This essay aims to provide a comprehensive account of the gastrointestinal disorder, Irritable Bowel Syndrome. The aetiology, pathology, and prognosis of the disorder will be described, along with details pertaining to its epidemiology. The diagnosis and management of the disorder will be described, followed by a discussion of the health implications experienced by patients and the economic costs of the disorder. Conclusions will be made based on the information and evidence discussed throughout the essay.
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Irritable Bowel Syndrome (IBS), also known as spastic colon, nervous diarrhoea, and functional bowel, is one of the most common gastrointestinal disorders worldwide (NICE, 2008). It is a chronic, functional disorder of the gastrointestinal tract which is characterised by symptoms of abdominal pain or discomfort of the lower abdomen, bloating, and disordered defecation (Silk, 2003). This latter symptom can manifest in four different forms (Allison, 2002): constipation predominant; diarrhoea predominant; alternating between constipation and diarrhoea; or, non-extreme. Furthermore, although symptoms are predominantly gastrointestinal, other symptoms can include back ache, nausea, heartburn, lethargy, urinary problems, faintness, palpitations, and loss of appetite (Fortson and Lee, 2004). Symptoms are usually worse after eating and most people experience ‘flare-ups’ lasting between 2-4 days. Indeed, a key characteristic of IBS is a cycle of relapse and remission (Silk, 2003).
Worldwide, IBS affects an estimated 10-20% of the population at any one time, although the figure may be higher because not everyone seeks help for the condition (Hungin et al. 2003; Hungin et al., 2005). IBS can affect both genders of all ages, although it is twice as common in females (Voci and Cramer, 2009). It can occur at any age, but typically develops in individuals who are 20-30 years old (Wangen, 2006). Incidence tends to reduce with age (Wilson et al., 2004). Furthermore, more women report constipation predominant IBS, while more men report diarrhoea predominant IBS (Heitkemper and Jarrett, 2001). Women also tend to report a worsening of symptoms during menstruation, suggesting a hormonal link with IBS (Moore et al., 1998).
Despite there being no clear aetiology for IBS, there is a general consensus that it is a multifactorial disorder of a biopsychosocial nature (Allison, 2002). Possible factors involved in its development include an abnormality with how the muscles move food through the digestive tract, pain-sensitive digestive organs, a malfunctioning immune system, a problem between the central nervous system and the digestive system, or an abnormal response to infection. Environmental, dietary, and genetic factors that are as yet known are also suspected to play a role in the aetiology of IBS.
Diagnosis
A diagnosis of IBS can be made using the Rome III criteria of ‘red flag’ symptoms (Paterson et al., 1999). According to these criteria, an individual is diagnosed with IBS if they have experienced, for at least 6-months, any of the following symptoms: abdominal pain or discomfort; bloating; or, change in bowel habit. In addition, the individual has to present with abdominal pain or discomfort that is relieved by defecation or associated with changes in bowel frequency or stool formation, and have at least two of the following: altered stool evacuation (i.e. straining, urgency, incomplete evacuation); abdominal bloating (i.e. distension, tension, or hardness); symptoms made worse by eating; mucus from the rectum. Reported lethargy, nausea, backache and bladder symptoms are also indicators that might inform a diagnosis of IBS. Furthermore, there are a number of tests that are carried out to exclude other diagnoses. These include a full blood count, erythrocyte sedimentation rate or plasma viscosity (screening test), c-reactive protein (found in blood), and, antibody testing for coeliac disease (RCN, 2008).
The ‘red flag’ symptoms that require the individual to be referred to secondary care for further investigation include unintentional and unexplained weight loss, rectal bleeding, and, a family history of bowel or ovarian cancer (NICE, 2008). In people aged 60-years or over, a change in bowel habit lasting more than 6-weeks with looser and/or more frequent stools also acts a ‘red flag.’ Other indicators for referral include anaemia, abdominal or rectal masses, and inflammatory markers for inflammatory bowel disease (NICE, 2008).
Treatment
There is no cure for IBS, but it can be managed and controlled through lifestyle changes and medicine. NICE provide clinical guidelines on the management of IBS in primary care, which were developed through input from the National Collaborating Centre for Nursing and Supportive Care (NCC-NSC). These guidelines include the provision of general lifestyle advice, particularly in terms of dietary and physical activity advice (NICE, 2008). The treatment and management of IBS is largely focused on providing individuals with the information required to self-manage their condition through diet, physical activity, and medication for specific symptoms.
Dietary advice includes having regular meals, taking time to eat, drinking at least eight cups of water daily, and restricting consumption of tea, coffee, alcohol, fizzy drinks, high-fibre foods, resistant starch (i.e. whole grains, legumes, seeds), and fresh fruit. Individuals with diarrhoea are advised to avoid sorbitol, which is an artificial sweetener found in sugar-free sweets and drinks. Individuals with wind and bloating, on the other hand, are advised to increase intake of oats and linseeds. If diet is assessed as being a key factor in the IBS symptoms, the individual is referred to a dietician for single food avoidance and exclusion diets.
In terms of physical activity, individuals who score low in physical activity on the General Practice Physical Activity Questionnaire (GPPAQ) are provided with brief advice and counselling aimed at increasing their activity. The importance of physical activity in the management of IBS cannot be underestimated. Indeed, a study conducted in Sweden demonstrated that even a minimal increase in physical activity can improve symptoms of IBS (n=102) (Johannesson et al., 2011).
First-line pharmacological treatment is dependent on the primary symptoms reported by the individual. For example, there is support for the provision of antispasmodic agents such as hyoscine or peppermint oil to control symptoms of abdominal pain and spasms (Ford, 2008). Laxatives are an option for constipation, whilst loperamide is the recommended first choice of antimobility agent for diarrhoea (NICE, 2008). Second-line pharmacological treatment includes the consideration of tricyclic antidepressants for mood and analgesic (pain relieving) effect if first-line treatments do not work (Bell, 2004). Selective serotonin reuptake inhibitors are considered if tricyclic antidepressants do not work. However, due to the potential side-effects of these second-line medications, follow-up after 4-weeks and then every 6-12 months is advised (NICE, 2008).
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Psychological Implications
If individuals with IBS do not respond to second-line pharmacological treatments after 12-months, referral for psychological support such as cognitive behavioural therapy (CBT), hypnotherapy, or psychotherapy requires consideration (NICE, 2008). Indeed, although it is not a life-threatening condition, IBS can result in a great deal of psychological distress. One study found that half of the patients attending IBS clinics presented with a diagnosable psychiatric disorder (Silk, 2003). Anxiety and depression have been reported in people with IBS and stress and major life events have been found to often precede the onset of bowel symptoms (Silk, 2003). Strong associations have been found between IBS and Generalised Anxiety Disorder (GAD), with this comorbidity adding to social impairments (Lee et al., 2009). There is also a higher prevalence of childhood physical and sexual abuse among individuals diagnosed with IBS, further indicating the potential efficacy of providing psychological support (Allison, 2002).
The psychological impact of IBS is likely to result from that fact that it can be extremely debilitating and can severely impact quality of life (Heitkemper and Jarrett, 2001). Activities of daily living can be detrimentally impacted and individuals with IBS often experience lethargy and fatigue, which can limit physical activity and social life (Jones et al., 2000). Bertram et al. (2001), who conducted focus groups with people diagnosed with IBS, found that the condition resulted in high levels of frustration and social isolation. There was also an inconsistency in how individuals with IBS perceived their illness and how they felt others perceived their illness. In particular, there was frustration with a lack of understanding from family, friends, and colleagues in terms of the severity and unpredictability of the illness. Many participants also felt that health care professionals did not take the illness seriously. There is some evidence, however, to suggest that health professionals’ attitudes towards IBS are changing. In a study conducted by Nunn (2003), the majority of nurses disagreed with a statement suggesting that patients with IBS were demanding and lazy.
Nevertheless, the stigma surrounding IBS can result in individuals with IBS not accessing the support they need. When combined with the general lack of effective treatments for IBS, people often try to treat themselves. It has been estimated that 50% of people with IBS use complementary and alternative medicine (Hussain and Quigley, 2006). The NICE (2008) guidelines on the use of complementary and alternative medicine, however, recommend against encouraging their use, especially acupuncture and reflexology.
Economic Implications
Evidence suggests that disease relapse and remission accounts for 36-50% of all gastrointestinal consultations, although many patients do not seek help and often attempt to self-treat (Gunn et al., 2003; Parker, 2004). IBS has a significant impact on healthcare resources in both primary and secondary care (Ringstrom et al., 2007). It also contributes to both direct and indirect costs. Evidence suggests that disease relapse and remission accounts for 36-50% of all gastrointestinal consultations, although many patients do not seek help and often attempt to self-treat (Gunn et al., 2003; Parker, 2004).
IBS can lead to increased absenteeism at work and higher rates of health care utilisation, making it a public health problem (Talley, 2008). In a systematic review of the economic cost of IBS in the UK and US, total direct cost estimates per patient per year ranged from $348-8750 (£211.79-5325.25) (calculated for year 2002) (Maxion-Bergemann, Thielecke, and Bergemann, 2006). The average number of days off work per year because of IBS was between 8.5 and 21.6; indirect costs ranged from $355-3344 (£216.25-2037.04). Of note, however, is that the total costs and cost components of IBS were influenced by factors such as the demographic of the patient group and study variables, such as design and databases used. Further research is needed on the cost-effectiveness of diagnostic procedures and treatments for IBS in order to help define strategies to help IBS patients improve their quality of life and, in turn, reduce related healthcare and economic costs.
Conclusion
This essay has outlined the aetiology and epidemiology of Irritable Bowel Syndrome, which is one of the most common gastrointestinal disorders worldwide. IBS is a chronic disorder that cannot be cured, but requires self-management through lifestyle, pharmacological treatments, and psychological support. The direct and indirect costs of the condition are vast due to the relapsing and remitting nature of the symptoms. Due to there being no clear cause for IBS, stigma still exists regarding its seriousness, which can prevent people seeking medical support. In order to reduce the direct and indirect costs of this common, quality of life depleting illness, healthcare professionals need to take it seriously and assist patients in the long-term management of the physically and psychologically limiting symptoms.
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