Search

Introduction Studies have suggested that organic diseases particularly bile acid diarrhoea/malabsorption, carbohydrate malabsorption, microscopic colitis, pancreatic exocrine insufficiency and small intestinal bacterial overgrowth, may be misdiagnosed as irritable bowel syndrome (IBS). We conducted a systematic review and meta-analysis of the prevalence of these conditions in adults with IBS-like symptoms. Methods PubMed, EMBASE, CINAHL and Cochrane were searched from January 1978 (1st publication of the Manning Criteria) to July 2019. Studies were included if they prospectively or retrospectively evaluated the prevalence of any of these conditions in consecutive patients meeting Manning, Kruis or Rome I-IV criteria for IBS. These disorders were defined as follows: Bile acid diarrhoea/malabsorption –a 75Selenium taurocholic acid scan (SeHCAT) with 7-day retention 105 cfu/mL in the jejunal aspirate. Results Bile acid diarrhoea/malabsorption: the pooled prevalence of an abnormal scan in 8 studies (n=706) was 36.1%. Carbohydrate malabsorption: 36 papers (n=7,667) gave a pooled prevalence of a positive lactose, fructose, sorbitol or mannitol breath test as 47.4%, 67.8%, 60% and 20%, respectively. Microscopic colitis: the pooled prevalence from 16 studies (n=4,770) was 2.9%. Pancreatic exocrine insufficiency: the pooled prevalence from 2 papers (n=478) was 4.6%. Small intestinal bacterial overgrowth: 32 and 18 studies (n=4,381 and 1,710) used LHBT and GHBT giving a pooled prevalence of a positive LHBT or GHBT of 40.4% and 26.5% respectively. Prevalence was 18.3% from the 5 studies (n=448) using bacterial count. There was significant heterogeneity in effect sizes of each of these conditions. Conclusion Systematic review suggests that organic conditions in the gastrointestinal tract in patients with IBS-like symptoms are not rare. The need to exclude these treatable organic disorders systematically will be challenging in clinical practice in view of the large number of patients presenting with these symptoms. Future international guidelines on management of IBS should be revised accordingly.

AIM: An increased prevalence of irritable bowel syndrome has been reported in obese individuals. Factors important in weight loss after bariatric surgery are incompletely understood, and small intestinal bacterial overgrowth in individuals with type 2 diabetes mellitus is a potential risk factor. Our aims are to examine whether the increased prevalence of irritable bowel syndrome in obese individuals seeking bariatric surgery is associated with diabetes mellitus and whether weight loss after bariatric surgery is altered by irritable bowel syndrome. METHODS: This is a single-center, retrospective study performed in a large, urban community teaching hospital. Individuals seen in gastrointestinal bariatric clinic prior to bariatric surgery from 2010 to 2013 completed a Manning symptom criteria questionnaire prior to their medical evaluation; ≥3 Manning criteria is accepted as diagnostic of irritable bowel syndrome. Percent excess weight loss at 6-, 12-, and 24-months after bariatric surgery is recorded. RESULTS: Thirty percent of 278 individuals seeking bariatric surgery have ≥3 Manning criteria. There is no relationship between type 2 diabetes mellitus and the presence of ≥3 Manning criteria (p>.05), nor is body mass index a significant risk factor for irritable bowel syndrome (p>.05). At 6-, 12-, and 24-months after Roux-en-Y gastric bypass or vertical sleeve gastrectomy, there is no difference in percent excess weight loss in individuals with ≥3 Manning criteria compared to individuals with ≤2 Manning criteria (for both surgical procedures: p>.05). CONCLUSION: A diagnosis of diabetes mellitus or body mass index do not explain the high prevalence of irritable bowel syndrome identified in individuals with obesity seeking bariatric surgery, and irritable bowel syndrome does not alter weight loss after bariatric surgery.

Objective: The aim of this review was to examine (1) the prevalence of smoking in subjects with irritable bowel syndrome (IBS), (2) whether smoking prevalence significantly differs between subjects with and without IBS, and (3) whether smoking significantly predicts the presence or the development of IBS. Methods: Articles were retrieved by systematically searching the Scopus, Web of Science, and PubMed electronic databases from inception to July 2016, using the keywords “smoking” and “tobacco” combined with “irritable bowel syndrome.” Reference lists of included articles were also searched. Articles were included if they (1) reported data on smoking prevalence in subjects with IBS and/or on the association (assessed by means of multivariate analyses) between smoking and IBS, (2) identified IBS according to Manning criteria or Rome I–III criteria, (3) were English-language articles, and (4) involved only adult subjects. Results: The electronic searches yielded a total of 1,637 records, and 42 articles met inclusion criteria. Another 13 articles were retrieved through manual search, leading to a total of 55 included articles. Smoking prevalence in subjects with IBS was assessed by 48 articles and ranged from 0% in university students to 47.1% in patients with microscopic colitis. Thirty-three articles compared smoking prevalence between subjects with and without IBS. In 25 articles no significant difference was found. In seven articles smoking was significantly more frequent in subjects with IBS compared to those without IBS, while one study found a significantly higher smoking prevalence in controls. Eighteen multivariate analyses assessing the association between smoking and IBS were presented in 16 articles. Only one study employed a prospective design. In 11 analyses, smoking was not significantly associated with IBS after adjusting for covariates. In seven studies smoking independently predicted the presence of IBS. Conclusions: According to the selected articles, a significant association between smoking and IBS cannot be confirmed. However, different shortcomings may hinder generalizability and comparability of many studies. A dimensional assessment of smoking, a prospective design, the differentiation between IBS subgroups, and the recruitment of patients in clinical settings, especially in primary care, are necessary to clarify the role of smoking in IBS.

Irritable Bowel Syndrome (IBS) is a functional disorder of the gastrointestinal tract characterized by chronic abdominal pain, cramping, constipation, and diarrhea. Manning criteria, Kruis criteria and Rome IV criteria have shown that certain symptoms derived from a 15-items questionnaire differentiated patients with Irritable Bowel Syndrome (IBS) from patients with organic diseases. The purpose of the study is to find out the reliability and discriminatory value of the Manning criteria, Kruis criteria and Rome IV criteria in the differentiation of Irritable Bowel Syndrome (IBS) from organic diseases and to find out if the three criteria could be combined. The study is a prospective cross-sectional analytical study of one hundred and thirty patients who presented with Diarrhea or Constipation to the Department of Medicine, Department of Surgery, Department of Medical Gastroenterology, Vydehi Institute of Medical Sciences and Research Centre, Bangalore between September- February, 2019-2020. After taking informed consent, patients were subjected to preformed questionnaire in the language best understood by them. Patient underwent diagnostic investigations like Complete blood count (CBC), Erythrocyte Sedimentation Rate (ESR), C- reactive protein, Serum albumin and Colonoscopy. A total of 130 patients were interviewed for the study. Manning criteria had the highest sensitivity (88%) compared to Kruis criteria (81%) and Rome IV criteria (80%). Kruis criteria had the highest specificity (91%) compared to Manning criteria (87%) and Rome IV criteria (86%). On combining the three criteria, while the sensitivity is 94.4%, the specificity fell drastically to 58%. Hence everything considered it is best to ply with the individual criteria for the diagnosis of irritable bowel syndrome.

The irritable bowel syndrome is the commonest gastrointestinal disorder seen in practice but its exact prevalence in India is not known. This study was carried out to determine the prevalence of symptoms compatible with this diagnosis in general population. A cross sectional random sample survey was conducted in various strata of urban population in Wanoworie area of Pune. Survey utilized personal interviews based on a questionnaire. Symptoms were evaluated as per Manning criteria and the diagnosis of irritable bowel syndrome was defined by Kruis diagnostic index. Of the 1010 subjects interviewed, 370 (37%) reported more than 6 episodes of abdominal pain in previous 6 months, with 333 reporting symptoms consistent with the the diagnosis of irritable bowel syndrome. At least one of the Manning's symptoms was present in 307 out of 370 subjects (83%). The male female ratio was 5.3:1. Among males, 288 (35%) and among females 82 (53.2%) persons had at least some degree of abdominal discomfort. Other common symptoms were: excessive passage of wind (42.2%), irregular bowel habits (33%), excessive belching (30.8%), constipation (27.5) and feeling of incomplete evacuation(28.1%). About one third of the symptomatic subjects (134 or 36.2%) had seen a doctor or wanted to be seen by a specialist. Overall prevalence of the symptoms consistent with irritable bowel syndrome thus, is 33 per cent though only about a third of these may possibly consult a doctor. Follow up of all these patients for a mean duration of 8.3 months showed that no case of organic disease was picked up either by the scoring system or by the gastroenterologist. Symptoms consistent with the diagnosis of irritable bowel syndrome are see in almost one third of the study population residing in Wanoworie area of Pune.

Background/Aim: Primary health care (PHC) physicians manage most patients with irritable bowel syndrome (IBS). In Saudi Arabia, there are limited data on their knowledge, attitudes, and practices about this disorder. This study aimed to assess knowledge, attitudes, and practices of primary care physicians about IBS. Patients and Methods: A cross-sectional survey of 70 practitioners aged 36 ± 10.25 years was carried out in primary care centers in AlJouf Province of Saudi Arabia. The physicians were asked to fill a valid questionnaire containing their sociodemographic data, and well-modified questions regarding their knowledge, attitudes, and practices about IBS. Data was processed and analyzed using SPSS (version 15) program, and the level of significance was set at P

Objective: This study examined the prevalence of irritable bowel syndrome (IBS) in patients with bulimia nervosa (BN), and the relationship between these disorders. Method: Sixty-four participants with a diagnosis of BN or a related condition were recruited from an outpatient eating disorders service. Questionnaire and interview measures were used to assess bulimic symptoms and attitudes, IBS symptoms, anxiety and depression. Cases of IBS were identified using the Manning criteria. Results: There was a high prevalence of IBS in the patient group (68.8%), but IBS status was not predicted by any of the other variables measured. Patients who met criteria for IBS reported more frequent self-induced vomiting than those who did not (U = 256.0, p = 0.038). Discussion: There is evidence of an high incidence of IBS in outpatients with BN, but the relationship between these conditions remains unclear. Future research should consider possible common risk factors. © 2011 by Wiley Periodicals, Inc.

Irritable bowel syndrome (IBS) has been one of the commonly presented gastrointestinal disorders. It is of interest how commonly it presents in the society. Western studies indicated that most population-based IBS prevalences range 10%-15%. It is believed that IBS is prevalent in both East and West countries without a significant prevalence difference. Most recently, the Asia IBS prevalence has a higher trend in the affluent cities compared to South Asia. Since many Asia IBS prevalence studies have been published in the recent decade, we could compare the IBS prevalence data divided by various criteria in looking whether they were also comparable to this of West community. Summarized together, most Asia community IBS prevalences based on various criteria are usually within the range 1%-10% and are apparently lower than these of selected populations. Within the same population, the prevalence orders are first higher based on Manning criteria, then followed by Rome I criteria and finally reported in Rome II criteria. Overall, the median value of Asia IBS prevalences defined by various criteria ranges 6.5%-10.1%. With regard to gender difference, female predominance is usually found but not uniquely existed. For the IBS subtypes, the proportions of diarrhea predominant-IBS distribute widely from 0.8% to 74.0%, while constipation predominant-IBS proportion ranges 12%-77%. In conclusions, current Asia IBS prevalence is at least equal to the Western countries. Female predominant prevalence in Asia is common but not uniquely existed, while the proportions of IBS subtypes are too variable to find a rule.

Irritable bowel syndrome (IBS) is a functional disorder of the gastrointestinal tract characterized by recurrent episodes of abdominal pain or discomfort along with changes in frequency or consistency of the stool in the absence of an organic etiology. The condition is heterogeneous, exhibiting variability in the frequency of symptoms reported within and between males and females.1 The pathophysiological mechanisms of IBS are not completely understood. Alterations in gut motility, visceral perception, and central processing of pain and motor function due to abnormalities in the enteric and central nervous system are believed to account for symptoms of IBS.2 The brain-gut axis and biopsychosocial model have been used to explain how intrinsic and extrinsic stimuli modulate disease expression.3,4 It is unknown whether IBS is primarily a disorder of abnormal perception to a normal stimulus, or a disorder of normal perception to an abnormal physiologic sensory stimulus. Since no structural abnormalities or biochemical markers characterize IBS, diagnosis is based on the presence of clinical symptoms.2 Symptom-based diagnostic criteria have been established to create uniformity in reporting and enhance diagnostic accuracy. All diagnostic criteria used to differentiate IBS from organic diseases are self-reported measures of abdominal pain and bowel habits (table 1 ▶).5–8 The diagnosis of IBS is confirmed by applying symptom-based criteria and pursuing further diagnostic evaluations to exclude organic diseases, as needed. Symptom-based criteria should be individualized, taking into account the patient’s age, associated conditions, duration of symptoms, previous diagnostic evaluations, severity of symptoms, travel history and lactose consumption. Table 1. Manning, Rome I and Rome II criteria. Criteria used to establish the diagnosis of IBS have evolved since the initial work of Manning et al5 in 1978 and reflect a better understanding of the symptomatology associated with this disease. The Rome I and II criteria reflect more specific clinical diagnostic standards than the Manning criteria.9 Thus, many patients previously diagnosed with IBS under the Manning criteria would not receive a diagnosis of IBS based on the most recent Rome criteria. However, if the more restrictive case definitions of the Rome I and II criteria are applied, patients with IBS may potentially be underdiagnosed.10,11 Previous studies evaluating case definitions were based on surveys and are limited by the diagnostic criteria used, the questions asked and the ethnicity and cultural background of the population sampled.9,10,12 In this retrospective study, we utilized data from medical records to evaluate the diagnosis of IBS in a population-based cohort within a clinical practice. The quality of medical record documentation of clinical symptoms of IBS was determined, and IBS diagnoses were validated based on the Manning, Rome I and Rome II criteria. These three alternative criteria used to diagnose IBS were compared in terms of biennial age- and gender-adjusted incidence rates beginning from January 1, 1993 through December 31, 2003 per 100,000 person-years. Percent concordance of each paired comparison of criteria-based IBS was also determined.

The publication of the Rome III consensus on functional bowel disorders one year ago has raised the question of whether a revision of the 1999 Celle consensus on the irritable bowel syndrome is necessary and who should be involved in this consensus. Therefore, the this review article attempts to reconstruct the history of the Rome criteria (and its predecessor, the Manning criteria) and contrasts this with the parallel history of the DSM/ICD classification in primary care and psychiatry/psychosomatics. The formulation of a common consensus between all medical societies (primary care, gastroenterology/neurogastroenterology, psychiatry/psychosomatics) is proposed instead of another consensus of gastroenterologists alone, in order to avoid the tendency - at both national and international levels - towards isolation between the medical subspecialties.

SUMMARY Background A subset of patients with gastro-oesophageal reflux disease (GERD) does not achieve complete symptom resolution with proton pump inhibitor (PPI) therapy. The factors which affect response to PPI therapy in GERD patients remain unclear. Aims To determine the prevalence and impact of irritable bowel syndrome (IBS) and psychological distress (PD) on GERD symptoms and diseasespecific quality of life (QoL) before and after PPI therapy and to assess the same outcomes before and after PPI therapy in non-erosive reflux disease (NERD) and erosive oesophagitis (EO) GERD patients. Methods Patients undergoing oesophago-gastroduodenoscopy (OGD) for heartburn were recruited. Participants completed validated surveys: Digestive Health Symptom Index, Reflux Disease Questionnaire, Quality of Life in Reflux and Dyspepsia and Brief Symptom Inventory (BSI). IBS was defined as >3 Manning criteria and PD as BSI score >63. At OGD, patients were classified as NERD or EO. Patients were treated with rabeprazole 20 mg ⁄day for 8 weeks before completing follow-up surveys. Results Of 132 GERD patients enrolled, 101 completed the study. The prevalence rates of IBS and PD were 36% and 41%, respectively. IBS independently predicted worse QoL before and after PPI therapy. PD independently predicted worse GERD symptoms and QoL before and after PPI therapy. There were no differences in symptoms or QoL between NERD and EO patients before or after PPI therapy. Conclusions IBS and PD impacted GERD symptoms and QoL before and after PPI therapy. Symptoms and QoL before and after PPI therapy were similar in NERD and EO patients.

Background: Microscopic colitis is diagnosed on the basis of histologic criteria, and irritable bowel syndrome (IBS) is diagnosed by symptom-based criteria. There has been little investigation into the symptomatic overlap between these conditions. Our aim was to assess the prevalence of symptoms of irritable bowel syndrome in a population-based cohort of patients with microscopic colitis. Methods: The Rochester Epidemiology Project (REP), a medical records linkage system providing all health care data for the defined population of Olmsted County, Minnesota, was used to identify all county residents with a diagnosis of microscopic colitis between 1985 and 2001. The medical records of these individuals were reviewed to ascertain symptoms consistent with Rome, Rome II, and Manning criteria for irritable bowel syndrome. Results: One hundred thirty-one cases of microscopic colitis were identified. Median age at diagnosis was 68 years (range, 24–95); 71% were women. Sixty-nine (53%) and 73 (56%) met Rome and Rome II criteria for irritable bowel syndrome, respectively. Fifty-four (41%) had three or more Manning criteria. Forty-three (33%) had previously been diagnosed with irritable bowel syndrome. Conclusions: In this population-based cohort of histologically confirmed microscopic colitis, approximately one-half met symptom-based criteria for the diagnosis of irritable bowel syndrome. The clinical symptom-based criteria for irritable bowel syndrome are not specific enough to rule out the diagnosis of microscopic colitis. Therefore, patients with suspected diarrhea-predominant irritable bowel syndrome should undergo biopsies of the colon to investigate for possible microscopic colitis if symptoms are not well controlled by antidiarrheal therapy. (Inflamm Bowel Dis 2006)

Employing a consensus approach, our working team critically considered the available evidence and multinational expert criticism, revised the Rome II diagnostic criteria for the functional bowel disorders, and updated diagnosis and treatment recommendations. Diagnosis of a functional bowel disorder (FBD) requires characteristic symptoms during the last 3 months and onsetor =6 months ago. Alarm symptoms suggest the possibility of structural disease, but do not necessarily negate a diagnosis of an FBD. Irritable bowel syndrome (IBS), functional bloating, functional constipation, and functional diarrhea are best identified by symptom-based approaches. Subtyping of IBS is controversial, and we suggest it be based on stool form, which can be aided by use of the Bristol Stool Form Scale. Diagnostic testing should be guided by the patient's age, primary symptom characteristics, and other clinical and laboratory features. Treatment of FBDs is based on an individualized evaluation, explanation, and reassurance. Alterations in diet, drug treatment aimed at predominant symptoms, and psychotherapy may be beneficial.

BACKGROUND: The childhood socioeconomic environment has been linked to adult health status in several studies. However, its role in the pathogenesis of adult irritable bowel syndrome (IBS) remains unknown. We aim to assess the influence of the childhood environment on adult IBS, using data from a New Zealand birth cohort study. METHODS: The Dunedin birth cohort was assembled in 1972-1973 and has been followed prospectively to age 26 (n = 980). IBS was classified according to both Rome and Manning criteria, using self-reported symptom data obtained at age 26 yr. Childhood social class was used as a proxy measure of the quality of the childhood socioeconomic environment and was assigned according to the highest average socioeconomic (SES) level of either parent from interviews across the first 15 yr of life. RESULTS: Childhood social class was significantly associated with IBS according to Manning Criteria (p = 0.05) and Rome II Criteria (p = 0.05). The prevailing trend was identical for both measures of IBS in the sex-adjusted models: this trend can be characterized as a general, and near-linear decrease in the odds of IBS across decreasing levels of social class. Contrasts with the reference group were significant on all comparisons for Manning Criteria IBS (high vs upper middle, p = 0.04; lower middle, p = 0.04; low, p = 0.01), and on comparisons involving the two lower social class groups for Rome II Criteria IBS (high vs lower middle, p = 0.03; low, p = 0.03). The associations were attenuated, but not eliminated by further adjustment for adult social class. CONCLUSIONS: An affluent childhood environment is an independent risk factor for adult IBS.

Summary Background : Prevalence of irritable bowel syndrome shows great variation among epidemiological studies, which may be due to different diagnostic criteria. Aim : To assess prevalence of irritable bowel syndrome according to various diagnostic criteria and to study differences in symptom severity, psychopathology, and use of health care resources between subjects fulfilling different diagnostic criteria. Methods : A questionnaire was mailed to 5000 randomly selected adults. Presence of irritable bowel syndrome was assessed by four diagnostic criteria: Manning 2 (at least two Manning symptoms), Manning 3 (at least three Manning symptoms), Rome I and Rome II. Results : Response rate was 73%. Prevalence of irritable bowel syndrome by Manning 2, Manning 3, Rome I and Rome II criteria was 16.2%, 9.7%, 5.6%, and 5.1% respectively. Of those fulfilling Rome II criteria, 97% fulfilled Manning 2. Severe or very severe abdominal pain was reported by 27–30% of Manning-positive subjects, and 44% of Rome-positives. Prevalence of depression in Manning 2, and Rome II groups was 30.6 and 39.3%. Conclusions : Prevalence of irritable bowel syndrome by Rome II criteria is considerably lower than by Manning criteria. Subjects fulfilling Rome criteria form a subgroup of Manning-positive subjects with more severe abdominal symptoms, more psychopathology, and more frequent use of the health care system.

Summary Background : The detailed population-based data on irritable bowel syndrome in South China are lacking. Aims : To assess the prevalence of irritable bowel syndrome in South China and its impact on health-related quality of life. Subjects and methods : A face-to-face interview was carried out in South China to assess the prevalence of irritable bowel syndrome. Random clustered sampling of permanent inhabitants aged 18–80 years was carried out under stratification of urban and suburban areas. The impact of irritable bowel syndrome on health-related quality of life was evaluated using the Chinese version of SF-36. Results : A total of 4178 subjects (1907 male and 2271 female) were interviewed. The adjusted prevalence of irritable bowel syndrome in South China is 11.50% according to the Manning criteria and 5.67% according to the Rome II criteria. Factors including history of analgesic use such as non-steroidal anti-inflammatory drug (odds ratio 3.83), history of food allergies (odds ratio 2.68), psychological distress (odds ratio 2.18), life events (odds ratio 1.89), history of dysentery (odds ratio 1.63) and negative coping style (odds ratio 1.28) were significantly associated with the presence of irritable bowel syndrome (P

Summary Background : Functional gastrointestinal symptoms generate a large workload in primary care. Research on functional gastrointestinal disorders is focused on hospital patients, but these patients may differ from those managed in primary care. Aim : To investigate any differences in attitudes of general practitioners and hospital specialists towards functional gastrointestinal illnesses. Methods : A questionnaire was sent to 200 general practitioners and 200 British Society of Gastroenterology members. Results : The response rate was 76%. Sixty-two general practitioners believed that functional gastrointestinal symptoms represented a ‘real’ currently unexplained gastrointestinal disorder, and 67 believed such symptoms probably represented somatization of a psychological illness. In contrast, most consultants (120) believed that functional gastrointestinal symptoms represented a ‘real’ gastrointestinal disorder, with only 36 perceiving them to have a psychological basis (χ2 = 26.7, P

Summary Aim : To determine the prevalence, symptom pattern and impact of the irritable bowel syndrome, across eight European countries, using a standardized methodology. Methods : A community survey of 41 984 individuals was performed using quota sampling and random digit telephone dialling to identify those with diagnosed irritable bowel syndrome or those meeting diagnostic criteria, followed by in-depth interviews. Results : The overall prevalence was 11.5% (6.2–12%); 9.6% had current symptoms, 4.8% had been formally diagnosed and a further 2.9%, 4.2% and 6.5% met the Rome II, Rome I or Manning criteria, respectively. Bowel habit classification varied by criteria: 63% had an ‘alternating’ bowel habit by Rome II vs. 21% by self-report. On average, 69% reported symptoms lasting for 1 h, twice daily, for 7 days a month. Irritable bowel syndrome sufferers reported more peptic ulcer (13% vs. 6%), reflux (21% vs. 7%) and appendectomy (17% vs. 11%), but not hysterectomy, cholecystectomy or bladder procedures. Ninety per cent had consulted in primary care and 17% in hospital; 69% had used medication. Irritable bowel syndrome substantially interfered with lifestyle and caused absenteeism. Conclusions : Irritable bowel syndrome is common with major effects on lifestyle and health care. The majority of cases are undiagnosed and the prevalence varies strikingly between countries. Diagnostic criteria are associated with varying prevalences and bowel habit sub-types. This limits their utility in clinical practice and the transferability of research findings using them.

OBJECTIVE: The aim of this study was to systematically review published literature about the prevalence, incidence, and natural history of irritable bowel syndrome (IBS) in North America. METHODS: A computer-assisted search of MEDLINE, EMBASE, and Current Contents/Science Edition databases was performed independently by two investigators. Study selection criteria included: 1) North American population-based sample of adults; 2) objective diagnostic criteria for IBS (i.e., Rome or Manning criteria); and 3) publication in full manuscript form in English. Eligible articles were reviewed in a duplicate and independent manner. Data extracted were converted into individual tables and presented in descriptive form. RESULTS: The prevalence of IBS in North America ranges from 3% to 20%, with most prevalence estimates ranging from 10% to 15%. The prevalences of diarrhea-predominant and constipation-predominant IBS are both approximately 5%. Published prevalence estimates by gender range from 2:1 female predominance to a ratio of 1:1. Constipation-predominant IBS is more common in female individuals. The prevalence of IBS varies minimally with age. No true population-based incidence studies or natural history studies were found. In one cohort surveyed on two occasions 1 yr apart, 9% of subjects who were free of IBS at baseline reported IBS at follow-up producing an onset rate of 67 per 1000 person-years. In all, 38% of patients meeting criteria for IBS did not meet IBS criteria at 1-yr follow-up. CONCLUSION: Approximately 30 million people in North America meet the diagnostic criteria for IBS. However, data about the natural history of IBS is quite sparse and renewed efforts should be focused at developing appropriately designed trials of the epidemiology of IBS.

Irritable bowel syndrome (IBS) is a recurrent disorder characterised by chronic abdominal pain or discomfort (often bloating), in association with altered generation and interpretation of bowel function, which is not accompanied by anatomical anomalies or biochemical abnormalities. Symptoms tend to vary in manifestation and time course, worsen during flares, and affect patient's quality of life.1 A dysregulation of the brain-gut axis that interacts with visceral hypersensitivity and associated with observed digestive motor disturbances and micro-inflammation of the gut, with possibly an imbalance of the intestinal bio-flora. These are factors that may be responsible for the symptoms generation. Psychosocial stressors may then interact with biological factors and are modulated by cultural beliefs and practices resulting in variations on observed symptoms constellation and health seeking behaviours, a biopsychosocial disorder. A better outcome is achievable if a positive diagnosis of IBS is made, based on clinical symptoms (in the absence of alarm signs) alone, rather than making a diagnosis by exclusion. Several diagnostic criteria exist and each new criterion refers to the insufficiencies of the previous ones. The most commonly accepted diagnostic criteria include the original Manning criteria and the subsequent series of "Rome foundation" defined criteria. A formal definition according to the Rome III criteria is recurrent abdominal pain or discomfort for at least 3 days per month during the previous 3 months associated with two or more of the following with onset at least 6 months before diagnosis: (1) symptoms improvement with defecation, (2) onset associated with a change in the frequency of stools and (3) onset associated with a change in form or appearance of stools.1-4 The prevalence of IBS varies across the world, ranging from as high as 10%-20% in the West,5,6 to as low as 4.2% in India.7 There is a perception that IBS is less of a problem in Asia and its epidemiology to be different. In addition, the prevalence rates of IBS itself vary in Asia with higher rates being documented from more affluent urban communities of Japan, Singapore and Guangzhou in China.8-10 Prevalence rates also differ within the same country (Beijing 7.3% and Guangzhou 12%) and within the same racial community from different countries.8,11,12 Such observed differences may be due to the different criteria (Manning vs Rome II vs Rome III) used to diagnose IBS or due to a different target population studied. However more recently, Park et al13 reported similar prevalence rates using Rome II (8%) and Rome III criteria (9%) in a Korean IBS population. In this study Makharia et al reported a prevalence rate of 4% which is in good agreement (4.2%) with a previous study by Ghoshal et al.7 This is interesting as the population involved in both studies were quite different. Ghoshal looked at subjects from mainly the hospital/clinic setting (recruitment centres from Northern, Central and Southern India) while the present study was solely community based (Northern India). Furthermore Makharia's group used a questionnaire based on the new Rome III module while Ghoshal's "local criteria" was more clinical and practical. Yet the resulting prevalence rates from both centers were quite similar. The observed prevalence rate is low compared to data from other Asian centers and also lower than the Western prevalence rates. We would expect lower prevalence rates from a rural community in Northern India, as IBS is recognized to be a disorder of developed nations and communities.8-10 However, Ghoshal's hospital based study confirmed that the prevalence rate is indeed low in India. One possible explanation for the low prevalence rate could be from the use of different diagnostic tools or criteria for the detection of a variable condition that is solely symptom based. One of the weaknesses of this study is that the used questionnaire was not validated for the study population. This might affect the quality of data acquired. However, a study from Nam et al14 using validated Rome III criteria in Korea gave a prevalence rate of 8.2% which is still lower than the prevalence rates observed from communities in Europe or America. Another unique observation is the much higher incidence of diarrhea predominant IBS (1.5%) compared to IBS constipation (0.3%). This was also reported from Ghoshal's study who also suggested that in general, Indians tend to pass 1-2 soft stool per day. This may be due to the higher fiber intake and faster gut transit time. Is it possible that another form of "functional bowel" or IBS exist in this sub-continent which is different from the West? Western patients tend to be more "neurotic" compared to the Asian patients who are more likely to be "post infectious." This difference may also arise from other contributing factors such as race, different cultural practices, variation in food intake and co-existing lactose intolerance. The other notable difference reported from this study is the increasing prevalence of IBS with advancing age, with the maximum in the 50-60 age groups. Across Asia, it has been noted that the prevalence of IBS is higher in the younger age group.8,9,11,12,15,16 In a rural community where the younger folks need to work hard for daily sustenance, symptoms of abdominal discomfort or alteration of bowel pattern is often too trivial to be considered as abnormal enough to visit the hospital. The time of day in which the study was conducted in this native rural community of Northern India would also be important. The often quoted male preponderance in Asian Indian IBS population was not demonstrated in this study. The prevalence of IBS was significantly higher in females compared with males. In the previous study by Ghoshal et al7 the subset of complainants in the study group showed a distinct predominance of male gender (68% vs 32%). The explanation given by the authors is that in a male dominant society, the health seeking behaviour of males can best account for the disparity in prevalence rates seen in the hospital/clinic setting compared to a rural community setting. In conclusion, this study by Makharia et al is the first large scale IBS study in India using the Rome III criteria. However, this study has few limitations. Firstly, the diagnostic tool used, the Rome III questionnaire was not validated for this population. Secondly, it was also noted that the Glasgow pictorial stool chart was not used to determine stool forms. Even if patients can describe their stool forms adequately, pictorial definition is still the best method of evaluation since patient's perception is often very different from the actual stool form. Despite all of these, this study has contributed to a better understanding of the epidemiology of IBS in India, by providing an alternative view point to the more accepted norms.

OBJECTIVES We investigated the nature of illness behavior and the meaning of emotional deficiencies during childhood in patients with irritable bowel diseases (IBS). DATA A consecutive study in two tertiary referral centers was conducted with 48 patients suffering from irritable bowel diseases (IBS) and 91 patients with inflammatory bowel disease (IBD). METHODS The diagnosis of IBS was made by following the Manning criteria, a positive diagnosis of IBD was established through physical, endoscopic and radiologic examinations and was confirmed histologically. Psychological data were obtained by structured psychiatric interviews and psychological self-report measures (GBB). RESULTS We found that the rate of physician visits given in the course of the disease, is increased for those having irritable bowel disease (IBS). These patients are dissatisfied with the physicians and prone to psychophysiological complaint. In the daily routine and in occupation they are more impaired than those with inflammatory disease. This finding emphasizes in particular that patients with irritable bowel diseases (IBS) have experienced emotional deficiencies in childhood as an after effect of loss, divorce of the parents etc. CONCLUSIONS Implications for doctor-patient relationship and the necessity for epidemiological studies in Germany are discussed.

Background: Patients consulting with gastro-oesophageal reflux symptoms (GORS) may differ from nonconsulters. Aim: To describe these differences in a UK population. Methods: A postal questionnaire was sent to 4432 adults. Definitions used were GORS (either heartburn or acid regurgitation on more than six occasions during the previous year), dyspepsia (upper abdominal pain or discomfort on more than six occasions during the previous year) and irritable bowel syndrome (abdominal pain with three or more Manning criteria). Socio-economic status was identified by the Standard Occupational Classification. Results: With a 71.7% response, GORS were reported by 28.7% of the sample, it was unaffected by gender and age but was more common among the socially disadvantaged (P

OBJECTIVES: It has been suggested that the variation in the prevalence of irritable bowel syndrome (IBS) may be due to the application of different diagnostic criteria. New criteria for IBS have been proposed (Rome II). It is unknown whether persons meeting different criteria for IBS have similar psychological and symptom features. The aim of this study was to measure the prevalence of IBS according to Manning and Rome definitions of IBS and to evaluate the clinical and psychological differences between diagnostic categories. METHODS: A total of 4500 randomly selected subjects, with equal numbers of male and female subjects aged ≥18 yr and representative of the Australian population, took part in this study. Subjects were mailed a questionnaire (response rate, 72%). Characteristics measured were gastrointestinal symptoms over the past 12 months, neuroticism and extroversion (Eysenck Personality Questionnaire), anxiety and depression (Delusions-Symptoms-States Inventory), mental and physical functioning (SF-12), and somatic distress (Sphere). RESULTS: The prevalence for IBS according to Manning, Rome I, and Rome II was 4.4% (95% confidence interval [CI] = 3.5–5.1%), 6.9% (CI 6.0–7.8%), and 13.6% (CI 12.3–14.8%), respectively. Only 12 persons with Rome I did not also meet Rome II criteria; 196 persons with Manning criteria did not meet Rome II cut-offs. Having IBS regardless of which criteria were used was significantly associated with psychological morbidity, but psychological factors were not important in discriminating between diagnostic categories. However, pain and bowel habit severity independently discriminated between diagnostic groups. CONCLUSIONS: IBS is a relatively common disorder in the community. The new Rome II criteria may be unnecessarily restrictive in practice.

I believe there are four essential elements in the management of patients with irritable bowel syndrome (IBS): to establish a good physician-patient relationship; to educate patients about their condition; to emphasize the excellent prognosis and benign nature of the illness; and to employ therapeutic interventions centering on dietary modifications, pharmacotherapy, and behavioral strategies tailored to the individual. Initially, I establish the diagnosis, exclude organic causes, educate patients about the disease, establish realistic expectations and consistent limits, and involve patients in disease management. I find it critical to determine why the patient is seeking assistance (eg, cancer phobia, disability, interpersonal distress, or exacerbation of symptoms). Most patients can be treated by their primary care physician. However, specialty consultations may be needed to reinforce management strategies, perform additional diagnostic tests, or institute specialized treatment. Psychological co-morbidities do not cause symptoms but do affect how patients respond to them and influence health care-seeking behavior. I find that these issues are best explored over a series of visits when the physician-patient relationship has been established. It can be helpful to have patients fill out a self-administered test to identify psychological co-morbidities. I often use these tests as a basis for extended inquiries into this area, resulting in the initiation of appropriate therapies. I encourage patients to keep a 2-week diary of food intake and gastrointestinal symptoms. In this way, patients become actively involved in management of their disease, and I may be able to obtain information from the diary that will be valuable in making treatment decisions. I do not believe that diagnostic studies for food intolerances are cost-effective or particularly helpful; however, exclusion diets may be beneficial. I introduce fiber supplements gradually and monitor them for tolerance and palatability. Synthetic fiber is often better-tolerated than natural fiber, but must be individualized. In my experience, excessive fiber supplementation often is counterproductive, as abdominal cramps and bloating may worsen. Antidiarrheal agents are very effective when used correctly, preferably in divided doses. I use them in patients in anticipation of diarrhea and especially in those who fear symptoms when engaged in activities outside the home. I encourage patients to make decisions as to when and how much to use. However, almost always, a morning dose before breakfast is used (loperamide, 2 to 6 mg) and, perhaps again later in the day when symptoms of diarrhea are prominent. I prefer antispasmodics to be used intermittently in response to periods of increased abdominal pain, cramps, and urgency. For patients with daily symptoms, especially after meals, agents such as dicyclomine before meals are useful. For patients with infrequent but severe episodes of unpredictable pain, sublingual hyoscyamine often produces rapid relief and instills confidence. In general, I recommend that oral antispasmodics be used for a limited period of time rather than indefinitely, and generally for periods of time when symptoms are prominent. For chronic visceral pain syndromes, I recommend small doses of tricyclic antidepressants. These agents are especially effective in diarrhea-predominant patients with disturbed sleep patterns but may be unacceptable to patients with constipation. I educate patients that side effects occur early and benefits may not be apparent for 3 to 4 weeks. I consider using SSRIs in low doses in patients with constipation-predominant IBS; cisapride, 10 to 20 mg three times per day, also may be beneficial. When taken with drugs that inhibit cytochrome P450, cisapride has been associated with serious cardiac arrhythmias caused by QT prolongation, including ventricular arrhythmias and torsades de pointes. These drugs include the azole fungicides; erythromycin, clarithromycin, and troleandomycin; some antidepressants; HIV protease inhibitors; and others. In patients with IBS with mild to moderate co-morbid depression, I have found that the use of SSRIs such as paroxetine, fluoxetine, or sertraline may be beneficial. It is important to tell patients that anxiety and disturbed sleep may occur during the first 10 days and benefits may not occur for 3 to 4 weeks. I prescribe a small amount of a short-acting benzodiazepine such as alprazolam, 0.5 mg two times per day, to control these symptoms. For generalized anxiety without depression, buspirone or clonazepam may be useful. I have found that patients who also have associated panic disorder may benefit from a benzodiazepine, tricyclic antidepressant, or an SSRI. However, these patients are best managed in conjunction with a psychiatrist or psychologist. I consider the use of alternative therapies in patients who fail to respond to conventional measures and who are receptive to alternative strategies. These include general relaxation techniques such as biofeedback and hypnosis therapies.

Objectives: To assess symptoms of irritable bowel syndrome (IBS) in patients with recurrent abdominal pain (RAP) 5 years after their initial evaluation, to identify the relation of IBS symptoms to functional disability and health service use, and to determine the extent to which IBS symptoms are associated with life stress and poor psychosocial adjustment. Methods: Patients with RAP ( n = 76) and control subjects ( n = 49) completed a telephone interview; measures included the Bowel Disease Questionnaire, the Functional Disability Inventory, the Life Events Questionnaire, the Family Inventory of Life Events, the Center for Epidemiological Studies Depression Scale, the Self-Perception Profile for Adolescents, and the Health Resources Inventory. Results: Five years after the initial evaluation, patients with RAP reported significantly more episodes of abdominal pain than did control subjects, as well as significantly higher levels of functional disability, school absence, and clinic visits for abdominal distress. Female patients with RAP were more likely than female control subjects to meet the Manning criteria for IBS. Among patients with RAP, higher levels of IBS symptoms were associated with significantly greater functional disability, more clinic visits, more life stress, higher levels of depression, and lower academic and social competence. Conclusion: Female patients with a history of RAP may be at increased risk of IBS during adolescence and young adulthood. Among adolescents and young adults with a history of RAP, IBS symptoms are likely to be associated with high levels of disability and health service use. (J Pediatr 1998;132:1010-5)

Epidemiology Although IBS is the cause of 20–50% of referrals to gastroenterology clinics, most patients with IBS do not seek medical care. In 1980, Thompson and Heaton, using a precoded questionnaire, found that 14% of patients had a spastic colon with abdominal pain that was relieved by defaecation. This was not a representative population sample drawn from medical technicians, a hospital screening clinic, or wardencontrolled flats; nor did the study use the Rome criteria to define IBS. Nevertheless, 14% remains the most commonly quoted figure for UK prevalence of IBS. A 1992 questionnaire study, which used the Manning criteria to define IBS in community patients obtained from general-practitioners lists, recorded a 22% prevalence of IBS. The male to female ratio was 1·38, and 33% of those with IBS had sought medical advice for it during the preceding 2 years. The study also showed that abdominal pain in childhood was reported significantly more commonly by patients with current IBS (12% vs 11%). Other investigators have also suggested that exaggeration of the importance of minor illnesses in early childhood increases the likelihood of adult IBS. The Rome criteria were used to identify IBS in 13% of women and 5% of men in a stratified randompopulation sample in Bristol. A reasonable assumption is that different definitions and population groups might well produce different prevalence rates for IBS, but there is remarkable consistency across the major surveys carried out in Europe, New Zealand, and the USA. In all groups women seem to be affected more frequently than men, except on the Indian subcontinent where the reverse is true; the reason for this difference is unclear, but it might be explained by a combination of reduced availability of medical care and different cultural approaches to illness. IBS is a chronic relapsing condition, and some suggest it occurs in most adults at some point in their lives. Symptoms begin before age 35 in 50% of patients, and 40% of patients are aged 35–50. IBS is recognised in Irritable bowel syndrome (IBS) has confounded clinicians for over a century. “Mucous colitis” was first described by Osler in 1892. He wrote of a disorder characterised by the passage of tubular casts of the colon, consisting of mucus (mucorrhoea), cell debris, and “intestinal sand”. Osler stated that the colonic epithelium was normal and that many of the patients were hysterical, hypochondriac, or depressed, and suffered from colicky abdominal pains. This condition was also recognised by Hurst, but the disease they described seemed to have disappeared from both clinical practice and medical texts by the late 1920s. The term “mucous colitis” persisted with a new definition, such that by 1928 it described only colonic spasm. The term “irritable colon” first appeared in published research in 1929 when Jordan and Kiefer used it to describe a colonic musculoneural disturbance present in 30% of gastroenterology outpatients. Irrritable colon described abdominal pain and disordered defaecation; it thus had a meaning similar to its present one.

Objective To determine the attributes of the irritable bowel syndrome (IBS) in general practice as perceived by the doctors. Subjects and methods We administered a 93-item questionnaire about the terminology, diagnosis and treatment of the irritable bowel to 43 of 55 randomly selected general practitioners (28 men, 15 women). Results General practitioners were unfamiliar with the Manning criteria for the irritable bowel syndrome. Nevertheless, most of them diagnosed the irritable bowel with reasonable confidence and it is less troublesome to them than pelvic pain, headache or backache. Their main concern was excluding organic disease (63%) and 65% believed their patients shared this concern. Nevertheless, they ordered few tests and were often (72%) prepared to make the diagnosis on the initial visit. They estimated that they referred only 14% of IBS patients to specialists, in most cases (56%) because of an unsatisfied patient and in 35% because of an uncertain diagnosis. For treatment, most (77%) chose 'explanation and reassurance'. Virtually all employed drugs, usually several. Conclusion General practitioners say they diagnose the irritable bowel syndrome with less difficulty than other common, painful disorders, but it would be helpful to find out exactly how they do so. Their confidence could be increased by use of diagnostic criteria. Patients referred to specialists are likely to be a minority of hard-to-satisfy people. The optimal approach to such patients should be developed by general practitioners and specialists together. Specialists should strive to satisfy the patient and confirm the diagnosis in the few that are referred. Drug usuage in the irritable bowel syndrome is more than is justified and should, in our view, be minimized.

Background & Aims There are few validation studies of existing diagnostic criteria for irritable bowel syndrome (IBS). We conducted a validation study of the Rome and Manning criteria in secondary care. Methods We collected complete symptom, colonoscopy, and histology data from 1848 consecutive adult patients with gastrointestinal symptoms at 2 hospitals in Hamilton, Ontario; the subjects then underwent colonoscopy. Assessors were blinded to symptom status. Individuals with normal colonoscopy and histopathology results, and no evidence of celiac disease, were classified as having no organic gastrointestinal disease. The reference standard used to define the presence of true IBS was lower abdominal pain or discomfort in association with a change in bowel habit and no organic gastrointestinal disease. Sensitivity, specificity, and positive and negative likelihood ratios, with 95% confidence intervals, were calculated for each diagnostic criteria. Results In identifying patients with IBS, sensitivities of the criteria ranged from 61.9% (Manning) to 95.8% (Rome I), and specificities from 70.6% (Rome I) to 81.8% (Manning). Positive likelihood ratios ranged from 3.19 (Rome II) to 3.39 (Manning), and negative likelihood ratios from 0.06 (Rome I) to 0.47 (Manning). The level of agreement between diagnostic criteria was greatest for Rome I and Rome II (κ = 0.95), and lowest for Manning and Rome III (κ = 0.59). Conclusions Existing diagnostic criteria perform modestly in distinguishing IBS from organic disease. There appears to be little difference in terms of accuracy. More accurate ways of diagnosing IBS, avoiding the need for investigation, are required.

Diagnosing irritable bowel syndrome (IBS) can be a challenge; many clinicians resort to invasive investigations in order to rule out other diseases and reassure their patients. Volatile organic metabolites (VOMs) are emitted from feces; understanding changes in the patterns of these VOMs could aid our understanding of the etiology of the disease and the development of biomarkers, which can assist in the diagnosis of IBS. We report the first comprehensive study of the fecal VOMs patterns in patients with diarrhea-predominant IBS (IBS-D), active Crohn's disease (CD), ulcerative colitis (UC) and healthy controls. 30 patients with IBS-D, 62 with CD, 48 with UC and 109 healthy controls were studied. Diagnosis of IBS-D was made using the Manning criteria and all patients with CD and UC met endoscopic, histologic and/or radiologic criteria. Fecal VOMs were extracted by solid phase microextraction (SPME) and analyzed by gas chromatography-mass spectrometry (GC-MS). 240 VOMs were identified. Univariate analysis showed that esters of short chain fatty acids, cyclohexanecarboxylic acid and its ester derivatives were associated with IBS-D (p

Accessible online at: www.karger.com/dig Symptoms consistent with irritable bowel syndrome (IBS) are reported by 10–20% of the Western population, but only a subgroup of people with IBS request medical attention and the majority of them are managed in primary care [1]. Considering that there is no biological marker for IBS, symptom-based diagnostic criteria have been developed in order to achieve a positive diagnosis of IBS and to ensure the homogeneity of patient populations in clinical research settings [1]. Kruis et al. [2] used a combination of clinical criteria and simple laboratory tests to develop a scoring system that differentiated IBS from organic disease in tertiary care patients. However, the scoring system and the addition of laboratory tests precluded a wide application, and pure symptom-based criteria were developed based on expert opinion and the Kruis scoring system. The criteria of Manning et al. [3] define IBS according to the presence of pain associated with altered bowel habit or defecation; the Rome I criteria added that these symptoms have to be continuous or recurrent for at least 3 months [4], and the Rome II revision added that symptoms have to have been present in the last year [5]. The sensitivity and specificity of these criteria in diagnosing IBS have been evaluated in a study on tertiary care patients [6]. This study has demonstrated a good sensitivity of the Manning criteria and a good specificity of the Rome I criteria. More recent articles have observed that the Rome II criteria are less sensitive compared to the Manning and Rome I criteria [7–9], but only a few studies have addressed the utility and applicability of these criteria in clinical practice [10, 11]. In this issue of Digestion, by selecting 68 general practitioners (GPs), 48 hospital gastroenterologists and 100 patients attending an outpatient clinic with a diagnosis of IBS made by experienced gastroenterologist, Lea et al. [12] have investigated the clinical utility of the Manning, Rome I and Rome II criteria. They report that only 20% of GPs know and 4% use these criteria, whereas 96% of consultants know and 70% use these criteria. The use of the Manning and Rome I criteria exclude from IBS diagnosis only 6 and 12%, respectively, of patients diagnosed in clinical practice. The Rome II criteria exclude 25 and 16%, respectively, of the patients with IBS according to the Manning and Rome I criteria. These results confirm the findings of previous studies that addressed the diagnosis of IBS in clinical practice [10, 11]. Gladman and Gorard [10] selected 137 GPs and 167 consultants and reported that 21 and 12% of GPs and 81 and 83% of consultants had heard of the Manning and Rome criteria, respectively, but only 11 and 3% of GPs and 40 and 60% of consultants had used these criteria. Thompson et al. [11] enrolled 36 GPs and reported that

Costs of management of irritable bowel syndrome (IBS) are unknown. The direct medical charges in community subjects with IBS were estimated.An age- and sex-stratified random sample of residents of Olmsted County, Minnesota, ranging in age from 20 to 95 years, was mailed a valid self-report questionnaire. Subjects were categorized as having IBS, having some symptoms but inadequate criteria for IBS, and controls. All charges (in 1992 U.S. dollars) for health services rendered in the year before completing the survey were obtained (except outpatient medications).A total of 88% of subjects with IBS, 86% of subjects with some symptoms of IBS, and 83% of controls incurred direct medical charges during the study year. The odds of incurring charges were 1.6 times greater in subjects with IBS relative to those without symptoms (P0.01) adjusting for age, sex, education, marital status, and employment. Overall median charges incurred by subjects with IBS were $742 compared with $429 for controls and $614 for subjects with some symptoms. Among those subjects with nonzero charges, there were significant positive associations with age, higher education, and symptom groups (all P0.01) but not sex.The economic impact of IBS is significant. A better understanding of the determinants of these costs is needed so that cost-saving strategies can be implemented.

Background & Aims: It has been suggested that irritable bowel syndrome (IBS) and functional dyspepsia represent the same disease entity, the irritable gut. The aim of this study was to test the stability, consistency, and relevance of the current classification in the entire, unselected population of persons with gastrointestinal and/or abdominal symptoms, including those who had not consulted physicians. Methods: Sequential postal questionnaires were sent to 1290 representative persons (age range, 20–79 years) sampled from the population. Questions were asked about the prevalence of 24 gastrointestinal and/or abdominal symptoms and the site and type of abdominal pain, if any. Results: The prevalence of dyspepsia was 14% (32% if predominant reflux symptoms and concomitant IBS symptoms were included), and the prevalence of IBS was 12.5%. The 3-month incidence rates of reflux, dyspepsia, and IBS among previously symptomless persons were 0.5, 8, and 2 per 1000, respectively. Of persons with IBS, 87% also fulfilled the dyspepsia criteria, and the overlap between dyspepsia subgroups was more than 50%. The use of stricter criteria did not eliminate this overlap. Over a 1-year period, approximately 50% changed their symptom profile. Principal component analysis did not show any natural clustering of the symptoms. Conclusions: The separation of functional gastrointestinal symptoms into dyspepsia, its subgroups, and IBS may be inappropriate.

We evaluated a standardized colonic air insufflation test in patients investigated for abdominal pain; 195 patients were evaluable. Of 164 patients with functional abdominal pain, 100 of the 128 (78%) with irritable bowel syndrome diagnosed on the basis of two or more Manning criteria (group A) had positive tests, compared with 19 of the 36 (53%) with functional abdominal pain not satisfying the diagnostic criteria for irritable bowel syndrome (group B). Eight of the 10 patients (80%) with structural colonic disease had positive tests (group C), and 3 of the 21 patients (14%) with structural noncolonic causes of abdominal pain (group D) had positive tests (group A vs. B, A vs. D, and C vs. D, p < 0.01). The air insufflation test had a sensitivity of 78% for the diagnosis of colonic pain and a specificity of 61%. The positive predictive value was 83% and the negative predictive value 54%. Sequential tests by two independent observers on 26 consecutive patients showed no interobserrer variation. The colonic air insufflation test warrants further evaluation as an adjunct to the Manning criteria in the diagnosis of irritable bowel syndrome. It can also serve as an investigative tool to define a subset of patients with functional abdominal pain who do not fulfill the current criteria for irritable bowel syndrome yet whose pain actually originates from the colon.

Background. Studies have shown that women are more likely to have irritable bowel syndrome (IBS) and more women seek healthcare because of IBS than men.Aim. We wanted to examine the natural history of IBS and dysmenorrhea in women over a 10-year period and to assess the change in IBS after menopause.Method. A population-based postal study. A questionnaire was mailed to the same age- and gender-stratified random sample of the Icelandic population aged 18–75 in 1996 and again in 2006.Results. 77% premenopausal women had dysmenorrhea in the year 1996 and 74% in 2006. 42% of women with dysmenorrhea had IBS according to Manning criteria in the year 2006 and 49% in 1996. 26% of women with dysmenorrhea had IBS according to Rome III 2006 and 11% in the year 1996. In 2006 30% women had severe or very severe dysmenorrhea pain severity. More women (27%) reported severe abdominal pain after menopause than before menopause 11%. Women without dysmenorrhea were twice more likely to remain asymptomatic than the women with dysmenorrhea. Women with dysmenorrhea were more likely to have stable symptoms and were twice more likely to have increased symptoms.Conclusion. Women with IBS are more likely to experience dysmenorrhea than women without IBS which seems to be a part of the symptomatology in most women with IBS. IBS symptom severity seems to increase after menopause.

Background Functional gastrointestinal disorders are common but information on their natural history is limited. Aims To document the natural history of functional gastrointestinal disorders in a population based study and to compare with the Olmsted County study. Method A questionnaire was mailed to the same age- and gender-stratified random sample of the Icelandic population aged 18–75 in 1996 and 2006. Results were compared to the Olmsted County study. Results Prevalence of functional gastrointestinal disorder symptoms was stable between these periods in time: 16.9% and 17.2% for irritable bowel syndrome, and 4.8% and 6.1% for functional dyspepsia. Onset of each disorder was more often higher in the Olmsted County study than in Iceland. Disappearance rates were similar for both studies. Transition probabilities varied across the different subgroups and were different between studies. The same proportion had the same symptoms in the initial and final studies. More subjects had no symptoms in Iceland (52% vs. 40%) and different symptoms at follow up (38% vs. 23%). Conclusion Prevalence of functional gastrointestinal disorder symptoms was stable over time but the turnover in symptoms was high. A higher number of subjects had no symptoms in Iceland than in Olmsted County and there was a greater variation in subjects having different symptoms at follow up.

Medical students are taught that 90% of all diagnoses are made through careful assessment of the patients' symptoms. Clinicians now rely heavily on techniques such as endoscopy or radiology before making a definitive diagnosis of organic disease. Most gastroenterologists would require endoscopic confirmation before labeling a patient as having peptic ulcer disease and would make a diagnosis of Crohn disease based on small bowel radiology or colonoscopy. However, the most common causes of symptoms of the gastrointestinal tract are functional. It is important that clinicians obtain a thorough history so that the disorder of the patient can be accurately defined.

Our objective was to obtain national data of the estimated prevalence, sociodemographic relationships, and health impact of persons with functional gastrointestinal disorders. We surveyed a stratified probability random sample of U.S. householders selected from a data base of a national market firm (National Family Opinion, Inc.). Questions were asked about bowel symptoms, sociodemographic associations, work absenteeism, and physician visits. The sampling frame was constructed to be demographically similar to the U.S. householder population based on geographic region, age of householder, population density, household income, and household size. Of 8250 mailings, 5430 were returned suitable for analysis (66% response). The survey assessed the prevalence of 20 functional gastrointestinal syndromes based on fulfillment of multinational diagnostic (Rome) criteria. Additional variables studied included: demographic status, work absenteeism, health care use, employment status, family income, geographic area of residence, population density, and number of persons in household. For this sample, 69% reported having at least one of 20 functional gastrointestinal syndromes in the previous three months. The symptoms were attributed to four major anatomic regions: esophageal (42%), gastroduodenal (26%), bowel (44%), and anorectal (26%), with considerable overlap. Females reported greater frequencies of globus, functional dysphagia, irritable bowel syndrome, functional constipation, functional abdominal pain, functional biliary pain and dyschezia; males reported greater frequencies of aerophagia and functional bloating. Symptom reporting, except for incontinence, declines with age, and low income is associated with greater symptom reporting. The rate of work/school absenteeism and physician visits is increased for those having a functional gastrointestinal disorder. Furthermore, the greatest rates are associated with those having gross fecal incontinence and certain more painful functional gastrointestinal disorders such as chronic abdominal pain, biliary pain, functional dyspepsia and IBS. Preliminary information on the prevalence, socio-demographic features and health impact is provided for persons who fulfill diagnostic criteria for functional gastrointestinal disorders.

A study of irritable bowel-type symptoms in 1264 health examinees using a self-administered questionnaire and psychological tests revealed they are common throughout adulthood. Of affected subjects 68% were female, and those with the more severe type (or = 3 Manning criteria) were predominantly female (80%). Fewer Asians than other racial/ethnic groups had these symptoms. Nongastrointestinal symptoms, physician visits, incontinence, laxative use, a stress effect on bowel pattern and abdominal pain, abdominal surgery, hysterectomy, childhood abuse, use of mind-altering drugs, depression, and anxiety were correlated with irritable bowel-type symptoms. Regression analysis found some of the clinical correlates were independent markers for irritable bowel-type symptoms and that sexual abuse was related to nongastrointestinal symptoms and abdominal surgery independent of irritable bowel-type symptoms. More severe irritable bowel-type symptoms were especially associated with nongastrointestinal symptoms, stress effects, sexual abuse, use of sedatives and oral narcotics, and a past alcohol problem. There are important demographic and clinical correlates with irritable bowel-type symptoms.

BACKGROUND Irritable bowel syndrome is one of the most commonly encountered gastrointestinal disorders, for which there are no established diagnostic criteria. Thus, a diagnosis of IBS is made by exclusion of any organic diseases. Recently, important attempts for the positive diagnosis of irritable bowel syndrome by questionnaire surveys of physical symptoms have been made. We performed a questionnaire survey to evaluate the diagnostic value of the Manning criteria and to observe the major symptoms in irritable bowel syndrome. METHODS A symptom questionnaire which consisted of 22 items, including 6 cardinal symptoms of the Manning criteria, were answered by 172 outpatients who had gastrointestinal complaints. According to a final diagnosis based on independent clinical evaluation, all patients were categorized in three groups: irritable bowel syndrome group, nonulcer dyspepsia group and organic gastrointestinal disease group. The results of the questionnaire were analyzed for each group. RESULTS The sensitivity and specificity of the Manning criteria for the diagnosis of irritable bowel syndrome were 67% and 70% if three or more items were regarded as positive. The mean score and overall frequency of the Manning criteria were significantly higher in irritable bowel syndrome group than in nonuclear dyspepsia (p < 0.01) or organic gastrointestinal disease group (p < 0.05). Among subgroups of the irritable bowel syndrome group, the pain-predominant subgroup showed a significantly higher score and overall frequency than the painless subgroup (p < 0.05). CONCLUSIONS The Manning criteria would be useful as a simple and reliable backup tool for the diagnosis of irritable bowel syndrome and seem to be more useful in pain-predominant subgroup. More detailed history-taking should prevent unnecessary extensive investigations for the diagnosis of irritable bowel syndrome.

Aliment Pharmacol Ther 2010; 32: 670–680 Summary Background The irritable bowel syndrome (IBS) is a common disorder, but information on its natural history is limited. Aim To study the performance of four IBS criteria in detecting incidence and stability of categories over a 10-year period. Method This study was a population-based postal study. Questionnaire was mailed to the same age- and gender-stratified random sample of the Icelandic population aged 18–75 years in 1996 and again in 2006. IBS was estimated by the Manning criteria, Rome II, Rome III, subgroups and self-report. Results Prevalence of IBS varied according to criteria: Manning showed the highest (32%) and Rome II the lowest (5%). Younger subjects and females were more likely to have IBS. Prevalence was stable over 10 years for all criteria except Rome III. There was a turnover in all IBS subgroups and a strong correlation among IBS, functional dyspepsia and heartburn. Conclusions The prevalence of the IBS remained stable over a 10-year period with a turnover in symptoms. The study suggests that IBS is a cluster of symptoms that float in time between different IBS categories, functional dyspepsia and heartburn. The irritable bowel syndrome in Iceland is very common and indicates a chronic condition, which poses a heavy burden on the health care system.

Gastroesophageal reflux disease (GERD), functional dyspepsia (FD) and irritable bowel syndrome (IBS) are very common in the general population. GERD has been shown to be less common in the East as compared to the West. Furthermore, erosive esophagitis (EE) is usually milder (predominantly Los Angeles grades A and B), and GERD complications are relatively uncommon in Asia.1 However, an overall rapid increase in the incidence and prevalence of GERD in Asia has been reported in the last decade.2 Since the aforementioned disorders are very common, there is a higher likelihood that they will overlap by chance. However, recent epidemiologic studies have demonstrated that the overlap between IBS and GERD is greater than anticipated by coincidence. Studies clearly demonstrated that GERD is prevalent in IBS patients and vice versa. The reason for this close relationship between the 2 disorders remains unknown. Presently, there are 2 leading hypotheses that attempt to explain this relationship. The first suggests that IBS-like symptoms are part of the spectrum of GERD manifestations. The other suggests that IBS and GERD are 2 distinct disorders with similar underlying pathophysiology.3 Thus far, there is paucity of information about the overlap between GERD and IBS or FD in Asia. Definitions for IBS and FD have varied over the years, primarily due to the short intervals in re-examining the criteria for these disorders by the Rome Committee for Functional Bowel Disorders. Consequently, the degree of overlap between these disorders and GERD depends on the definition used. In the Rome III classification, FD was redefined, and the term was replaced by 2 new symptom-related entities: epigastric pain syndrome (EPS) and postprandial distress syndrome (PDS).4 Furthermore, the Rome III criteria emphasize the possibility of demonstrating overlap between lower and upper gut functional disorders. However, the impact of Rome III criteria as compared to the previous Rome criteria (I or II) on the level of overlap between the different functional bowel disorders remains to be elucidated. In this issue of the journal, Noh et al. compared the prevalence and risk factors for overlap between GERD [EE and non-erosive reflux disease (NERD)] and FD or IBS (defined by the Rome III criteria). This is the first published study evaluating the overlap between GERD and functional bowel disorders in an Asian population using the Rome III criteria. A total of 2,388 Korean subjects who underwent upper endoscopy for health-screening purposes were enrolled. Of those, 15% were found to have GERD (80% with EE and 20% with NERD). The prevalence of FD and IBS in this patient population was 8% and 10%, respectively. In the NERD group, 74% fulfilled the diagnostic criteria for FD, and EPS was more prevalent than PDS. Forty-two percent of NERD patients fulfilled the diagnostic criteria for IBS. Diarrhea-predominant IBS and the unclassified-pattern were the most frequent overlapping IBS subtypes with NERD. The prevalence of FD (10%) and IBS (11%) in EE patients was similar to the prevalence of these functional bowel disorders in the reference group (subjects without reflux symptoms). Significant risk factors for NERD were high somatization score and having FD, while those for EE were male gender and current smoking. Two characteristics of the patients included in this study are highly intriguing. First, the prevalence of EE in the study's cohort was unusually high. As mentioned above, approximately 80% of the GERD patients were found to have EE. Admittedly, most of them demonstrated mild esophageal inflammation (87% Los Angeles grade A and 12% grade B). Studies in Western populations have demonstrated that EE accounts for 30-40% of the patients with GERD. In addition, the prevalence of FD and IBS in this study was similar to previous reported studies.2,5 However, the extent of overlap between FD or IBS and NERD was exceptionally high in this study. In a previous population-based survey performed in Korea, only 27% and 24% of GERD patients suffered from FD and IBS (as defined by Rome II criteria), respectively.2 The findings of the study by Noh et al. raise questions about the characteristics of the study population. A possible explanation for the high overlap between NERD and IBS or FD is the definition of NERD used by the study authors. NERD was diagnosed based on typical GERD symptoms and normal upper endoscopy. The authors did not attempt to perform pH testing demonstrating abnormal esophageal acid exposure. This kind of definition of NERD allowed a substantial number of functional heartburn patients to enter the study. It has been previously shown that functional heartburn patients frequently demonstrate traits of functional bowel disorders more commonly than pH-positive NERD patients.6 Noh et al. found that the EPS subtype of FD overlapped with NERD more frequently than the PDS subtype. Presently, there are no other studies examining the overlap between NERD or EE and the different subtypes of FD as defined by Rome III criteria. Studies have shown that patients with overlap between FD and IBS reported more dysmotility-like symptoms.7,8 A recent study from China demonstrated that the PDS subtype of FD overlapped more frequently with IBS than the EPS subtype of FD. Presently, it is not clear if the high overlap between EPS and NERD, as was demonstrated in the current study, is more specific to the study's patient population or is a more general phenomenon. In this study, there was a significant difference in the extent of overlap with FD and IBS between NERD and EE patients. Studies comparing the extent of overlap between the different GERD groups and functional bowel disorders have yielded conflicting results. In one study that used Rome II criteria and tried to exclude functional heartburn patients from the NERD group, the authors demonstrated that NERD patients had a significantly higher prevalence of FD and IBS as compared with EE patients.9 However, in another study, there was no difference in the prevalence of IBS (as defined by the Manning criteria) between NERD and EE patients.10 An analysis of 14 clinical trials (6,810 patients that used the ReQuest-Reflux questionnaire) revealed that IBS and dyspepsia-like symptoms are not more common in NERD patients as compared to those with EE.11 However, none of the aforementioned studies utilized Rome III criteria to diagnose FD and IBS. Thus, it is possible that the presence or absence of significant difference in the prevalence of IBS and FD between NERD and EE is driven by what criteria are used to define functional bowel disorders. To ensure better understanding of the extent of overlap between GERD groups and functional bowel disorders, authors should "level the playing field" by using only the Rome III criteria. In summary, the very informative study by Noh et al. demonstrated a significantly higher overlap between NERD patients and functional bowel disorders, such as IBS and FD, as compared to EE patients and normal controls. This is the first study that utilized Rome III criteria to diagnose functional bowel disorders in the different GERD groups. The study also clearly demonstrated that having NERD increases patient's risk of having a functional bowel disorder. This finding will likely have important clinical implications in the management of NERD. For example, several recent studies have suggested that GERD patients who concomitantly suffer from a functional bowel disorder demonstrate a lower response rate to standard-dose PPI as compared to those without a functional bowel disorder. Lastly, this study may provide us with an essential clue as to why NERD patients are less likely to respond to antireflux treatment as compared with the other GERD groups.

Irritable bowel syndrome (IBS) is associated with increased use of health care services. This study aims to estimate the costs of IBS in relation to differing diagnostic criteria of IBS, duration of symptoms, gender, and age.A two-phase postal survey. Questionnaire I covering gastrointestinal (GI) symptoms by Manning and Rome II criteria was mailed to 5000 randomly selected adults. Questionnaire II, mailed to those fulfilling IBS criteria of Questionnaire I, recorded data on physician visits, medications, and diagnostic procedures performed.Proportion of GI consulters was 48% (95% CI 41-55%) and 32% (95% CI 28-36%) for Rome II and Manning groups. Annual GI related individual costs were euro 497 (95% CI euro 382-621) and euro 295 (95% CI euro 246-347) by Rome II and Manning criteria. Societal GI costs were euro 82 million and euro 154 million by Rome II and Manning criteria. Direct non-GI costs amounted to euro 43 million and euro 126 million by Rome II and Manning criteria. Duration of GI symptoms, gender, or age had no impact on GI costs.IBS incurs substantial GI and non-GI costs corresponding to a share of up to 5% of the national direct outpatient and medicine expenditures. The more restrictive Rome II criteria identify an IBS population incurring higher GI related individual costs than Manning criteria. Costs due to GI endoscopies are not lower for those with a long history of symptoms suggesting that guideline recommendations for avoiding repeated diagnostic procedures may not be followed.