Delfini IBS Notes

IBS is characterized by chronic and/or recurrent symptoms which may be in combination: abdominal pain, discomfort, altered bowel habits, episodes of diarrhea and/or constipation.

The abdominal discomfort in IBS is frequently described as a cramping pain, located in the lower abdomen and sometimes relieved by defecation. Patients frequently describe abdominal distention, increased gas, passage of mucous in stools, a sensation of incomplete emptying with defecation and onset associated with a change in the form of the stool.

In a retrospective series, the Rome criteria in the absence of red flags (symptoms or signs associated with serious illness), had a sensitivity of 65%, specificity of 100%, and positive predictive value of 100% (IBS vs. organic disease). None of these patients required revision of their diagnosis during a 2-year follow-up. In a prospective study, the positive predictive value was 98% (6). The Manning Criteria have been reported to have a sensitivity for IBS of 42-90% and a specificity of 70-100% (6,7,20).

The American College of Gastroenterology (ACG) Functional Gastrointestinal Disorders Task Force recommended that physicians should use a broad definition for IBS and defined it as “abdominal discomfort associated with altered bowel habits” (1). This task force also concluded that, because the symptoms of IBS may change (e.g., from constipation alone to alternating constipation and diarrhea), IBS patients should be identified using symptom-based criteria:

IBS alternating between diarrhea and constipation;
IBS associated with abdominal discomfort, bloating, and constipation;
IBS associated with abdominal discomfort, fecal urgency, and diarrhea (2).

Emotional support appears to be equally important. Systematic reviews have been done on styles of communication including information and emotional support issues, their effects on patient satisfaction, health outcomes and adherence.

Physician-Patient Communications and Improvement in Health Outcomes

Stewart (8) found in a systematic review of 21 studies dealing with the quality of physician-patient communication and health outcomes that 16 studies reported positive associations, 4 reported non-significant results and 1 was inconclusive.

Outcomes included emotional well-being, symptom resolution, intermediate outcome measures (e.g. blood pressure), and pain control.

In the medical interview and discussion of the management plan, those physician behaviors which correlated with improved outcomes included the following »

Encouraging patients to ask questions
Enquiring about the patient’s feelings
Showing support and empathy
Providing information and emotional support to patients during the interview
Being willing to share decision-making
Reaching agreement about the nature of the problem and need for follow-up

Clinician Behaviors and Improved Outcomes Hall, Roter and Katz (9), in a meta-analysis of 41 studies of objectively measured clinician behaviors, reported statistically significant associations between physician behaviors and satisfaction, adherence and recall. These authors hypothesize that patients reciprocate socio-emotional and other behaviors and that, for patients to accept and use information provided by clinicians, clinicians must demonstrate caring and technical competence — as described here:
Satisfaction	Amount of information imparted to patients Technical and interpersonal competence of physicians Partnership building Social conversation Positive talk and non-verbal communication Avoiding negative talk
Adherence	More information giving Fewer overall questions Positive talk (and avoiding negative talk)
Patient Recal	More information giving Partnership building Less question-asking Positive talk

Verbal Behaviors by Physicians Associated with Statistically Significant Positive Patient Outcomes for
Health & Patient Satisfaction

Beck (10) et al in a systematic review of physician-patient communications (verbal and non-verbal behaviors) in primary care offices reported the following significant associations between physician behavior and health outcomes or patient satisfaction. Care outcomes included satisfaction, trust, rapport, comprehension, adherence and long-term health effects (e.g., glucose control). In 14 studies meeting pre-defined criteria, the following verbal behaviors were statistically significant »

Verbal Behaviors
Empathy
Reassurance
Friendliness
Information sharing
Summarizing
Clarification
Support
Positive reinforcement
Psychosocial talk

Non-verbal Communications Used by Physicians Associated with Improved Outcomes
In 8 studies of non-verbal communication, the following were associated with improved outcomes »	Non-Verbal Behaviors Head nodding Forward leaning Direct body orientation Uncrossed legs and arms Less mutual gaze

Behaviors Used by Physicians Negatively Associated with Patient Outcomes
Beck also summarized the behaviors that have been shown in other studies to be negatively associated with patient outcomes:	Negative Behaviors Negative social and emotional interactions Formal behavior Antagonism and passive rejection High rates of biomedical questioning Interruptions Not providing information to patient (information collection without feedback) Antagonistic behavior Directive behavior Demonstrating irritation, nervousness, anxiety or tension Dominance Directiveness

NOTE 2: DIAGNOSTIC TESTING

DIAGNOSTIC TESTING: Evidence Grade B – Possibly useful
There is insufficient evidence to conclude that any routine diagnostic testing improves outcomes in patients with typical irritable bowel symptoms (and without alarm signs or symptoms). There is insufficient evidence to conclude that the likelihood of disease (colitis, colorectal cancer, lactose malabsorption, celiac disease, thyroid disease, infection in the gastrointestinal tract) is greater in patients with IBS than in control populations. Note: Colon cancer screening and other screening or routine testing are not addressed in this guideline.

This guideline recommends a hematocrit to R/O anemia. Recommendations for diagnostic testing of patients with suspected IBS have frequently included blood tests (e.g., CBC, thyroid function tests, tests for celiac sprue), radiologic exams (e.g., barium enema), stool tests (e.g., hemoccult testing, stool cultures or preps) or endoscopic diagnostic testing (e.g., sigmoidoscopy, colonoscopy, upper endoscopy). However, benefits of routine diagnostic testing in patients suspected of having IBS have not been demonstrated to outweigh the risks and costs. (It should be emphasized, however, that lack of evidence is not equivalent to proof of ineffectiveness.)

Basic laboratory tests are reviewed in a well-done systematic review by Cash et al. In this systematic review of patients meeting symptom-based criteria for IBS (11), six of 154 potentially relevant studies met the symptom-based criteria (Manning, Rome I, Rome II, or International Congress of Gastroenterology criteria). In these studies (average age of patients 39-56), the pretest probability of inflammatory bowel disease, colorectal cancer, or infectious diarrheas was less than 1%. The pretest probability of inflammatory bowel disease, lactose malabsorption, and thyroid dysfunction in patients with suspected IBS was similar to the prevalence of these disorders in the general population. However, the pretest probability of celiac disease in patients meeting symptom-based criteria for IBS was 10 times higher than the prevalence of celiac disease in the general population.

Conclusions
A diagnostic evaluation is indicated if the patient has “alarm” symptoms (see Box A in algorithm) and management of these patients is beyond the scope of the guideline.
Currently recommended diagnostic tests rarely identify organic GI disease in patients fulfilling symptom-based criteria for IBS who do not have alarm signs or symptoms. Invasive diagnostic evaluations in patients who clearly fulfill symptom-based criteria for IBS, and who do not have alarm signs or symptoms, may not be necessary.
Patients should be made aware of this evidence and a shared decision-making process between clinician and patient should be utilized in determining whether diagnostic testing is to be performed.