Jacob E. Kurlander

Irritable Bowel Syndrome: A Clinical Review

IMPORTANCE Irritable bowel syndrome (IBS) affects 7% to 21% of the general population. It is a chronic condition that can substantially reduce quality of life and work productivity. OBJECTIVES To summarize the existing evidence on epidemiology, pathophysiology, and diagnosis of IBS and to provide practical treatment recommendations for generalists and specialists according to the best available evidence. EVIDENCE REVIEW A search of Ovid (MEDLINE) and Cochrane Database of Systematic Reviews was performed for literature from 2000 to December 2014 for the terms pathophysiology, etiology, pathogenesis, diagnosis, irritable bowel syndrome, and IBS. The range was expanded from 1946 to December 2014 for IBS, irritable bowel syndrome, diet, treatment, and therapy. FINDINGS The database search yielded 1303 articles, of which 139 were selected for inclusion. IBS is not a single disease but rather a symptom cluster resulting from diverse pathologies. Factors important to the development of IBS include alterations in the gut microbiome, intestinal permeability, gut immune function, motility, visceral sensation, brain-gut interactions, and psychosocial status. The diagnosis of IBS relies on symptom-based criteria, exclusion of concerning features (symptom onset after age 50 years, unexplained weight loss, family history of selected organic gastrointestinal diseases, evidence of gastrointestinal blood loss, and unexplained iron-deficiency anemia), and the performance of selected tests (complete blood cell count, C-reactive protein or fecal calprotectin, serologic testing for celiac disease, and age-appropriate colorectal cancer screening) to exclude organic diseases that can mimic IBS. Determining the predominant symptom (IBS with diarrhea, IBS with constipation, or mixed IBS) plays an important role in selection of diagnostic tests and treatments. Various dietary, lifestyle, medical, and behavioral interventions have proven effective in randomized clinical trials. CONCLUSIONS AND RELEVANCE The diagnosis of IBS relies on the identification of characteristic symptoms and the exclusion of other organic diseases. Management of patients with IBS is optimized by an individualized, holistic approach that embraces dietary, lifestyle, medical, and behavioral interventions.

A meta-analysis of the utility of C-reactive protein, erythrocyte sedimentation rate, fecal calprotectin, and fecal lactoferrin to exclude inflammatory bowel disease in adults with IBS.

Objectives:Irritable bowel syndrome (IBS) is viewed as a diagnosis of exclusion by most providers. The aim of our study was to perform a systematic review and meta-analysis to evaluate the utility of C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), fecal calprotectin, and fecal lactoferrin to distinguish between patients with IBS and inflammatory bowel disease (IBD) and healthy controls (HCs).Methods:A systematic online database search was performed. Included studies were prospective, adult, diagnostic cohort studies with any of the four tests. The means and s.d. values of biomarker logarithms were estimated based on studies that gave medians and either confidence intervals for the median, interquartile ranges, or ranges. We used a Naive Bayes approach to estimate the probability of being a HC, having IBS, or having IBD based on the biomarker values.Results:Systematic review identified 1,252 citations. After cross-referencing medical subject headings, detailed evaluation identified 140 potentially relevant journal articles/abstracts for CRP, ESR, calprotectin, and lactoferrin of which 4, 4, 8, and 2 fulfilled our inclusion criteria, respectively. None of the biomarkers reliably distinguished between IBS and healthy controls. At a CRP level of ≤0.5 or calprotectin level of ≤40 μg/g, there was a ≤1% probability of having IBD. Individual analysis of ESR and lactoferrin had little clinical utility.Conclusion:CRP and calprotectin of ≤0.5 or 40, respectively, essentially excludes IBD in patients with IBS symptoms. The addition of CRP and calprotectin to symptom-based criteria may improve the confident diagnosis of IBS.

Diagnosis and treatment of narcotic bowel syndrome

With increased prescription of opioids has come increased recognition of adverse consequences, including narcotic bowel syndrome (NBS). Characterized by incompletely controlled abdominal pain despite continued or increasing doses of opioids, NBS is estimated to occur in 4.2–6.4% of patients chronically taking opioids. Patients with NBS have a high degree of comorbid psychiatric illness, catastrophizing and disability; comorbid substance abuse must also be considered among this population. NBS should be distinguished from opioid-induced bowel disorder, which results from the effects of opioids on gastrointestinal motility and secretion. By contrast, the mechanisms of NBS are probably centrally mediated and include glial cell activation, bimodal opioid modulation in the dorsal horn, descending facilitation of pain and the glutaminergic system. Few treatments have been rigorously studied. A trial of opioid detoxification resulted in complete detoxification for the vast majority of patients with reduction in pain symptoms; however, despite improvement in pain, approximately half of patients returned to opioid use within 3 months. Improved strategies are needed to identify patients who will respond to detoxification and remain off opioids. Comorbid psychiatric and substance abuse disorders are barriers to durable response after detoxification and should be actively sought out and treated accordingly. An effective patient–physician relationship is essential.

A Telephone-Based Education Program Improves Bowel Preparation Quality in Patients Undergoing Outpatient Colonoscopy

there were a multiple choice examination querying the best diagnostic test for indeterminate bile duct strictures, potential answers might include clinical history, cholangiographic features, cytology brushings, forceps biopsies, EUS-FNA, and FISH. Although the options increase in number (every test takers nightmare), the correct answer remains “all of the above.” We should calibrate our practices accordingly.

Bridging Anticoagulation Before Colonoscopy: Results of a Multispecialty Clinician Survey.

Bridging Anticoagulation Before Colonoscopy: Results of a Multispecialty Clinician Survey Long-term anticoagulant therapy is essential for stroke prevention among patients with atrial fibrillation, but increasing evidence also points to substantial risk for adverse events, especially when anticoagulation is temporarily interrupted.1,2 The recently published Effectiveness of Bridging Anticoagulation for Surgery Trial confirmed prior observational evidence that using short-acting anticoagulants periprocedurally increases bleeding risk without any reduction in stroke risk.3 Little is known about how medical specialists coordinate the complex decision of which patients to bridge. To investigate this question, we conducted a regional multispecialty, multicenter survey study regarding bridging practices.

Development and validation of the Patient‐Physician Relationship Scale among patients with irritable bowel syndrome

An effective patient‐physician relationship (PPR) is essential to the care of patients with irritable bowel syndrome (IBS). We sought to develop and validate an IBS‐specific instrument to measure expectations of the PPR.

Sa1079 A Meta-Analysis of the Utility of Common Serum and Fecal Biomarkers in Adults With IBS

G A A b st ra ct s range 22-81 years) of patients who got FMT by using fresh feces, and in 16 of 17 patients (95%; 95%CI 71-100%) (mean age 61, range 20-88 years) receiving the frozen stool (p= ns). Mild transient fever appeared for two patients receiving frozen stool, but no other significant side effects were found. Conclusions: FMT is effective and safe treatment for CDI. Standardization of fecal material preparation by freezing the donated stool simplified the practical aspects of FMT without loss of efficacy.

The Right Idea for the Wrong Patient: Results of a National Survey on Stopping PPIs

*Veterans Affairs Ann Arbor Health Care System, Ann Arbor, Michigan; Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan; Research Center, American College of Physicians, Philadelphia, Pennsylvania; kDepartment of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, Michigan; and VA Ann Arbor Center for Clinical Management Research, Ann Arbor, Michigan

How Efficacious Are Patient Education Interventions to Improve Bowel Preparation for Colonoscopy? A Systematic Review

Background Bowel preparation is inadequate in a large proportion of colonoscopies, leading to multiple clinical and economic harms. While most patients receive some form of education before colonoscopy, there is no consensus on the best approach. Aims This systematic review aimed to evaluate the efficacy of patient education interventions to improve bowel preparation. Methods We searched the Cochrane Database, CINAHL, EMBASE, Ovid, and Web of Science. Inclusion criteria were: (1) a patient education intervention; (2) a primary aim of improving bowel preparation; (3) a validated bowel preparation scale; (4) a prospective design; (5) a concurrent control group; and, (6) adult participants. Study validity was assessed using a modified Downs and Black scale. Results 1,080 abstracts were screened. Seven full text studies met inclusion criteria, including 2,660 patients. These studies evaluated multiple delivery platforms, including paper-based interventions (three studies), videos (two studies), re-education telephone calls the day before colonoscopy (one study), and in-person education by physicians (one study). Bowel preparation significantly improved with the intervention in all but one study. All but one study were done in a single center. Validity scores ranged from 13 to 24 (maximum 27). Four of five abstracts and research letters that met inclusion criteria also showed improvements in bowel preparation. Statistical and clinical heterogeneity precluded meta-analysis. Conclusion Compared to usual care, patient education interventions appear efficacious in improving the quality of bowel preparation. However, because of the small scale of the studies and individualized nature of the interventions, results of these studies may not be generalizable to other settings. Healthcare practices should consider systematically evaluating their current bowel preparation education methods before undertaking new interventions.

Irritable Bowel Syndrome

What Causes IBS? Irritable bowel syndrome can disrupt normal routines. But it is not lifethreatening,noris itrelatedtoahigherriskofcancer. Ithasmanycauses. For example, your bowels might contract abnormally. You might have changes in the bacteria in your bowels. Or you might be sensitive to stress or certain foods. Sometimes these conditions can be triggered by severe infections. Other causes are possible. A Clinical Review in the March 3, 2015, issue of JAMA provides more information on IBS.