Systematic Review

The Perceptions, Diagnosis and Management of Irritable Bowel Syndrome in Primary Care

A Rome Foundation Working Team Report

A. P. S. Hungin; M. Molloy-Bland; R. Claes; J. Heidelbaugh; W. E. Cayley Jr; J. Muris; B. Seifert; G. Rubin; N. de Wit

Disclosures

Aliment Pharmacol Ther. 2014;40(10):1133-1145. 

In This Article

Abstract and Introduction

Abstract

Objective To review studies on the perceptions, diagnosis and management of irritable bowel syndrome (IBS) in primary care.

Methods Systematic searches of PubMed and Embase.

Results Of 746 initial search hits, 29 studies were included. Relatively few primary care physicians were aware of (2–36%; nine studies) or used (0–21%; six studies) formal diagnostic criteria for IBS. Nevertheless, most could recognise the key IBS symptoms of abdominal pain, bloating and disturbed defaecation. A minority of primary care physicians [7–32%; one study (six European countries)] preferred to refer patients to a specialist before making an IBS diagnosis, and few patients [4–23%; three studies (two European, one US)] were referred to a gastroenterologist by their primary care physician. Most PCPs were unsure about IBS causes and treatment effectiveness, leading to varied therapeutic approaches and broad but frequent use of diagnostic tests. Diagnostic tests, including colon investigations, were more common in older patients (>45 years) than in younger patients [<45 years; five studies (four European, one US)].

Conclusions There has been much emphasis about the desirability of an initial positive diagnosis of IBS. While it appears most primary care physicians do make a tentative IBS diagnosis from the start, they still tend to use additional testing to confirm it. Although an early, positive diagnosis has advantages in avoiding unnecessary investigations and costs, until formal diagnostic criteria are conclusively shown to sufficiently exclude organic disease, bowel investigations, such as colonoscopy, will continue to be important to primary care physicians.

Introduction

Irritable bowel syndrome (IBS) is a functional bowel disorder that is characterised by abdominal pain, bloating and disturbed defaecation.[1] IBS affects an estimated 10–15% of people in Western Europe and North America[2–5] and 5–10% in Asia.[6]

Since no specific biological markers for IBS have been identified, clinicians usually rely on symptom-based criteria for diagnosis. A number of diagnostic tools have been developed for use in IBS including the Rome criteria, which were last revised in 2006,[7] and the Manning criteria.[8] Diagnostic criteria have also been developed for use in primary care.[9] The Rome criteria are the most widely accepted among gastroenterologists and are used as research and diagnostic tools. However, according to a recent systematic review, few studies have validated the Rome I or Rome II criteria,[10] and no consistent differences have been observed in the sensitivity or specificity of the Rome I, Rome II and Manning criteria.[11] Furthermore no studies have validated Rome III criteria,[10] and their uptake has been variable in clinical practice, possibly because they were developed partly for research purposes.[10] There is still a need for development and validation of diagnostic criteria in primary care practice, to address patients' and physicians' concerns that organic disease might be missed without endoscopy.

Treatment strategies for IBS are also based on the nature, type and severity of symptoms.[2] Although generally speaking the effectiveness of drug treatment in IBS is limited, several treatments have been shown to be superior to placebo. These include anti-spasmodic agents and drugs acting on the 5-hydroxytryptamine receptor for diarrhoea-predominant IBS (IBS-D), soluble fibre for increasing stool-frequency in constipation-predominant IBS (IBS-C), chloride channel agonists for IBS-C and anti-depressants for chronic pain.[12] In addition, several psychotherapeutic interventions have established effectiveness in IBS.[13,14] However, there is a need for further consensus and guidance on which treatments should be used for which patients with IBS, as was done recently for probiotics.[15]

Less than half of those suffering from IBS consult a physician.[16] Although most clinical studies on IBS have been performed in patients referred to gastroenterologists, the majority of patients are likely to present in primary care where their diagnosis and management is initiated. Previous reviews of IBS in primary care have focused on the interactions between PCPs and patients with IBS,[17] and on differences/similarities in IBS between primary and secondary care.[18] Here, we aimed to focus on reviewing the literature on PCPs perceptions, understanding and views of IBS, including how they choose to diagnose and manage this challenging problem.

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