypes in irritable bowel syndrome: implications for diagnosis and treatment. Gastroenterol Clin North Am 2005;34:30517. Ioannidis JPA, Trikalinos TA, Ntzani EE, et al. Genetic associations in large versus small studies: an empirical assessment. Lancet 2003;361:56771. Melke J, Landen M, Baghei F, et al. Serotonin transporter gene polymorphisms are associated with anxiety-related personality traits in women. Am J Med Genet 2001;105:45863. Kendler KS, Walters EE, Truett KR, et al. A twin-family study of self-report symptoms of panic-phobia and somatization. Behav Genet 1995;25:499515. Kendler KS, Walters EE, Neale MC, et al. The structure of the genetic and environmental risk factors for six major psychiatric disorders in women. Phobia, generalized anxiety disorder, panic disorder, bulimia, major depression, and alcoholism. Arch Gen Psychiatry 1995;52:37483. McKee DP, Quigley EM. Intestinal motility in irritable bowel syndrome: is IBS a motility disorder? Part 1. Definition of IBS and colonic motility. Dig Dis Sci 1993;38:176172. Van Wijk HJ, Smout AJPM, Akkermans LMA, et al. Gastric emptying and dyspeptic symptoms in the irritable bowel syndrome. Scand J Gastroenterol 1992;27:99102. Evans PR, Bak YT, Shuter B, et al. Gastroparesis and small bowel dysmotility in irritable bowel syndrome. Dig Dis Sci 1997;42:208793. Caballero-Plasencia AM, Valenzuela-Barranco M, Herrerias-Gutierrez JM, et al. Altered gastric emptying in patients with irritable bowel syndrome. Eur J Nucl Med 1999;26:4049. van dV I, Osmanoglou E, Seybold M, et al. Electrogastrography as a diagnostic tool for delayed gastric emptying in functional dyspepsia and irritable bowel syndrome. Neurogastroenterol Motil 2003;15:46773. Van der Voort IR, Osmanoglou E, Seybold M, et al. Electrogastrography as a diagnostic tool for delayed gastric emptying in functional dyspepsia and irritable bowel syndrome. Neurogastroenterol Motil 2003;15:46773. van dV I, Osmanoglou E, Seybold M, et al. Electrogastrography as a diagnostic tool for delayed gastric emptying in functional dyspepsia and irritable bowel syndrome. Neurogastroenterol Motil 2003;15:46773. Welgan P, Meshkinpour H, Ma L. Role of anger in antral motor activity in irritable bowel syndrome. Dig Dis Sci 2000;45:24851. Kumar D, Wingate DL. The irritable bowel syndrome a paroxysmal motor disorder. Lancet 1985;ii:9737. Kellow JE, Gill RC, Wingate DL. Prolonged ambulant recordings of small bowel motility demonstrate abnormalities in the irritable bowel syndrome. Gastroenterology 1990;98:120818. Simren M, Castedal M, Svedlund J, et al. Abnormal propagation pattern of duodenal pressure waves in the irritable bowel syndrome (IBD). Dig Dis Sci 2000;45:215161. Kellow JE, Phillips SF. Altered small bowel motility in irritable bowel syndrome is correlated with symptoms. Gastroenterology 1987;92:188593. Kellow JE, Phillips SF, Miller LJ, et al. Dysmotility of the small intestine in irritable bowel syndrome. Gut 1988;29:123643. Schmidt T, Hackelsberger N, Widmer R, et al. Ambulatory 24-hour jejunal motility in diarrhea-predominant irritable bowel syndrome. Scand J Gastroenterol 1996;31:5819. Fukudo S, Nomura T, Hongo M. Impact of corticotropin-releasing hormone on gastrointestinal motility and adrenocorticotropic hormone in normal controls and patients with irritable bowel syndrome. Gut 1998;42:8459. Cann PA, Read NW, Brown C, et al. Irritable bowel syndrome: relationship of disorders in the transit of a single solid meal to symptom patterns. Gut 1983;24:40511. Fukudo S, Kanazawa M, Kano M, et al. Exaggerated motility of the descending colon with repetitive distention of the sigmoid colon in patients with irritable bowel syndrome. J Gastroenterol 2002;37(suppl 14):14550. McKee DP, Quigley EM. Intestinal motility in irritable bowel syndrome: Is IBS a motility disorder? Part 2. Motility of the small bowel, esophagus, stomach, and gall-bladder. Dig Dis Sci 1993;38:177382. Narducci F, Bassotti G, Granata MT, et al. Colonic motility and gastric emptying in patients with irritable bowel syndrome. Effect of pretreatment with octylonium bromide. Dig Dis Sci 1986;31:2416. Rogers J, Henry MM, Misiewicz JJ. Increased segmental activity and intraluminal pressures in the sigmoid colon of patients with the irritable bowel syndrome. Gut 1989;30:63441. Sullivan MA, Cohen S, Snape WJJ. Colonic myoelectrical activity in irritablebowel syndrome. Effect of eating and anticholinergics. N Engl J Med 1978;298:87883. Chey WY, Jin HO, Lee MH, et al. Colonic motility abnormality in patients with irritable bowel syndrome exhibiting abdominal pain and diarrhea. Am J Gastroenterol 2001;96:1499506. Welgan P, Meshkinpour H, Beeler M. Effect of anger on colon motor and myoelectric activity in irritable bowel syndrome. Gastroenterology 1988;94:11506. Harvey RF, Read AE. Effect of cholecystokinin on colonic motility and symptoms in patients with the irritable bowel syndrome. Lancet 1973;i:13.

Spiller, Aziz, Creed, et al

154 Whitehead WE, Engel BT, Schuster MM. Irritable bowel syndrome: physiological and psychological differences between diarrhea-predominant and constipation-predominant patients. Dig Dis Sci 1980;25:40413. 155 Trotman IF, Misiewicz JJ. Sigmoid motility in diverticular disease and the irritable bowel syndrome. Gut 1988;29:21822. 156 Anders G, Wangel G, Deller DJ. Intestinal motility in man. Mechanisms of constipation and diarrhea with particular reference to the irritable colon syndrome. Gastroenterol 1965;48:6983. 157 Welgan P, Meshkinpour H, Hoehler F. The effect of stress on colon motor and electrical activity in irritable bowel syndrome. Psychosom Med 1985;47:13949. 158 Wangel AG, Deller DJ. Intestinal motility in man.3. Mechanisms of constipation and diarrhea with particular reference to irritable colon syndrome. Gastroenterology 1965;48:6984. 159 Misiewicz JJ, Connell AM, Pontes FA. Comparison of effect of meals and prostigmine on proximal and distal colon in patients with and without diarrhoea. Gut 1966;7:46873. 160 McKee DP, Quigley EM. Intestinal motility in irritable bowel syndrome: is IBS a motility disorder? Part 1. Definition of IBS and colonic motility. Dig Dis Sci 1993;38:176172. 161 Katschinski M, Lederer P, Ellermann A, et al. Myoelectric and manometric patterns of human rectosigmoid colon in irritable bowel syndrome and diverticulosis. Scand J Gastroenterol 1990;25:7618. 162 Hamdorf JM, Ingram DM, Sallie RJ, et al. The motility of the colon in the irritable bowel syndrome. Hepatogastroenterology 1988;35:20816. 163 Rogers J, Misiewicz JJ. Increased intraluminal pressures and activity in the sigmoid colon of patients with the irritable bowel syndrome. Hepatogastroenterology 1988;35:209. 164 Vassallo MJ, Camilleri M, Phillips SF, et al. Colonic tone and motility in patients with irritable bowel syndrome. Mayo Clin Proc 1992;67:72531. 165 Bassotti G, Chistolini F, Marinozzi G, et al. Abnormal colonic propagated activity in patients with slow transit constipation and constipation-predominant irritable bowel syndrome. Digestion 2003;68:17883. 166 Bazzocchi G, Ellis J, Villanueva-Meyer J, et al. Postprandial colonic transit and motor activity in chronic constipation. Gastroenterology 1990;98:68693. 167 Stivland T, Camilleri M, Vassallo M, et al. Scintigraphic measurement of regional gut transit in idiopathic constipation. Gastroenterology 1991;101:10715. 168 Atkinson W, Lockhart SJ, Keevil BG, et al. Exaggerated postprandial colonic motility in irritable bowel syndrome (IBS): a role for 5-hydroxytryptamine (5Ht)? [Abstract] Gastroenterology, 2005;128:A103. 169 Atkinson W, Lockhart S, Whorwell PJ, et al. Altered 5-hydroxytryptamine signaling in patients with constipation- and diarrhea-predominant irritable bowel syndrome. Gastroenterology 2006;130:3443. 170 OBrien MD, Phillips SF. Colonic motility in health and disease. Gastroenterol Clin North Am 1996;25:14762. 171 Choi MG, Camilleri M, OBrien MD, et al. A pilot study of motility and tone of the left colon in patients with diarrhea due to functional disorders and dysautonomia. Am J Gastroenterol 1997;92:297302. 172 Di Stefano M, Miceli E, Missanelli A, et al. Meal induced rectosigmoid tone modification: a low caloric meal accurately separates functional and organic gastrointestinal disease patients. Gut 2006;55:140914. 173 Vassallo MJ, Camilleri M, Phillips SF, et al. Colonic tone and motility in patients with irritable bowel syndrome. Mayo Clin Proc 1992;67:72531. 174 Hammer J, Phillips SF, Talley NJ, et al. Effect of a 5HT3-antagonist (ondansetron) on rectal sensitivity and compliance in health and the irritable bowel syndrome. Aliment Pharmacol Ther 1993;7:54351. 175 Slater BJ, Plusa SM, Smith AN, et al. Rectal hypersensitivity in the irritable bowel syndrome. Int J Colorectal Dis 1997;12:2932. 176 Steens J, van der Schaar PJ, Penning C, et al. Compliance, tone and sensitivity of the rectum in different subtypes of irritable bowel syndrome. Neurogastroenterol Motil 2002;14:2417. 177 Kwan CL, Davis KD, Mikula K, et al. Abnormal rectal motor physiology in patients with irritable bowel syndrome. Neurogastroenterol Motil 2004;16:25163. 178 Munakata J, Naliboff B, Harraf F, et al. Repetitive sigmoid stimulation induces rectal hyperalgesia in patients with irritable bowel syndrome. Gastroenterology 1997;112:5563. 179 Lembo T, Munakata J, Mertz H, et al. Evidence for the hypersensitivity of lumbar splanchnic afferents in irritable bowel syndrome. Gastroenterology 1994;107:168696. 180 Bradette M, Delvaux M, Staumont G, et al. Evaluation of colonic sensory thresholds in IBS patients using a barostat. Definition of optimal conditions and comparison with healthy subjects. Dig Dis Sci 1994;39:44957. 181 Zighelboim J, Talley NJ, Phillips SF, et al. Visceral perception in irritable bowel syndrome. Rectal and gastric responses to distension and serotonin type 3 antagonism. Dig Dis Sci 1995;40:81927. 182 Penning C, Steens J, van der Schaar PJ, et al. Motor and sensory function of the rectum in different subtypes of constipation. Scand J Gastroenterol 2001;36:328. 183 Kwan CL, Diamant NE, Mikula K, et al. Characteristics of rectal perception are altered in irritable bowel syndrome. Pain 2005;113:16071. 184 van dV I, Osmanoglou E, Seybold M, et al. Electrogastrography as a diagnostic tool for delayed gastric emptying in functional dyspepsia and irritable bowel syndrome. Neurogastroenterol Motil 2003;15:46773. 185 Ritchie J. Pain from the distension of the pelvic colon by inflating a balloon in the irritable colon syndrome. Gut 1973;14:12532.

123 124 125 126 127 128 129

130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153

www.gutjnl.com

Guidelines on the irritable bowel syndrome

186 Trimble KC, Farouk R, Pryde A, et al. Heightened visceral sensation in functional gastrointestinal disease is not site-specific. Evidence for a generalized disorder of gut sensitivity. Dig Dis Sci 1995;40:160713. 187 Bueno L, Fioramonti J, Delvaux M, et al. Mediators and pharmacology of visceral sensitivity: from basic to clinical investigations. Gastroenterology 1997;112:171443. 188 Coutinho SV, Su X, Sengupta JN, et al. Role of sensitized pelvic nerve afferents from the inflamed rat colon in the maintenance of visceral hyperalgesia. Prog Brain Res 2000;129:37587. 189 Torebjork HE, Lundberg LER, Lamotte RH. Central changes in processing of mechanoreceptive input in capsaicin-induced secondary hyperalgesia in humans. J Physiol (Lond) 1992;448:76580. 190 Treede RD, Meyer RA, Raja SN, et al. Peripheral and central mechanisms of cutaneous hyperalgesia. Prog Neurobiol 1992;38:397421. 191 Woolf CJ. Somatic pain pathogenesis and prevention. Br J Anaesth 1995;75:16976. 192 Longstreth GF, Hawkey CJ, Mayer EA, et al. Characteristics of patients with irritable bowel syndrome recruited from three sources: implications for clinical trials. Aliment Pharmacol Ther 2001;15:95964. 193 Moriarty KJ, Dawson AM. Functional abdominal pain: further evidence that whole gut is affected. BMJ 1982;284:16702. 194 Chang L, Mayer EA, Johnson T, et al. Differences in somatic perception in female patients with irritable bowel syndrome with and without fibromyalgia. Pain 2000;84:297307. 195 Aziz Q, Thompson DG, Ng VW, et al. Cortical processing of human somatic and visceral sensation. J Neurosci 2000;20:265763. 196 Derbyshire SWG. A systematic review of neuroimaging data during visceral stimulation. Am J Gastroenterol 2003;98:1220. 197 Reynolds DV. Surgery in rat during electrical analgesia induced by focal brain stimulation. Science 1969;164:4445. 198 Lebars D, Dickenson AH, Besson JM. Diffuse noxious inhibitory controls (Dnic).1. Effects on dorsal horn convergent neurons in the rat. Pain 1979;6:283304. 199 Wand-Tetley JI. Historical methods of counter-irritation. Ann Phys Med 1956;3:909. 200 Coffin B, Bouhassira D, Sabate JM, et al. Alteration of the spinal modulation of nociceptive processing in patients with irritable bowel syndrome. Gut 2004;53:146570. 201 Silverman DH, Munakata JA, Ennes H, et al. Regional cerebral activity in normal and pathological perception of visceral pain. Gastroenterology 1997;112:6472. 202 Mertz H, Morgan V, Tanner G, et al. Regional cerebral activation in irritable bowel syndrome and control subjects with painful and nonpainful rectal distention. Gastroenterology 2000;118:8428. 203 Bonaz B, Baciu M, Papillon E, et al. Central processing of rectal pain in patients with irritable bowel syndrome: an fMRI study. Am J Gastroenterol 2002;97:65461. 204 Hobson AR, Aziz Q. Brain imaging and functional gastrointestinal disorders: has it helped our understanding? Gut 2004;53:1198206. 205 Hobson AR, Furlong PL, Sarkar S, et al. Neurophysidogic assessment of esophageal sensory processing in noncardiac chest pain. Gastroenterology 2006;130:808. 206 Elenkov IJ, Chrousos GP. Stress hormones, proinflammatory and antiinflammatory cytokines, and autoimmunity. Neuroendocr Immune Basis Rheum Dis 2002;966:290303. 207 Turnbull AV, Rivier C. Corticotropin-releasing factor (CRF) and endocrine responses to stress: CRF receptors, binding protein, and related peptides. Proc Soc Exp Biol Med 1997;215:110. 208 Spiller RC. Postinfectious irritable bowel syndrome. Gastroenterology 2003;124:166271. 209 Creed F, Craig T, Farmer R. Functional abdominal pain, psychiatric illness, and life events. Gut 1988;29:23542. 210 Dinan TG, OKeane V, OBoyle C, et al. A comparison of the mental status, personality profiles and life events of patients with irritable bowel syndrome and peptic ulcer disease. Acta Psychiatr Scand 1991;84:268. 211 Howell S, Poulton R, Talley NJ. The natural history of childhood abdominal pain and its association with adult irritable bowel syndrome: birth-cohort study. Am J Gastroenterol 2005;100:20718. 212 Drossman DA, Li Z, Leserman J, et al. Health status by gastrointestinal diagnosis and abuse history. Gastroenterology 1996;110:9991007. 213 Ford MJ, Miller PMC, Eastwood J, et al. Life events, psychiatric illness and the irritable bowel syndrome. Gut 1987;28:1605. 214 Gwee KA, Leong YL, Graham C, et al. The role of psychological and biological factors in postinfective gut dysfunction. Gut 1999;44:4006. 215 Dunlop SP, Jenkins D, Neal KR, et al. Relative importance of enterochromaffin cell hyperplasia, anxiety, and depression in postinfectious IBS. Gastroenterology 2003;125:16519. 216 Naliboff BD, Munakata J, Chang L, et al. Toward a biobehavioral model of visceral hypersensitivity in irritable bowel syndrome. J Psychosom Res 1998;45:48592. 217 Dickhaus B, Mayer EA, Firooz N, et al. Irritable bowel syndrome patients show enhanced modulation of visceral perception by auditory stress. Am J Gastroenterol 2003;98:13543. 218 Posserud I, Agerforz P, Ekman R, et al. Altered visceral perceptual and neuroendocrine response in patients with irritable bowel syndrome during mental stress. Gut 2004;53:11028. 219 Ritchie JA, Ardran GM, Truelove SC. Observations on experimentally induced colonic pain. Gut 1972;13:841.

1795
220 Mertz H, Naliboff B, Munakata J, et al. Altered rectal perception is a biological marker of patients with irritable bowel syndrome. Gastroenterology 1995;109:4052. 221 Naliboff BD, Munakata J, Fullerton S, et al. Evidence for two distinct perceptual alterations in irritable bowel syndrome. Gut 1997;41:50512. 222 Nomura T, Fukudo S, Matsuoka H, et al. Abnormal electroencephalogram in irritable bowel syndrome. Scand J Gastroenterol 1999;34:47884. 223 Murray CDR, Flynn J, Ratcliffe L, et al. Effect of acute physical and psychological stress on gut autonomic innervation in irritable bowel syndrome. Gastroenterology 2004;127:1695703. 224 Aggarwal A, Cutts TF, Abell TL, et al. Predominant symptoms in irritable bowel syndrome correlate with specific autonomic nervous system abnormalities. Gastroenterology 1994;106:94550. 225 Emmanuel AV, Kamm MA. Laser Doppler measurement of rectal mucosal blood flow. Gut 1999;45:649. 226 Dinan TG, Quigley EM, Ahmed SM, et al. Hypothalamic-pituitary-gut axis dysregulation in irritable bowel syndrome: plasma cytokines as a potential biomarker? Gastroenterology 2006;130:30411. 227 Morgan V, Pickens D, Gautam S, et al. Amitriptyline reduces rectal pain related activation of the anterior cingulate cortex in patients with irritable bowel syndrome. Gut 2005;54:6017. 228 Chrousos GP, Gold PW. The concepts of stress and stress system disorders. Overview of physical and behavioral homeostasis. JAMA 1992;267:124452. 229 Million M, Wang L, Wang Y, et al. CRF2 receptor activation prevents colorectal distension-induced visceral pain and spinal ERK1/2 phosphorylation in rats. Gut 2006;55:17281. 230 Parry SD, Stansfield R, Jelley D, et al. Does bacterial gastroenteritis predispose people to functional gastrointestinal disorders? A prospective, communitybased, casecontrol study. Am J Gastroenterol 2003;98:19705. 231 Rodriguez LA, Ruigomez A. Increased risk of irritable bowel syndrome after bacterial gastroenteritis: cohort study. BMJ 1999;318:5656. 232 Thornley JP, Jenkins D, Neal K, et al. Relationship of Campylobacter toxigenicity in vitro to the development of postinfectious irritable bowel syndrome. J Infect Dis 2001;184:6069. 233 Gwee KA, Graham JC, McKendrick MW, et al. Psychometric scores and persistence of irritable bowel after infectious diarrhoea. Lancet 1996;347:1503. 234 Wang LH, Fang XC, Pan GZ. Bacillary dysentery as a causative factor of irritable bowel syndrome and its pathogenesis. Gut 2004;53:1096101. 235 McKendrick MW. Post Salmonella irritable bowel syndrome 5 year review [letter; comment]. J Infect 1996;32:1701. 236 Mearin F, Pqrez-Oliveras M, Perell A, et al. Dyspepsia and irritable bowel syndrome after a salmonella gastroenteritis outbreak: one-year follow-up cohort study. Gastroenterology 2005;129:98104. 237 Neal KR, Hebden J, Spiller R. Prevalence of gastrointestinal symptoms six months after bacterial gastroenteritis and risk factors for development of the irritable bowel syndrome: postal survey of patients. BMJ 1997;314:77982. 238 Wheatcroft J, Wakelin D, Smith A, et al. Enterochromaffin cell hyperplasia and decreased serotonin transporter in a mouse model of postinfectious bowel dysfunction. Neurogastroenterol Motil 2005;17:86370. 239 Gwee KA, Collins SM, Read NW, et al. Increased rectal mucosal expression of interleukin 1beta in recently acquired post-infectious irritable bowel syndrome. Gut 2003;52:5236. 240 Dunlop SP, Coleman NS, Blackshaw E, et al. Abnormalities of 5hydroxytryptamine metabolism in irritable bowel syndrome. Clin Gastroenterol Hepatol 2005;3:34957. 241 Parry SD, Barton JR, Welfare MR. Is lactose intolerance implicated in the development of post-infectious irritable bowel syndrome or functional diarrhoea in previously asymptomatic people? Eur J Gastroenterol Hepatol 2002;14:122530. 242 Spiller RC, Jenkins D, Thornley JP, et al. Increased rectal mucosal enteroendocrine cells, T lymphocytes, and increased gut permeability following acute Campylobacter enteritis and in post-dysenteric irritable bowel syndrome. Gut 2000;47:80411. 243 Marshall JK, Thabane M, Garg AX, et al. Intestinal permeability in patients with irritable bowel syndrome after a waterborne outbreak of acute gastroenteritis in Walkerton, Ontario. Aliment Pharmacol Ther 2004;20:131722. 244 Santos J, Saunders PR, Hanssen NP, et al. Corticotropin-releasing hormone mimics stress-induced colonic epithelial pathophysiology in the rat. Am J Physiol 1999;277:G3919. 245 Soderholm JD, Yang PC, Ceponis P, et al. Chronic stress induces mast celldependent bacterial adherence and initiates mucosal inflammation in rat intestine. Gastroenterology 2002;123:1099108. 246 OMahony L, McCarthy J, Kelly P, et al. Lactobacillus and bifidobacterium in irritable bowel syndrome: symptom responses and relationship to cytokine profiles. Gastroenterology 2005;128:54151. 247 Gonsalkorale WM, Perrey C, Pravica V, et al. Interleukin 10 genotypes in irritable bowel syndrome: evidence for an inflammatory component? Gut 2003;52:913. 248 van der Veek PP, van den BM, de Kroon YE, et al. Role of tumor necrosis factoralpha and interleukin-10 gene polymorphisms in irritable bowel syndrome. Am J Gastroenterol 2005;100:251016. 249 Houghton LA, Whorwell PJ. Towards a better understanding of abdominal bloating and distension in functional gastrointestinal disorders. Neurogastroenterol Motil 2005;17:50011. 250 Chang L, Lee OY, Naliboff B, et al. Sensation of bloating and visible abdominal distension in patients with irritable bowel syndrome. Am J Gastroenterol 2001;96:33417.

www.gutjnl.com

1796
251 Houghton LA, Lea R, Agrawal A, et al. Relationship of abdominal bloating to distention in irritable bowel syndrome and effect of bowel habit. Gastroenterology 2006;131:100310. 252 Serra J, Azpiroz F, Malagelada JR. Impaired transit and tolerance of intestinal gas in the irritable bowel syndrome. Gut 2001;48:1419. 253 King TS, Elia M, Hunter JO. Abnormal colonic fermentation in irritable bowel syndrome. Lancet 1998;352:11879. 254 Maxton DG, Martin DF, Whorwell PJ, et al. Abdominal distension in female patients with irritable bowel syndrome: exploration of possible mechanisms. Gut 1991;32:6624. 255 Caldarella MP, Serra J, Azpiroz F, et al. Prokinetic effects in patients with intestinal gas retention. Gastroenterology 2002;122:174855. 256 Serra J, Salvioli B, Azpiroz F, et al. Lipid-induced intestinal gas retention in irritable bowel syndrome. Gastroenterology 2002;123:7006. 257 Cann PA, Read NW, Brown C, et al. Irritable bowel syndrome: relationship of disorders in the transit of a single solid meal to symptom patterns. Gut 1983;24:40511. 258 Lewis MJ, Reilly B, Houghton LA, et al. Ambulatory abdominal inductance plethysmography: towards objective assessment of abdominal distension in irritable bowel syndrome. Gut 2001;48:21620. 259 Reilly BP, Bolton MP, Lewis MJ, et al. A device for 24 hour ambulatory monitoring of abdominal girth using inductive plethysmography. Physiol Meas 2002;23:66170. 260 Agrawal A, Whorwell PJ, Houghton LA. Is abdominal distension related to delayed small and large bowel transit in patients with constipation predominant irritable bowel syndrome (C-IBS)? [abstract] Gastroenterology, 2006;130:A632. 261 Lea R, Reilly B, Whorwell PJ, et al. Abdominal bloating in the absence of physical distension. [Abstract] Gastroenterology, 2004;126:A432. 262 McManis PG, Newall D, Talley NJ. Abdominal wall muscle activity in irritable bowel syndrome with bloating. Am J Gastroenterol 2001;96:113942. 263 Tremolaterra F, Villoria A, Azpiroz F, et al. Impaired viscerosomatic reflexes and abdominal-wall dystony associated with bloating. Gastroenterology 2006;130:10628. 264 Owens DM, Nelson DK, Talley NJ. The irritable bowel syndrome: long-term prognosis and the physicianpatient interaction. Ann Intern Med 1995;122:10712. 265 Kettell J, Jones R, Lydeard S. Reasons for consultation in irritable bowel syndrome: symptoms and patient characteristics. Br J Gen Pract 1992;42:45961. 266 Heaton KW, ODonnell LJ. An office guide to whole-gut transit time. Patients recollection of their stool form. J Clin Gastroenterol 1994;19:2830. 267 Maxwell PR, Rink E, Kumar D, et al. Antibiotics increase functional abdominal symptoms. Am J Gastroenterol 2002;97:1048. 268 Costanza CD, Longstreth GF, Liu AL. Chronic abdominal wall pain: clinical features, health care costs, and long-term outcome. Clin Gastroenterol Hepatol 2004;2:3959. 269 Gregory PL, Biswas AC, Batt ME. Musculoskeletal problems of the chest wall in athletes. Sports Med 2002;32:23550. 270 Scott EM, Scott BB. Painful rib syndrome: a review of 76 cases. Gut 1993;34:10068. 271 Vanner SJ, Depew WT, Paterson WG, et al. Predictive value of the Rome criteria for diagnosing the irritable bowel syndrome. Am J Gastroenterol 1999;94:291217. 272 Hamm LR, Sorrells SC, Harding JP, et al. Additional investigations fail to alter the diagnosis of irritable bowel syndrome in subjects fulfilling the Rome criteria. Am J Gastroenterol 1999;94:127982. 273 Locke GR, Murray JA, Zinsmeister AR, et al. Celiac disease serology in irritable bowel syndrome and dyspepsia: a population-based casecontrol study. Mayo Clin Proc 2004;79:47682. 274 Sanders DS, Carter MJ, Hurlstone DP, et al. Association of adult coeliac disease with irritable bowel syndrome: a case-control study in patients fulfilling ROME II criteria referred to secondary care. Lancet 2001;358:15048. 275 Kroenke K, Spitzer RL, Williams JB. The PHQ-15: validity of a new measure for evaluating the severity of somatic symptoms. Psychosom Med 2002;64:25866. 276 Miller AR, North CS, Clouse RE, et al. The association of irritable bowel syndrome and somatization disorder. Ann Clin Psychiatry 2001;13:2530. 277 Dunlop MG. Guidance on large bowel surveillance for people with two first degree relatives with colorectal cancer or one first degree relative diagnosed with colorectal cancer under 45 years. Gut 2002;51(suppl 5):V1720. 278 Olesen M, Eriksson S, Bohr J, et al. Microscopic colitis: a common diarrhoeal disease. An epidemiological study in Orebro, Sweden, 19931998. Gut 2004;53:34650. 279 Simoons FJ. The geographic hypothesis and lactose malabsorption a weighing of the evidence. Dig Dis Sci 1978;23:96379. 280 Sinha L, Liston R, Testa HJ, et al. Idiopathic bile acid malabsorption: qualitative and quantitative clinical features and response to cholestyramine. Aliment Pharmacol Ther 1998;12:83944. 281 Williams AJK, Merrick MV, Eastwood MA. Idiopathic bile acid malabsorption: a review of clinical presentation, diagnosis, and response to treatment. Gut 1991;32:10046. 282 Behar J, Corazziari E, Guelrud M, et al. Functional gallbladder and sphincter of Oddi disorders. Gastroenterology 2006;130:1498509. 283 May C, Allison G, Chapple A, et al. Framing the doctor-patient relationship in chronic illness: a comparative study of general practitioners accounts. Sociol Health Illn 2004;26:13558. 284 Knottnerus JA, van Weel C, Muris JW. Evaluation of diagnostic procedures. BMJ 2002;324:47780.

Spiller, Aziz, Creed, et al

285 Murphy MK, Black NA, Lamping DL, et al. Consensus development methods, and their use in clinical guideline development. Health Technol Assess 1998;2:i88. 286 Rubin G, de Wit N, Meineche-Schmidt V, et al. Identification and diagnosis of patients with irritable bowel syndrome in primary care: nominal group technique. [Abstract] Gut, 2005;54:A3. 287 Whitehead WE, Bosmajian LS. Behavioral medicine approaches to gastrointestinal disorders. J Consult Clin Psychol 1982;50:97283. 288 Arroll B, Goodyear-Smith F, Kerse N, et al. Effect of the addition of a help question to two screening questions on specificity for diagnosis of depression in general practice: diagnostic validity study. BMJ 2005;331:884. 289 Muris JWM, Starmans R, Wolfs GGMC, et al. The diagnostic-value of rectal examination. Fam Pract 1993;10:347. 290 Spiegel BM, DeRosa VP, Gralnek IM, et al. Testing for celiac sprue in irritable bowel syndrome with predominant diarrhea: a cost-effectiveness analysis. Gastroenterology 2004;126:172132. 291 Sanders DS, Patel D, Stephenson TJ, et al. A primary care cross-sectional study of undiagnosed adult coeliac disease. Eur J Gastroenterol Hepatol 2003;15:40713. 292 Francis CY, Whorwell PJ. Bran and irritable bowel syndrome: time for reappraisal. Lancet 1994;344:3940. 293 Prior A, Whorwell PJ. Double blind study of ispaghula in irritable bowel syndrome. Gut 1987;28:151013. 294 Bijkerk CJ, Muris JWM, Knottnerus JA, et al. Systematic review: the role of different types of fibre in the treatment of irritable bowel syndrome. Aliment Pharmacol Ther 2004;19:24551. 295 Petitpierre M, Gumowski P, Girard J-P. Irritable bowel syndrome and hypersensitivity to food. Ann Allergy 1985;54:53840. 296 Lunardi C, Bambara LM, Biasi D, et al. Double-blind cross-over trial of oral sodium cromoglycate in patients with irritable bowel syndrome due to food intolerance. Clin Exp Allergy 1991;21:56972. 297 Stefanini GF, Prati E, Albini MC, et al. Oral disodium cromoglycate treatment on irritable bowel syndrome: an open study on 101 subjects with diarrheic type. Am J Gastroenterol 1992;87:557. 298 Stefanini GF, Saggioro A, Alvisi V, et al. Oral cromolyn sodium in comparison with elimination diet in the irritable bowel syndrome, diarrheic type. Multicenter study of 428 patients. Scand J Gastroenterol 1995;30:53541. 299 Jones VA, Shorthouse M, Hunter JO. Food intolerance: A major factor in the pathogenesis of irritable bowel syndrome. Lancet 1982;2:111517. 300 Niec AM, Frankum B, Talley NJ. Are adverse food reactions linked to irritable bowel syndrome? Am J Gastroenterol 1998;93:218490. 301 Atkinson W, Sheldon TA, Shaath N, et al. Food elimination based on IgG antibodies in irritable bowel syndrome: a randomised controlled trial. Gut 2004;53:145964. 302 Zar S, Mincher L, Benson MJ, et al. Food-specific IgG4 antibody-guided exclusion diet improves symptoms and rectal compliance in irritable bowel syndrome. Scand J Gastroenterol 2005;40:8007. 303 Zar S, Benson MJ, Kumar D. Food-specific serum IgG4 and IgE titers to common food antigens in irritable bowel syndrome. Am J Gastroenterol 2005;100:15507. 304 Fernandez-Banares F, Esteve-Pardo M, De Leon R, et al. Sugar malabsorption in functional bowel disease: clinical implications. Am J Gastroenterol 1993;88:204450. 305 Bohmer CJM, Tuynman HARE. The effect of a lactose-restricted diet in patients with a positive lactose tolerance test, earlier diagnosed as irritable bowel syndrome: a 5-year follow-up study. Eur J Gastroenterol Hepatol 2001;13:9414. 306 Farup PG, Monsbakken KW, Vandvik PO. Lactose malabsorption in a population with irritable bowel syndrome: prevalence and symptoms. A case control study. Scand J Gastroenterol 2004;39:6459. 307 Newcomer AD, McGill DB. Irritable bowel syndrome: role of lactase deficiency. Mayo Clin Proc 1983;58:33941. 308 Tolliver BA, Jackson MS, Jackson KL, et al. Does lactose maldigestion really play a role in the irritable bowel? J Clin Gastroenterol 1996;23:1517. 309 Vernia P, Ricciardi MR, Frandina C, et al. Lactose malabsorption and irritable bowel syndrome. Effect of a long-term lactose-free diet. It J Gastroenterol 1995;27:11721. 310 Goldstein R, Braverman D, Stankiewicz H. Carbohydrate malabsorption and the effect of dietary restriction on symptoms of irritable bowel syndrome and functional bowel complaints [In Process Citation]. Isr Med Assoc J 2000;2:5837. 311 Nelis GF, Vermeeren MAP, Jansen W. Role of fructose-sorbitol malabsorption in the irritable bowel syndrome. Gastroenterology 1990;99:101620. 312 Symons P, Jones MP, Kellow JE. Symptom provocation in irritable bowel syndrome. Effects of differing doses of fructose-sorbitol. Scand J Gastroenterol 1992;27:9404. 313 Bohmer CJM, Tuynman HARE. The clinical relevance of lactose malabsorption in irritable bowel syndrome. Eur J Gastroenterol Hepatol 1996;8:101316. 314 Caldarella MP, Milano A, Laterza F, et al. Visceral sensitivity and symptoms in patients with constipation- or diarrhea-predominant irritable bowel syndrome (IBS): effect of a low-fat intraduodenal infusion. Am J Gastroenterol 2005;100:3839. 315 Parker TJ, Naylor SJ, Riordan AM, et al. Management of patients with food intolerance in irritable bowel syndrome: the development and use of an exclusion diet. J Hum Nutr Dietet 1995;8:15966. 316 Nanda R, James R, Smith H, et al. Food intolerance and the irritable bowel syndrome. Gut 1989;30:1099104. 317 Van Dulmen AM, Fennis JM, Mokkink HA, et al. The relationship between complaint-related cognitions in referred patients with irritable bowel syndrome

www.gutjnl.com

Guidelines on the irritable bowel syndrome

and subsequent health care seeking behaviour in primary care. Fam Pract 1996;13:1217. Van Dulmen AM, Fennis JM, Mokkink HA, et al. Doctor-dependent changes in complaint-related cognitions and anxiety during medical consultations in functional abdominal complaints. Psychol Med 1995;25:101118. Ilnyckyj A, Graff LA, Blanchard JF, et al. Therapeutic value of a gastroenterology consultation in irritable bowel syndrome. Aliment Pharmacol Ther 2003;17:87180. Lucock MP, Morley S, White C, et al. Responses of consecutive patients to reassurance after gastroscopy: results of self administered questionnaire survey. BMJ 1997;315:5725. Ilnyckyj A, Balachandra B, Elliott L, et al. Post-travelers diarrhea irritable bowel syndrome: a prospective study. Am J Gastroenterol 2003;98:5969. Creed F, Ratcliffe J, Fernandez L, et al. Health-related quality of life and health care costs in severe, refractory irritable bowel syndrome. Ann Intern Med 2001;134:8608. Creed F, Ratcliffe J, Fernandes L, et al. Outcome in severe irritable bowel syndrome with and without accompanying depressive, panic and neurasthenic disorders. Br J Psychiatry 2005;186:50715. Spanier JA, Howden CW, Jones MP. A systematic review of alternative therapies in the irritable bowel syndrome. Arch Intern Med 2003;163:26574. Lackner JM, Quigley BM, Blanchard EB. Depression and abdominal pain in IBS patients: the mediating role of catastrophizing. Psychosom Med 2004;66:43541. Blanchard EB, Schwarz SP, Suls JM, et al. Two controlled evaluations of multicomponent psychological treatment of irritable bowel syndrome. Behav Res Ther 1992;30:17589. Payne A, Blanchard EB. A controlled comparison of cognitive therapy and selfhelp support groups in the treatment of irritable bowel syndrome. J Consult Clin Psychol 1995;63:77986. Guthrie E, Creed F, Dawson D, et al. A controlled trial of psychological treatment for the irritable bowel syndrome. Gastroenterology 1991;100:4507. Guthrie E, Creed F, Dawson D, et al. A randomised controlled trial of psychotherapy in patients with refractory irritable bowel syndrome. Br J Psychiatry 1993;163:31521. Svedlund J. Psychotherapy in irritable bowel syndrome. A controlled outcome study. Acta Psychiatr Scand 1983;67:86. Corney RH, Stanton R, Newell R, et al. Behavioural psychotherapy in the treatment of irritable bowel syndrome. J Psychosomc Res 1991;35:4619. Heymann-Monnikes I, Arnold R, Florin I, et al. The combination of medical treatment plus multicomponent behavioral therapy is superior to medical treatment alone in the therapy of irritable bowel syndrome. Am J Gastroenterol 2000;95:98194. Svedlund J, Sjodin I, Ottosson J, et al. Controlled study of psychotherapy in irritable bowel syndrome. Lancet, 1983;ii, 58992. Lackner JM, Mesmer C, Morley S, et al. Psychological treatments for irritable bowel syndrome: a systematic review and meta-analysis. J Consult Clin Psychol 2004;72:110013. Drossman DA, Toner BB, Whitehead WE, et al. Cognitive-behavioral therapy versus education and desipramine versus placebo for moderate to severe functional bowel disorders. Gastroenterology 2003;125:1931. Creed F, Fernandes L, Guthrie E, et al. The cost-effectiveness of psychotherapy and paroxetine for severe irritable bowel syndrome. Gastroenterology 2003;124:30317. Raine R, Haines A, Sensky T, et al. Systematic review of mental health interventions for patients with common somatic symptoms: can research evidence from secondary care be extrapolated to primary care? BMJ 2002;325:1082. Whitehead WE, Crowell MD, Robinson JC, et al. Effects of stressful life events on bowel symptoms: subjects with irritable bowel syndrome compared with subjects without bowel dysfunction. Gut 1992;33:82530. Blanchard EB, Greene B, Scharff L, et al. Relaxation training as a treatment for irritable bowel syndrome. Biofeedback Self Regul 1993;18:12532. Voirol MW, Hipolito J. Relaxation in the treatment of irritable gut: Results after 40 months. Schweiz Med Wochenschr 1987;117:111719. Blanchard EB, Schwarz SP, Neff DF, et al. Prediction of outcome from the selfregulatory treatment of irritable bowel syndrome. Behav Res Ther 1988;26:18790. Neff DF, Blachard EB. A multi-component treatment for irritable bowel syndrome. Behav Ther 1987;18:7083. Lynch PM, Zamble E. A controlled behavioral treatment study of irritable bowel syndrome. Behav Ther 1989;20:50923. Van Dulmen AM, Fennis JM, Bleijenberg G. Cognitive-behavioral group therapy for irritable bowel syndrome: Effects and long-term follow-up. Psychosom Med 1996;58:50814. Guthrie E. Brief psychotherapy with patients with refractory irritable bowel syndrome. Br J Psychother 1991;8:17588. Creed F, Guthrie E, Ratcliffe J, et al. Reported sexual abuse predicts impaired functioning but a good response to psychological treatments in patients with severe irritable bowel syndrome. Psychosom Med 2005;67:4909. Whorwell PJ, Prior A, Faragher EB. Controlled trial of hypnotherapy in the treatment of severe refractory irritable-bowel syndrome. Lancet 1984;ii:12324. Palsson OS, Turner MJ, Johnson DA, et al. Hypnosis treatment for severe irritable bowel syndrome: investigation of mechanism and effects on symptoms. Dig Dis Sci 2002;47:260514. Whorwell PJ. Review article: the history of hypnotherapy and its role in the irritable bowel syndrome. Aliment Pharmacol Ther 2005;22:10617.

1797
350 Tan G, Hammond DC, Gurrala J. Hypnosis and irritable bowel syndrome: A review of efficacy and mechanism of action. Am J Clin Hypnosis 2005;47:16178. 351 Palsson OS, Turner MJ, Whitehead WE. Hypnosis home treatment for irritable bowel syndrome: a pilot study. Int J Clin Exp Hypnosis 2006;54:8599. 352 Gonsalkorale WM, Miller V, Afzal A, et al. Long term benefits of hypnotherapy for irritable bowel syndrome. Gut 2003;52:16239. 353 Lea R, Houghton LA, Calvert EL, et al. Gut-focused hypnotherapy normalizes disordered rectal sensitivity in patients with irritable bowel syndrome. Aliment Pharmacol Ther 2003;17:63542. 354 Whorwell PJ, Houghton LA, Taylor EE, et al. Physiological effects of emotion: Assessment via hypnosis. Lancet 1992;340:6972. 355 Gonsalkorale WM, Toner BB, Whorwell PJ. Cognitive change in patients undergoing hypnotherapy for irritable bowel syndrome. J Psychosom Res 2004;56:2718. 356 Rainville P, Duncan GH, Price DD, et al. Pain affect encoded in human anterior cingulate but not somatosensory cortex. Science 1997;277:96871. 357 Whorwell PJ. Effective management of irritable bowel syndrome the Manchester model. Int J Clin Exp Hypnosis 2006;54:216. 358 Spiller RC. Problems and challenges in the design of irritable bowel syndrome clinical trials: experience from published trials. Am J Med 1999;107:917S. 359 Pitz M, Cheang M, Bernstein CN. Defining the predictors of the placebo response in irritable bowel syndrome. Clin Gastroenterol Hepatol 2005;3:23747. 360 Enck P, Klosterhalfen S. The placebo response in functional bowel disorders: perspectives and putative mechanisms. Neurogastroenterol Motil 2005;17:32531. 361 Thompson WG. Placebos: a review of the placebo response. Am J Gastroenterol 2000;95:163743. 362 Quartero AO, Meineche-Schmidt V, Muris J, et al. Bulking agents, antispasmodic and antidepressant medication for the treatment of irritable bowel syndrome. Cochrane Database Syst Rev, 2005;CD003460.. 363 Klein KB. Controlled treatment trials in the irritable bowel syndrome: a critical appraisal. Gastroenterology 1988;95:23241. 364 Poynard T, Naveau S, Mory B, et al. Meta-analysis of smooth muscle relaxants in the treatment of irritable bowel syndrome. Aliment Pharmacol Ther 1994;8:499510. 365 Jailwala J, Imperiale TF, Kroenke K. Pharmacologic treatment of the irritable bowel syndrome: a systematic review of randomized, controlled trials. Ann Intern Med 2000;133:13647. 366 Poynard T, Regimbeau C, Benhamou Y. Meta-analysis of smooth muscle relaxants in the treatment of irritable bowel syndrome. Aliment Pharmacol Ther 2001;15:35561. 367 Jones RH, Holtmann G, Rodrigo L, et al. Alosetron relieves pain and improves bowel function compared with mebeverine in female nonconstipated irritable bowel syndrome patients. Aliment Pharmacol Ther 1999;13:141927. 368 Mitchell SA, Mee AS, Smith GD, et al. Alverine citrate fails to relieve the symptoms of irritable bowel syndrome: results of a double-blind, randomized, placebo-controlled trial. Aliment Pharmacol Ther 2002;16:118795. 369 Awad R, Dibildox M, Ortiz F. Irritable bowel syndrome treatment using pinaverium bromide as a calcium channel blocker. A randomized double-blind placebo-controlled trial. Acta Gastroenterol Latinoam 1995;25:13744. 370 Luttecke K. A three-part controlled study of trimebutine in the treatment of irritable colon syndrome. Curr Med Res Opin 1980;6:43743. 371 McQuay HJ, Tramer M, Nye BA, et al. A systematic review of antidepressants in neuropathic pain. Pain 1996;68:21727. 372 Mertz H, Fass R, Kodner A, et al. Effect of amitriptyline on symptoms, sleep, and visceral perception in patients with functional dyspepsia. Am J Gastroenterol 1998;93:1605. 373 Clouse RE, Lustman PJ. Use of psychopharmacological agents for functional gastrointestinal disorders. Gut 2005;54:133241. 374 Jackson JL, OMalley PG, Tomkins G, et al. Treatment of functional gastrointestinal disorders with antidepressant medications: a meta-analysis. Am J Med 2000;108:6572. 375 Andresen V, Camilleri M. Challenges in drug development for functional gastrointestinal disorders. Part II: visceral pain. Neurogastroenterol Motil 2006;18:35460. 376 Greenbaum DS, Mayle JE, Vanegeren LE, et al. Effects of desipramine on irritable bowel syndrome compared with atropine and placebo. Dig Dis Sci 1987;32:25766. 377 Mertz HR. Irritable bowel syndrome. N Engl J Med 2003;349:213646. 378 OMalley PG, Jackson JL, Santoro J, et al. Antidepressant therapy for unexplained symptoms and symptom syndromes. J Fam Pract 1999;48:98090. 379 Tack J, Broekaert D, Fischler B, et al. A controlled crossover study of the selective serotonin reuptake inhibitor citalopram in irritable bowel syndrome. Gut 2006;55:1095103. 380 Kuiken SD, Tytgat GN, Boeckxstaens GE. The selective serotonin reuptake inhibitor fluoxetine does not change rectal sensitivity and symptoms in patients with irritable bowel syndrome: a double blind, randomized, placebo-controlled study. Clin Gastroenterol Hepatol 2003;1:21928. 381 Tabas G, Beaves M, Wang J, et al. Paroxetine to treat irritable bowel syndrome not responding to high-fiber diet: a double-blind, placebo-controlled trial. Am J Gastroenterol 2004;99:91420. 382 Aragona M, Bancheri L, Perinelli D, et al. Randomized double-blind comparison of serotonergic (citalopram) versus noradrenergic (reboxetine) reuptake inhibitors in outpatients with somatoform, DSM-IV-TR pain disorder. Eur J Pain 2005;9:338.

318 319 320 321 322 323 324 325 326 327 328 329 330 331 332

333 334 335 336 337

338 339 340 341 342 343 344 345 346 347 348 349

www.gutjnl.com

1798
383 Snook J, Shepherd HA. Bran supplementation in the treatment of irritable bowel syndrome. Aliment Pharmacol Ther 1994;8:51114. 384 Attar A, Lemann M, Ferguson A, et al. Comparison of a low dose polyethylene glycol electrolyte solution with lactulose for treatment of chronic constipation. Gut 1999;44:22630. 385 Cann PA, Read NW, Holdsworth CD, et al. Role of loperamide and placebo in management of irritable bowel syndrome (IBS). Dig Dis Sci 1984;29:23947. 386 Lavo B, Stenstam M, Nielsen A-L. Loperamide in treatment of irritable bowel syndrome - A double-blind placebo controlled study. Scand J Gastroenterol Suppl 1987;22:7780. 387 Palmer KR, Corbett CL, Holdsworth CD. Double-blind cross-over study comparing loperamide, codeine and diphenoxylate in the treatment of chronic diarrhea. Gastroenterology 1980;79:12725. 388 Merrick MV, Eastwood MA, Ford MJ. Is bile acid malabsorption underdiagnosed? An evaluation of accuracy of diagnosis by measurement of SeHCAT retention. BMJ 1985;290:6658. 389 Niaz SK, Sandrasegaran K, Renny FH, et al. Postinfective diarrhoea and bile acid malabsorption. J R Coll Phys Lond 1997;31:536. 390 Ung KA, Gillberg R, Kilander A, et al. Role of bile acids and bile acid binding agents in patients with collagenous colitis. Gut 2000;46:1705. 391 Spiller RC. Effects of serotonin on intestinal secretion and motility. Curr Opin Gastroenterol 2001;17:99103. 392 Gershon MD. Review article: roles played by 5-hydroxytryptamine in the physiology of the bowel. Aliment Pharmacol Ther 1999;13(suppl 2):1530. 393 De Ponti F. Pharmacology of serotonin: what a clinician should know. Gut 2004;53:152035. 394 Houghton LA, Atkinson W, Whitaker RP, et al. Increased platelet depleted plasma 5-hydroxytryptamine concentration following meal ingestion in symptomatic female subjects with diarrhoea predominant irritable bowel syndrome. Gut 2003;52:66370. 395 McLaughlin J, Houghton LA. The rationale, efficacy and safety evidence for tegaserod in the treatment of irritable bowel syndrome. Expert Opin Drug Saf 2006;5:31327. 396 Degen L, Matzinger D, Merz M, et al. Tegaserod, a 5-HT4 receptor partial agonist, accelerates gastric emptying and gastrointestinal transit in healthy male subjects. Aliment Pharmacol Ther 2001;15:174551. 397 Mayer EA, Bradesi S. Alosetron and irritable bowel syndrome. Expert Opin Pharmacother 2003;4:208998. 398 Houghton, Foster, Whorwell. Alosetron, a 5-HT3 receptor antagonist, delays colonic transit in patients with irritable bowel syndrome and healthy volunteers. Aliment Pharmacol Ther 2000;14:77582. 399 Delvaux M, Louvel D, Mamet JP, et al. Effect of alosetron on responses to colonic distension in patients with irritable bowel syndrome. Aliment Pharmacol Ther 1998;12:84955. 400 Lesbros-Pantoflickova D, Michetti P, Fried M, et al. Meta-analysis: the treatment of irritable bowel syndrome. Aliment Pharmacol Ther 2004;20:125369. 401 Evans BW, Clark WK, Moore DJ, et al. Tegaserod for the treatment of irritable bowel syndrome. Cochrane Database Syst Rev, 2004;CD003960.. 402 Patrick D, Barghout V, Pecher E. Tegaserod significantly improves health related QOL and patient satisfaction in patients with IBS-C. [Abstract] Gastroenterology, 2005;128:A287. 403 Schneider H, Goncalbes J, Bloch H. Tegaserod significantly improves QOL and effectively relieves the multiple dysmotility symptoms associated with IBS-C in South African women. [Abstract] Gastroenterology, 2006;128:A468. 404 Reilly MC, Barghout V, McBurney CR, et al. Effect of tegaserod on work and daily activity in irritable bowel syndrome with constipation. Aliment Pharmacol Ther 2005;22:37380. 405 Anonymous. Glaxo Wellcome withdraws irritable bowel syndrome medication. FDA Consum 2001;35:3. 406 Cremonini F, Delgado-Aros S, Camilleri M. Efficacy of alosetron in irritable bowel syndrome: a meta-analysis of randomized controlled trials. Neurogastroenterol Motil 2003;15:7986. 407 Chey WD, Chey WY, Heath AT, et al. Long-term safety and efficacy of alosetron in women with severe diarrhea-predominant irritable bowel syndrome. Am J Gastroenterol 2004;99:2195203. 408 Bradette M, Moennikes H, Carter, F. Cilansetron in irritable bowel syndrome with diarrhea predominant (IBS-D): efficacy and safety in a 6 month global study. [Abstract] Gastroenterology, 2004;126:A43. 409 Coremans G, Clouse RE, Carter F, et al. Cilansetron, a novel 5-HT3 antagonist, demonstrated efficacy in males with irritable bowel syndrome with diarrhoeapredomiance (IBS-D). [Abstract] Gastroenterology, 2004;126:A634. 410 Camilleri M, McKinzie S, Fox J, et al. Effect of renzapride on transit in constipation-predominant irritable bowel syndrome. Clin Gastroenterol Hepatol 2004;2:895904. 411 Pimentel M, Chow EJ, Lin HC. Eradication of small intestinal bacterial overgrowth reduces symptoms of irritable bowel syndrome. Am J Gastroenterol 2000;95:35036.

Spiller, Aziz, Creed, et al

412 Riordan SM, McIver CJ, Walker BM, et al. The lactulose breath hydrogen test and small intestinal bacterial overgrowth. Am J Gastroenterol 1996;91:1795803. 413 Pimentel M, Chow EJ, Lin HC. Normalization of lactulose breath testing correlates with symptom improvement in irritable bowel syndrome. a doubleblind, randomized, placebo-controlled study. Am J Gastroenterol 2003;98:41219. 414 Pimentel M, Park S, Mirocha J, et al. The effect of a nonabsorbed oral antibiotic (rifaximin) on the symptoms of the irritable bowel syndrome: a randomized trial. Ann Intern Med 2006;145:55763. 415 Pimentel M, Constantino T, Kong Y, et al. A 14-day elemental diet is highly effective in normalizing the lactulose breath test. Dig Dis Sci 2004;49:737. 416 Kajander K, Hatakka K, Poussa T, et al. A probiotic mixture alleviates symptoms in irritable bowel syndrome patients: a controlled 6-month intervention. Aliment Pharmacol Ther 2005;22:38794. 417 Kim HJ, Camilleri M, McKinzie S, et al. A randomized controlled trial of a probiotic, VSL#3, on gut transit and symptoms in diarrhoea-predominant irritable bowel syndrome. Aliment Pharmacol Ther 2003;17:895904. 418 Sen S, Mullan MM, Parker TJ, et al. Effect of Lactobacillus plantarum 299v on colonic fermentation and symptoms of irritable bowel syndrome. Dig Dis Sci 2002;47:261520. 419 Niedzielin K, Kordecki H, Birkenfeld B. A controlled, double-blind, randomized study on the efficacy of Lactobacillus plantarum 299V in patients with irritable bowel syndrome. Eur J Gastroenterol Hepatol 2001;13:11437. 420 Nobaek S, Johansson ML, Molin G, et al. Alteration of intestinal microflora is associated with reduction in abdominal bloating and pain in patients with irritable bowel syndrome. Am J Gastroenterol 2000;95:12318. 421 Whorwell PJ, Altringer L, Morel J, et al. Efficacy of an encapsulated probiotic Bifidobacterium infantis 35624 in women with irritable bowel syndrome. Am J Gastroenterol 2006;101:158190. 422 Dunlop SP, Jenkins D, Neal KR, et al. Randomized, double-blind, placebocontrolled trial of prednisolone in post-infectious irritable bowel syndrome. Aliment Pharmacol Ther 2003;18:7784. 423 Mathias JR, Clench MH, Abell TL, et al. Effect of leuprolide acetate in treatment of abdominal pain and nausea in premenopausal women with functional bowel disease: a double-blind, placebo-controlled, randomized study. Dig Dis Sci 1998;43:134755. 424 Fielding JF. Domperidone treatment in the irritable bowel syndrome. Digestion 1982;23:1257. 425 Cann PA, Read NW, Holdsworth CD. Oral domperidone: double blind comparison with placebo in irritable bowel syndrome. Gut 1983;24:113540. 426 Milo R. Use of the peripheral dopamine antagonist, domperidone, in the management of gastrointestinal symptoms in patients with irritable bowel syndrome. Curr Med Res Opin 1980;6:57784. 427 Madisch A, Holtmann G, Plein K, Hotz J. Treatment of irritable bowel syndrome with herbal preparations: results of a double-blind, randomized, placebocontrolled, multi-centre trial. Aliment Pharmacol Ther 2004;19:2719. 428 Bensoussan A, Talley NJ, Hing M, et al. Treatment of irritable bowel syndrome with Chinese herbal medicine: a randomized controlled trial. JAMA 1998;280:15859. 429 Lea R, Reilly B, Whorwell PJ, et al. Abdominal bloating in absence of physical distension is related to increased visceral sensitivity. [Abstract] Gut, 2004;53(suppl III):A28. 430 Hungin AP, Whorwell PJ, Tack J, et al. The prevalence, patterns and impact of irritable bowel syndrome: an international survey of 40,000 subjects. Aliment Pharmacol Ther 2003;17:64350. 431 Bray BD, Nicol F, Penman ID, et al. Symptom interpretation and quality of life in patients with irritable bowel syndrome. Br J Gen Pract 2006;56:1226. 432 Roberts L, Wilson S, Singh S, et al. Gut-directed hypnotherapy for irritable bowel syndrome: piloting a primary care-based randomised controlled trial. Br J Gen Pract 2006;56:11521. 433 Kerse N, Elley CR, Robinson E, et al. Is physical activity counseling effective for older people? A cluster randomized, controlled trial in primary care. J Am Geriatr Soc 2005;53:19516. 434 Kennedy A, Robinson A, Rogers A. Incorporating patients views and experiences of life with IBS in the development of an evidence based self-help guidebook. Patient Educ Couns 2003;50:30310. 435 Wells NE, Hahn BA, Whorwell PJ. Clinical economics review: irritable bowel syndrome. Aliment Pharmacol Ther 1997;11:101930. 436 Leong SA, Barghout V, Birnbaum HG, et al. The Economic Consequences of Irritable Bowel Syndrome: A US Employer Perspective. Arch Intern Med 2003;163:929. 437 Burns DG. The risk of abdominal surgery in irritable bowel syndrome. S Afr Med J 1986;70:91. 438 Longstreth GF, Wilson A, Knight K, et al. Irritable bowel syndrome, health care use, and costs: a US managed care perspective. Am J Gastroenterol 2003;98:6007.

www.gutjnl.com