Irritable bowel syndrome

This article is about a functional disorder. For bowel inflammation, see Inflammatory bowel disease.

Irritable bowel syndrome
Classification and external resources
ICD-10	K58
ICD-9	564.1
DiseasesDB	30638
MedlinePlus	000246
eMedicine	med/1190
MeSH	D043183

Irritable bowel syndrome (IBS, or spastic colon) is a diagnosis of exclusion. It is a functional bowel disorder characterized by chronic abdominal pain, discomfort, bloating, and alteration of bowel habits in the absence of any detectable organic cause.^[1] In some cases, the symptoms are relieved by bowel movements.^[2] Diarrhea or constipation may predominate, or they may alternate (classified as IBS-D, IBS-C or IBS-A, respectively). IBS may begin after an infection (post-infectious, IBS-PI), a stressful life event, or onset of maturity without any other medical indicators.

Although there is no cure for IBS, there are treatments that attempt to relieve symptoms, including dietary adjustments, medication and psychological interventions. Patient education and a good doctor-patient relationship are also important.^[2]

Several conditions may present as IBS including coeliac disease, fructose malabsorption,^[3] mild infections, parasitic infections like giardiasis,^[4] several inflammatory bowel diseases, bile acid malabsorption, functional chronic constipation, and chronic functional abdominal pain. In IBS, routine clinical tests yield no abnormalities, although the bowels may be more sensitive to certain stimuli, such as balloon insufflation testing. The exact cause of IBS is unknown. The most common theory is that IBS is a disorder of the interaction between the brain and the gastrointestinal tract, although there may also be abnormalities in the gut flora or the immune system.^[5][6]

IBS does not lead to more serious conditions in most patients.^{[7][8][9][10][11]} However, it is a source of chronic pain, fatigue, and other symptoms and contributes to work absenteeism.^[12][13] Researchers have reported that the high prevalence of IBS,^[14][15][16] in conjunction with increased costs, produces a disease with a high social cost.^[17] It is also regarded as a chronic illness and can dramatically affect the quality of a sufferer's life.

Classification

IBS can be classified as either diarrhea-predominant (IBS-D), constipation-predominant (IBS-C) or IBS with alternating stool pattern (IBS-A or pain-predominant^[18]). In some individuals, IBS may have an acute onset and develop after an infectious illness characterized by two or more of the following: fever, vomiting, diarrhea, or positive stool culture. This post-infective syndrome has consequently been termed "post-infectious IBS" (IBS-PI)

Symptoms

The primary symptoms of IBS are abdominal pain or discomfort in association with frequent diarrhea or constipation, a change in bowel habits.^[19] There may also be urgency for bowel movements, a feeling of incomplete evacuation (tenesmus), bloating or abdominal distention.^[20] People with IBS, more commonly than others, have gastroesophageal reflux, symptoms relating to the genitourinary system, chronic fatigue syndrome, fibromyalgia, headache, backache and psychiatric symptoms such as depression and anxiety.^[20][21] Some studies indicate that up to 60% of persons with IBS also have a psychological disorder, typically anxiety or depression.^[22]

Causes

The cause of IBS is unknown, but several hypotheses have been proposed. The risk of developing IBS increases sixfold after acute gastrointestinal infection. Post-infection, further risk factors are young age, prolonged fever, anxiety, and depression.^[23] Publications suggesting the role of brain-gut "axis" appeared in the 1990s, such as a study entitled Brain-gut response to stress and cholinergic stimulation in IBS published in the Journal of Clinical Gastroenterology in 1993.^[24] A 1997 study published in Gut magazine suggested that IBS was associated with a "derailing of the brain-gut axis."^[25] Psychological factors may be important in the etiology of IBS .^[21]

Active infections

Prevalence of protozoal infections in industrialized countries (United States and Canada) in 21st century.^[26][27]

There is research to support IBS being caused by an as-yet undiscovered active infection. Studies have shown that the nonabsorbed antibiotic Rifaximin can provide sustained relief for some IBS patients.^[28] While some researchers see this as evidence that IBS is related to an undiscovered agent, others believe IBS patients suffer from overgrowth of intestinal flora and the antibiotics are effective in reducing the overgrowth (known as small intestinal bacterial overgrowth).^[29] Other researchers have focused on an unrecognized protozoal infection as a cause of IBS^[6] as certain protozoal infections occur more frequently in IBS patients.^[30][31] Two of the protozoa investigated have a high prevalence in industrialized countries and infect the bowel, but little is known about them as they are recently emerged pathogens.

Blastocystis is a single-cell organism that has been reported to produce symptoms of abdominal pain, constipation and diarrhea in patients^[32] though these reports are contested by some physicians.^[33] Studies from research hospitals in various countries have identified high Blastocystis infection rates in IBS patients, with 38% being reported from London School of Hygiene & Tropical Medicine,^[34] 47% reported from the Department of Gastroenterology at Aga Khan University in Pakistan^[30] and 18.1% reported from the Institute of Diseases and Public Health at University of Ancona in Italy.^[31] Reports from all three groups indicate a Blastocystis prevalence of approximately 7% in non-IBS patients. Researchers have noted that clinical diagnostics fail to identify infection,^[35] and Blastocystis may not respond to treatment with common antiprotozoals.^{[33][36][37][38]}

Dientamoeba fragilis is a single-cell organism that produces abdominal pain and diarrhea. Studies have reported a high incidence of infection in developed countries, and symptoms of patients resolve following antibiotic treatment.^[26][39] One study reported on a large group of patients with IBS-like symptoms who were found to be infected with Dientamoeba fragilis, and experienced resolution of symptoms following treatment.^[40] Researchers have noted that methods used clinically may fail to detect some Dientamoeba fragilis infections.^[39] It is also found in people without IBS.^[41]

Diagnosis

There is no specific laboratory or imaging test that can be performed to diagnose irritable bowel syndrome. Diagnosis of IBS involves excluding conditions that produce IBS-like symptoms, and then following a procedure to categorize the patient's symptoms. Ruling out parasitic infections, lactose intolerance, small intestinal bacterial overgrowth and celiac disease is recommended for all patients before a diagnosis of irritable bowel syndrome is made. In patients over 50 years old it is recommended that they undergo a screening colonoscopy.^[42]

Differential diagnosis

Colon cancer, inflammatory bowel disease, thyroid disorders and giardiasis can all feature abnormal defecation and abdominal pain. Less common causes of this symptom profile are carcinoid syndrome, microscopic colitis, bacterial overgrowth, and eosinophilic gastroenteritis; IBS is, however, such a common presentation and testing for these conditions would yield such low numbers of positive results that it is considered difficult to justify the expense.^[43] Because there are many causes of diarrhea that give IBS-like symptoms, the American Gastroenterological Association published a set of guidelines for tests to be performed to rule out other causes for these symptoms. These include gastrointestinal infections, lactose intolerance, and coeliac disease. Research has suggested that these guidelines are not always followed.^[42] Once other causes have been excluded, the diagnosis of IBS is performed using a diagnostic algorithm. Well-known algorithms include the Manning Criteria, the obsolete Rome I and II criteria, the Kruis Criteria, and studies have compared their reliability.^[44] The more recent Rome III Process was published in 2006. Physicians may choose to use one of these guidelines, or may simply choose to rely on their own anecdotal experience with past patients. The algorithm may include additional tests to guard against mis-diagnosis of other diseases as IBS. Such "red flag" symptoms may include weight loss, gastrointestinal bleeding, anemia, or nocturnal symptoms. However, researchers have noted that red flag conditions may not always contribute to accuracy in diagnosis — for instance, as many as 31% of IBS patients have blood in their stool many possibly from hemorrhoidal bleeding.^[44]

The diagnostic algorithm identifies a name that can be applied to the patient's condition based on the combination of the patient's symptoms of diarrhea, abdominal pain, and constipation. For example, the statement "50% of returning travelers had developed functional diarrhea while 25% had developed IBS" would mean that half the travelers had diarrhea while a quarter had diarrhea with abdominal pain. While some researchers believe this categorization system will help physicians understand IBS, others have questioned the value of the system and suggested that all IBS patients have the same underlying disease but with different symptoms.^[45]

Investigations

Investigations are performed to exclude other conditions:

• Stool microscopy and culture (to exclude infectious conditions)
• Blood tests: Full blood examination, Liver function tests, Erythrocyte sedimentation rate, serological testing for coeliac disease
• Abdominal ultrasound (to exclude gallstones and other biliary tract diseases)
• Endoscopy and biopsies (to exclude peptic ulcer disease, coeliac disease, inflammatory bowel disease, malignancies)
• Hydrogen breath testing (to exclude fructose and lactose malabsorption)

Misdiagnosis

Published research has demonstrated that some poor patient outcomes are due to treatable causes of diarrhea being mis-diagnosed as IBS. Common examples include infectious diseases, coeliac disease,^[46] Helicobacter pylori,^[47][48] parasites.^[6][49][50]

Coeliac disease in particular is often misdiagnosed as IBS. The American College of Gastroenterology recommends that all patients with symptoms of IBS be tested for coeliac disease.^[51]

Bile acid malabsorption is also often missed in patients with diarrhea-predominant IBS. SeHCAT tests suggest that around 30% of D-IBS have this condition and most respond to bile acid sequestrants.^[52]

Chronic use of certain sedative-hypnotic drugs especially the benzodiazepines may cause irritable bowel like symptoms that can lead to a misdiagnosis of irritable bowel syndrome.^[53]

Comorbidities

Researchers have identified several medical conditions, or comorbidities, which appear with greater frequency in patients diagnosed with IBS.

Headache, Fibromyalgia, Chronic fatigue syndrome and Depression: A study of 97,593 individuals with IBS identified comorbidities such as headache, fibromyalgia, and depression.^[54] A systematic review found that IBS occurs in 51% of chronic fatigue syndrome patients and 49% of fibromyalgia patients, and psychiatric disorders were found to occur in 94% of IBS patients.^[21]

Inflammatory bowel disease (IBD): Some researchers have suggested that IBS is a type of low-grade inflammatory bowel disease.^[7] Researchers have suggested that IBS and IBD are interrelated diseases,^[8] noting that patients with IBD experience IBS-like symptoms when their IBD is in remission.^[9][10] A 3-year study found that patients diagnosed with IBS were 16.3 times more likely to be diagnosed with IBD during the study period.^[11] Serum markers associated with inflammation have also been found in patients with IBS (see Causes).

Abdominal surgery: A recent (2008) study found that IBS patients are at increased risk of having unnecessary cholecystectomy (gall bladder removal surgery) not due to an increased risk of gallstones, but rather to abdominal pain, awareness of having gallstones, and inappropriate surgical indications.^[55] A 2005 study reported that IBS patients are 87% more likely to undergo abdominal and pelvic surgery, and three times more likely to undergo gallbladder surgery.^[56] A study published in Gastroenterology came to similar conclusions, and also noted IBS patients were twice as likely to undergo hysterectomy.^[57]

Endometriosis: One study reported a statistically significant link between migraine headaches, IBS, and endometriosis.^[58]

Other chronic disorders: Interstitial cystitis may be associated with other chronic pain syndromes, such as irritable bowel syndrome and fibromyalgia. The connection between these syndromes is unknown.^[59]

Management

A number of treatments have been found to be better than placebo, including fiber, antispasmodics, and peppermint oil.^[60]

Diet

Some people with IBS are likely to have food intolerances. In 2007 the evidence base was not strong enough to recommend restrictive diets.^[61]

Many different dietary modifications have been attempted to improve the symptoms of IBS. Some are effective in certain sub-populations. As lactose intolerance and IBS have such similar symptoms a trial of a lactose free diet is often recommended.^[62] A diet restricting fructose and fructan intake has been shown to successfully treat the symptoms in a dose-dependant manner in patients with fructose malabsorption and IBS.^[63]

While many IBS patients believe they have some form of dietary intolerance, tests attempting to predict food sensitivity in IBS have been disappointing. One study reported that an IgG antibody test was effective in determining food sensitivity in IBS patients, with patients on the elimination diet experiencing 10% greater symptom reduction than those on a sham diet.^[64] More data is necessary before IgG testing can be recommended.^[65]

There is no evidence that digestion of food or absorption of nutrients is problematic for those with IBS at rates different from those without IBS. However, the very act of eating or drinking can provoke an overreaction of the gastrocolic response in some patients with IBS due to their heightened visceral sensitivity, and this may lead to abdominal pain, diarrhea, and/or constipation.^[66]

Fiber

There is convincing evidence that soluble fiber supplementation (e.g., psyllium) is effective in the general IBS population. It acts as a bulking agent, and for many IBS-D patients, it allows for a more consistent stool. For IBS-C patients, it seems to allow for a softer, moister, more easily passable stool.
Insoluble fiber (e.g., bran) has not been found to be effective for IBS.^[67] In some people, insoluble fiber supplementation may aggravate symptoms.^[61]

Fiber might be beneficial in those who have a predominance of constipation. In patients who have constipation predominant irritable bowel, soluble fiber at doses of 20 grams per day can reduce overall symptoms but will not reduce pain. The research supporting dietary fiber contains conflicting, small studies that are complicated by the heterogeneity of types of fiber and doses used.^[68]

One meta-analysis found that only soluble fiber improved global symptoms of irritable bowel, but neither type of fiber reduced pain.^[68] However, an updated meta-analysis by the same authors found that soluble fiber reduced symptoms.^[69] Positive studies have used 10–30 grams per day of psyllium seed.^[70][71] One study specifically examined the effect of dose and found that 20 grams of ispaghula husk was better than 10 grams and equivalent to 30 grams per day.^[72] An uncontrolled study noted increased symptoms with insoluble fibers.^[73] It is unclear if these symptoms are truly increased compared with a control group. If the symptoms are increased, it is unclear if these patients were diarrhea predominant (which can be exacerbated by insoluble fiber^[74][75]), or if the increase is temporary before benefit occurs.

Medication

Medications may consist of stool softeners and laxatives in constipation-predominant IBS, and antidiarrheals (e.g., opiate, opioid, or opioid analogs such as loperamide, codeine, diphenoxylate) in diarrhea-predominant IBS for mild symptoms.^[76][77][78]

Drugs affecting serotonin (5-HT) in the intestines can help reduce symptoms.^[79] Serotonin stimulates the gut motility and so agonists can help constipation-predominate irritable bowel, while antagonists can help diarrhea-predominant irritable bowel.

Laxatives

For patients who do not adequately respond to dietary fiber, osmotic laxatives such as polyethylene glycol, sorbitol, and lactulose can help avoid "cathartic colon" which has been associated with stimulant laxatives.^[80] Among the osmotic laxatives, 17–26 grams/day of polyethylene glycol (PEG) has been well studied.

Lubiprostone (Amitiza), is a gastrointestinal agent used for the treatment of idiopathic chronic constipation and constipation-predominant IBS. It is well-tolerated in adults, including elderly patients. As of July 20, 2006, Lubiprostone had not been studied in pediatric patients. Lubiprostone is a bicyclic fatty acid (prostaglandin E1 derivative) that acts by specifically activating ClC-2 chloride channels on the apical aspect of gastrointestinal epithelial cells, producing a chloride-rich fluid secretion. These secretions soften the stool, increase motility, and promote spontaneous bowel movements (SBM). Unlike many laxative products, Lubiprostone does not show signs of tolerance, dependency, or altered serum electrolyte concentration.

Antispasmodics

The use of antispasmodic drugs (e.g., anticholinergics such as hyoscyamine or dicyclomine) may help patients, especially those with cramps or diarrhea. A meta-analysis by the Cochrane Collaboration concludes that if 6 patients are treated with antispasmodics, 1 patient will benefit.^[76] Antispasmodics can be divided in two groups: neurotropics and musculotropics.

• Neurotropics, such as a phenobarbital like Donnatal or atropine, act at the nerve fibre of the parasympathicus but also affect other nerves and have side effects.
• Musculotropics such as mebeverine act directly at the smooth muscle of the gastrointestinal tract, relieving spasm without affecting normal gut motility.^{[citation needed]} Since this action is not mediated by the autonomic nervous system, the usual anticholinergic side effects are absent.^{[citation needed]}

Tricyclic antidepressants

There is strong evidence that low doses of tricyclic antidepressants can be effective for irritable bowel syndrome. However, there is less robust evidence as to the effectiveness of other antidepressant classes such as SSRIs.^[61][67]

Serotonin agonists

• Tegaserod (Zelnorm), a selective 5-HT4 agonist for IBS-C, is available for relieving IBS constipation in women and chronic idiopathic constipation in men and women. On March 30, 2007, the Food and Drug Administration (FDA) requested that Novartis Pharmaceuticals voluntarily discontinue marketing of tegaserod based on the recently identified finding of an increased risk of serious cardiovascular adverse events (heart problems) associated with use of the drug. Novartis agreed to voluntarily suspend marketing of the drug in the United States and in many other countries. On July 27, 2007 the Food and Drug Administration (FDA) approved a limited treatment IND program for tegaserod in the USA to allow restricted access to the medication for patients in need if no comparable alternative drug or therapy is available to treat the disease. The USA FDA had issued two previous warnings about the serious consequences of tegaserod. In 2005, tegaserod was rejected as an IBS medication by the European Union. Tegaserod, marketed as Zelnorm in the United States, was the only agent approved to treat the multiple symptoms of IBS (in women only), including constipation, abdominal pain and bloating.
• Selective serotonin reuptake inhibitor anti-depressants (SSRIs), because of their serotonergic effect, would seem to help IBS, especially patients who are constipation predominant. Initial crossover studies^[81] and randomized controlled trials^[82][83][84] support this role.

Serotonin antagonists

Alosetron, a selective 5-HT3 antagonist for IBS-D and cilansetron (also a selective 5-HT3 antagonist) were trialed for irritable bowel syndrome. Due to severe adverse effects, namely ischemic colitis and severe constipation, they are not available or recommended for irritable bowel syndrome.^[61]

Other agents

Magnesium aluminum silicates and alverine citrate drugs can be effective for irritable bowel syndrome.^[61]

There is conflicting evidence about the benefit of antidepressants in IBS. Some meta-analysis have found a benefit while others have not.^[85] A meta-analysis of randomized controlled trials of mainly TCAs found 3 patients have to be treated with TCAs for one patient to improve.^[86] A separate randomized controlled trial found that TCAs are best for patients with diarrhea-predominant IBS.^[87]

Recent studies have suggested that rifaximin can be used as an effective treatment for abdominal bloating and flatulence,^[28][88] giving more credibility to the potential role of bacterial overgrowth in some patients with IBS.^[89]

Domperidone, a dopamine receptor blocker and a parasympathomimetic, has been shown to reduce bloating and abdominal pain as a result of an accelerated colon transit time and reduced faecal load, that is a relief from hidden constipation; defecation was similarly improved.^[90]

The use of opioids is controversial due to the lack of evidence supporting their benefit and the potential risk of tolerance, physical dependence and addiction.^[91]

Psychotherapy

The mind-body or brain-gut interactions has been proposed for irritable bowel syndrome and is gaining increasing research attention.^[67] For some patients psychological therapies may help with symptoms. Cognitive behavioural therapy and hypnosis have been found to be the most beneficial. Hypnosis can improve mental wellbeing and cognitive behavioural therapy can provide psychological coping strategies for dealing with distressing symptoms as well as help suppress thoughts and behaviours that increase the symptoms of irritable bowel syndrome.^[61][67] Cognitive behavioral therapy has been found to improve symptoms in a number of studies.^[92][93] Relaxation therapy has also been found to be helpful.^[94]

A questionnaire in 2006 designed to identify patients’ perceptions about IBS, their preferences on the type of information they need, as well as educational media and expectations from health care providers, revealed misperceptions about IBS developing into other conditions, including colitis, malnutrition, and cancer.^[95]

The survey found IBS patients were most interested in learning about foods to avoid (60%), causes of IBS (55%), medications (58%), coping strategies (56%), and psychological factors related to IBS (55%). The respondents indicated that they wanted their physicians to be available via phone or e-mail following a visit (80%), have the ability to listen (80%), and provide hope (73%) and support (63%).

Stress relief

Reducing stress may reduce the frequency and severity of IBS symptoms. Techniques that may be helpful include:

• Relaxation techniques such as meditation
• Physical activities such as yoga or tai chi
• Regular exercise such as swimming, walking or running^[96]

Exercise

Many patients find that exercise helps with IBS. At least 30 minutes of strenuous exercise 5 times a week is recommended.^[96]

Alternative medicine

Due to often unsatisfactory results from medical treatments for IBS up to 50 percent of people turn to complementary alternative medicine.^[67]

Probiotics

Probiotics can be beneficial in the treatment of IBS, taking 10 billion to 100 billion beneficial bacteria per day is recommended for beneficial results. However, further research is needed on individual strains of beneficial bacteria for more refined recommendations.^[67][97] A number of probiotics have been found to be effective including: Lactobacillus plantarum^[98] and Bifidobacteria infantis;^[99] however, one review found that only Bifidobacteria infantis showed efficacy.^[100] Some yogurt is made using probiotics that may help ease symptoms of irritable bowel syndrome.^[101]

Herbal remedies

• Peppermint oil: Enteric coated peppermint oil capsules have been suggested for IBS symptoms in adults and children.^[102] There is evidence of a beneficial effect of these capsules and it is recommended that peppermint be trialed in all irritable bowel syndrome patients.^[103][67] Safety during pregnancy has not been established however and caution is required not to chew or break the enteric coating otherwise gastroesophageal reflux may occur as a result of lower esophageal sphincter relaxation. Occasionally nausea and perianal burning occur as side effects.^[67]
• Iberogast: The multi-herbal extract Iberogast was found to be significantly superior to placebo via both an abdominal pain scale and an IBS symptom score after four weeks of treatment.,^[104][105]
• Cannabis^[106]
• Kiwifruit IBS/C ^[107]
• Commiphora mukul^[108]
• Plantago ovata^[108]

There is only limited evidence for the effectiveness of other herbal remedies for irritable bowel syndrome. As with all herbs it is wise to be aware of possible drug interactions and adverse effects.^[67]

Yoga

Yoga may be effective for some with irritable bowel syndrome, especially poses which exercise the lower abdomen.^[61].

Acupuncture

Acupuncture may be worth a trial in select patients, but the evidence base for effectiveness is weak.^[67] A meta-analysis by the Cochrane Collaboration concluded that most trials are of poor quality and that it is unknown whether acupuncture is more effective than placebo.^[109]

Epidemiology

Percentage of population with IBS reported in various studies in different countries

Studies have reported that the prevalence of IBS varies by country and by age range examined. The bar graph at right shows the percentage of the population reporting symptoms of IBS in studies from various geographic regions (see table below for references).

The following table contains a list of studies performed in different countries that measured the prevalence of IBS and IBS-like symptoms:

Percentage of population reporting symptoms of IBS in various studies from various geographic areas
Country	Prevalence	Author/Year	Notes
Canada	6%[14]	Boivin, 2001
Japan	10%[110]	Quigley, 2006	Study measured prevalence of GI abdominal pain/cramping
United Kingdom	8.2%[111] 10.5%[15]	Ehlin, 2003 Wilson, 2004	Prevalence increased substantially 1970-2004
United States	14.1%[112]	Hungin, 2005	Most undiagnosed
United States	15%[14]	Boivin, 2001	Estimate
Pakistan	14%[113]	Jafri, 2007	Much more common in 16-30 age range. Of IBS patients, 56% male, 44% female
Pakistan	34%[114]	Jafri, 2005	College students
Mexico City	35%[16]	Schmulson, 2006	n=324. Also measured functional diarrhea and functional vomiting. High rates attributed to "stress of living in a populated city."
Brazil	43%[110]	Quigley, 2006	Study measured prevalence of GI abdominal pain/cramping
Mexico	46%[110]	Quigley, 2006	Study measured prevalence of GI abdominal pain/cramping

A study of United States residents returning from international travel found a high rate of IBS and persistent diarrhea that developed during travel and persisted upon return. The study examined 83 subjects in Utah, most of whom were returning missionaries. Of the 68 who completed the gastrointestinal questionnaire, 27 reported persistent diarrhea that developed while traveling, and 10 reported persistent IBS that developed while traveling.^[115]

History

One of the first references to the concept of an "irritable bowel" appeared in the Rocky Mountain Medical Journal in 1950.^[116] The term was used to categorize patients who developed symptoms of diarrhea, abdominal pain, constipation, but where no well-recognized infective cause could be found. Early theories suggested that the irritable bowel was caused by a psychosomatic or mental disorder.

Economics

The aggregate cost of irritable bowel syndrome in the United States has been estimated at $1.7-$10 billion in direct medical costs, with an additional $20 billion in indirect costs, for a total of $21.7-$30 billion.^[17] A study by a managed care company comparing medical costs of IBS patients to non-IBS controls identified a 49% annual increase in medical costs associated with a diagnosis of IBS.^[117] A 2007 study from a managed care organization found that IBS patients incurred average annual direct costs of $5,049 and $406 in out-of-pocket expenses.^[118] A study of workers with IBS found that they reported a 34.6% loss in productivity, corresponding to 13.8 hours lost per 40 hour week.^[12] A study of employer-related health costs from a Fortune 100 company conducted with data from the 1990s found IBS patients incurred US $4527 in claims costs vs. $3276 for controls.^[119] A study on Medicaid costs conducted in 2003 by the University of Georgia's College of Pharmacy and Novartis found IBS was associated in an increase of $962 in Medicaid costs in California, and $2191 in North Carolina. IBS patients had higher costs for physician visits, outpatients visits, and prescription drugs. The study suggested the costs associated with IBS were comparable to those found in asthma patients.^[120]

Research

Gibson and Shepherd state a diet restricted in fermentable oligo di and monosaccharides and polyols (FODMAPs) now has an evidence base sufficiently strong to recommend its widespread application in conditions such as IBS and IBD.^[121] They also state the restriction of FODMAPs globally, rather than individually, controls the symptoms of functional gut disorders (e.g., IBS), and the majority of IBD patients respond just as well. It is more successful than restricting only fructose and fructans, which are also FODMAPs, as is recommended for those with fructose malabsorption. Longer term compliance with the diet was high.

A randomised controlled trial on IBS patients found relaxing an IgG-mediated food intolerance diet led to a 24% greater deterioration in symptoms compared to those on the elimination diet and concluded food elimination based on IgG antibodies may be effective in reducing IBS symptoms and is worthy of further biomedical research.^[64]

Further information: NIH funding of IBS Research

The National Institutes of Health provides a searchable database for grant awards since 1974 on its CRISP database, and provides dollar amounts for recent awards on its Intramural Grant Award Page. In 2006, the NIH awarded approximately 56 grants related to IBS, totalling approximately $18.7 million.

See also

• Chronic functional abdominal pain
• Food intolerance
• Functional constipation
• Functional dyspepsia
• Fructose malabsorption
• Hypersensitivity
• Lactose intolerance
• Bile acid malabsorption

References

1. ^ "irritable bowel syndrome" at Dorland's Medical Dictionary
2. ^ ^{a b} Mayer EA (April 2008). "Clinical practice. Irritable bowel syndrome". N. Engl. J. Med. 358 (16): 1692–9. doi:10.1056/NEJMcp0801447. PMID 18420501. 
3. ^ Ledochowski M et al.: Fruktosemalabsorption. Journal für Ernährungsmedizin, 2001 (German)
4. ^ Intestinal Infection^{[dead link]}
5. ^ Yang CM, Li YQ (2007). "[The therapeutic effects of eliminating allergic foods according to food-specific IgG antibodies in irritable bowel syndrome]" (in Chinese). Zhonghua Nei Ke Za Zhi 46 (8): 641–3. PMID 17967233. 
6. ^ ^{a b c} Stark D, van Hal S, Marriott D, Ellis J, Harkness J (2007). "Irritable bowel syndrome: a review on the role of intestinal protozoa and the importance of their detection and diagnosis". Int. J. Parasitol. 37 (1): 11–20. doi:10.1016/j.ijpara.2006.09.009. PMID 17070814. 
7. ^ ^{a b} Bercik P, Verdu EF, Collins SM (2005). "Is irritable bowel syndrome a low-grade inflammatory bowel disease?". Gastroenterol. Clin. North Am. 34 (2): 235–45, vi–vii. doi:10.1016/j.gtc.2005.02.007. PMID 15862932. 
8. ^ ^{a b} Quigley EM (2005). "Irritable bowel syndrome and inflammatory bowel disease: interrelated diseases?". Chinese journal of digestive diseases 6 (3): 122–32. doi:10.1111/j.1443-9573.2005.00202.x. PMID 16045602. 
9. ^ ^{a b} Simrén M, Axelsson J, Gillberg R, Abrahamsson H, Svedlund J, Björnsson ES (2002). "Quality of life in inflammatory bowel disease in remission: the impact of IBS-like symptoms and associated psychological factors". Am. J. Gastroenterol. 97 (2): 389–96. doi:10.1111/j.1572-0241.2002.05475.x. PMID 11866278. 
10. ^ ^{a b} Minderhoud IM, Oldenburg B, Wismeijer JA, van Berge Henegouwen GP, Smout AJ (2004). "IBS-like symptoms in patients with inflammatory bowel disease in remission; relationships with quality of life and coping behavior". Dig. Dis. Sci. 49 (3): 469–74. doi:10.1023/B:DDAS.0000020506.84248.f9. PMID 15139501. 
11. ^ ^{a b} García Rodríguez LA, Ruigómez A, Wallander MA, Johansson S, Olbe L (2000). "Detection of colorectal tumor and inflammatory bowel disease during follow-up of patients with initial diagnosis of irritable bowel syndrome". Scand. J. Gastroenterol. 35 (3): 306–11. doi:10.1080/003655200750024191. PMID 10766326. 
12. ^ ^{a b} Paré P, Gray J, Lam S, et al. (2006). "Health-related quality of life, work productivity, and health care resource utilization of subjects with irritable bowel syndrome: baseline results from LOGIC (Longitudinal Outcomes Study of Gastrointestinal Symptoms in Canada), a naturalistic study". Clinical therapeutics 28 (10): 1726–35; discussion 1710–1. doi:10.1016/j.clinthera.2006.10.010. PMID 17157129. 
13. ^ Maxion-Bergemann S, Thielecke F, Abel F, Bergemann R (2006). "Costs of irritable bowel syndrome in the UK and US". PharmacoEconomics 24 (1): 21–37. doi:10.2165/00019053-200624010-00002. PMID 16445300. 
14. ^ ^{a b c} Boivin M (October 2001). "Socioeconomic impact of irritable bowel syndrome in Canada". Can. J. Gastroenterol. 15 (Suppl B): 8B–11B. PMID 11694908. 
15. ^ ^{a b} Wilson S, Roberts L, Roalfe A, Bridge P, Singh S (July 2004). "Prevalence of irritable bowel syndrome: a community survey". Br J Gen Pract 54 (504): 495–502. PMC 1324800. PMID 15239910. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=1324800. 
16. ^ ^{a b} Schmulson M, Ortiz O, Santiago-Lomeli M, Gutierrez-Reyes G, Gutierrez-Ruiz MC, Robles-Diaz G, Morgan D (2006). "Frequency of functional bowel disorders among healthy volunteers in Mexico City" (PDF). Dig Dis. 24 (3–4): 342–7. doi:10.1159/000092887. PMID 16849861. http://content.karger.com/ProdukteDB/produkte.asp?Aktion=ShowPDF&ArtikelNr=92887&Ausgabe=231847&ProduktNr=224231&filename=92887.pdf. 
17. ^ ^{a b} Hulisz D (2004). "The burden of illness of irritable bowel syndrome: current challenges and hope for the future". J Manag Care Pharm. 10 (4): 299–309. PMID 15298528. 
18. ^ Holten KB, Wetherington A, Bankston L (2003). "Diagnosing the patient with abdominal pain and altered bowel habits: is it irritable bowel syndrome?". Am Fam Physician 67 (10): 2157–62. PMID 12776965. http://www.aafp.org/afp/20030515/2157.html. 
19. ^ Schmulson MW, Chang L (1999). "Diagnostic approach to the patient with irritable bowel syndrome". Am. J. Med. 107 (5A): 20S–26S. doi:10.1016/S0002-9343(99)00278-8. PMID 10588169. 
20. ^ ^{a b} Talley NJ (2006). "Irritable bowel syndrome". Intern Med J 36 (11): 724–8. doi:10.1111/j.1445-5994.2006.01217.x. PMC 1761148. PMID 17040359. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=1761148. 
21. ^ ^{a b c} Whitehead WE, Palsson O, Jones KR (2002). "Systematic review of the comorbidity of irritable bowel syndrome with other disorders: what are the causes and implications?". Gastroenterology 122 (4): 1140–56. doi:10.1053/gast.2002.32392. PMID 11910364. 
22. ^ http://www.webmd.com/ibs/irritable-bowel-syndrome-ibs-depression
23. ^ Thabane M, Kottachchi DT, Marshall JK (2007). [www3.interscience.wiley.com/cgi-bin/fulltext/117987841/HTMLSTART "Systematic review and meta-analysis: The incidence and prognosis of post-infectious irritable bowel syndrome"]. Aliment Pharmacol Ther 26 (4): 535–44. doi:10.1111/j.1365-2036.2007.03399.x. PMID 17661757. www3.interscience.wiley.com/cgi-bin/fulltext/117987841/HTMLSTART. 
24. ^ Fukudo S, Nomura T, Muranaka M, Taguchi F (1993). "Brain-gut response to stress and cholinergic stimulation in irritable bowel syndrome. A preliminary study". J. Clin. Gastroenterol. 17 (2): 133–41. doi:10.1097/00004836-199309000-00009. PMID 8031340. 
25. ^ Orr WC, Crowell MD, Lin B, Harnish MJ, Chen JD (1997). "Sleep and gastric function in irritable bowel syndrome: derailing the brain-gut axis". Gut 41 (3): 390–3. doi:10.1136/gut.41.3.390. PMC 1891498. PMID 9378397. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=1891498. 
26. ^ ^{a b} Lagacé-Wiens PR, VanCaeseele PG, Koschik C (2006). "Dientamoeba fragilis: an emerging role in intestinal disease". Canadian Medical Association Journal 175 (5): 468–9. doi:10.1503/cmaj.060265. PMC 1550747. PMID 16940260. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=1550747. 
27. ^ Amin OM (2002). "Seasonal prevalence of intestinal parasites in the United States during 2000". Am. J. Trop. Med. Hyg. 66 (6): 799–803. PMID 12224595. 
28. ^ ^{a b} Pimentel M, Park S, Mirocha J, Kane SV, Kong Y (2006). "The effect of a nonabsorbed oral antibiotic (rifaximin) on the symptoms of the irritable bowel syndrome: a randomized trial". Ann. Intern. Med. 145 (8): 557–63. PMID 17043337. 
29. ^ Posserud I, Stotzer PO, Björnsson ES, Abrahamsson H, Simrén M (2007). "Small intestinal bacterial overgrowth in patients with irritable bowel syndrome". Gut 56 (6): 802–8. doi:10.1136/gut.2006.108712. PMC 1954873. PMID 17148502. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=1954873. 
30. ^ ^{a b} Yakoob J, Jafri W, Jafri N, et al. (2004). "Irritable bowel syndrome: in search of an etiology: role of Blastocystis hominis". Am. J. Trop. Med. Hyg. 70 (4): 383–5. PMID 15100450. 
31. ^ ^{a b} Giacometti A, Cirioni O, Fiorentini A, Fortuna M, Scalise G (1999). "Irritable bowel syndrome in patients with Blastocystis hominis infection". Eur. J. Clin. Microbiol. Infect. Dis. 18 (6): 436–9. doi:10.1007/s100960050314. PMID 10442423. 
32. ^ Qadri SM, al-Okaili GA, al-Dayel F (1989). "Clinical significance of Blastocystis hominis". J. Clin. Microbiol. 27 (11): 2407–9. PMC 267045. PMID 2808664. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=267045. 
33. ^ ^{a b} Markell EK, Udkow MP (1986). "Blastocystis hominis: pathogen or fellow traveler?". Am. J. Trop. Med. Hyg. 35 (5): 1023–6. PMID 3766850. 
34. ^ Windsor J (2007). "B. hominis and D. fragilis: Neglected human protozoa". British Biomedical Scientist: 524–7. http://www.ibms.org/index.cfm?method=publications.biomedical_scientist&subpage=contents_2007_July. ^{[dead link]}
35. ^ Stensvold R, Brillowska-Dabrowska A, Nielsen HV, Arendrup MC (2006). "Detection of Blastocystis hominis in unpreserved stool specimens by using polymerase chain reaction". J. Parasitol. 92 (5): 1081–7. doi:10.1645/GE-840R.1. PMID 17152954. 
36. ^ Yakoob J, Jafri W, Jafri N, Islam M, Asim Beg M (2004). "In vitro susceptibility of Blastocystis hominis isolated from patients with irritable bowel syndrome". Br. J. Biomed. Sci. 61 (2): 75–7. PMID 15250669. 
37. ^ Haresh K, Suresh K, Khairul Anus A, Saminathan S (1999). "Isolate resistance of Blastocystis hominis to metronidazole". Trop. Med. Int. Health 4 (4): 274–7. doi:10.1046/j.1365-3156.1999.00398.x. PMID 10357863. 
38. ^ Ok UZ, Girginkardeşler N, Balcioğlu C, Ertan P, Pirildar T, Kilimcioğlu AA (1999). "Effect of trimethoprim-sulfamethaxazole in Blastocystis hominis infection". Am. J. Gastroenterol. 94 (11): 3245–7. doi:10.1111/j.1572-0241.1999.01529.x. PMID 10566723. 
39. ^ ^{a b} Stensvold CR, Arendrup MC, Mølbak K, Nielsen HV (2007). "The prevalence of Dientamoeba fragilis in patients with suspected enteroparasitic disease in a metropolitan area in Denmark". Clin. Microbiol. Infect. 13 (8): 839–42. doi:10.1111/j.1469-0691.2007.01760.x. PMID 17610603. 
40. ^ Borody T, Warren E, Wettstein A, et al. (2002). "Eradication of Dientamoeba fragilis can resolve IBS-like symptoms". J Gastroenterol Hepatol 17 (Suppl; pages=A103). 
41. ^ Windsor JJ, Macfarlane L (May 2005). "Irritable bowel syndrome: the need to exclude Dientamoeba fragilis". Am. J. Trop. Med. Hyg. 72 (5): 501; author reply 501–2. PMID 15891119. http://www.ajtmh.org/cgi/content/full/72/5/501. Retrieved 2009-11-04. 
42. ^ ^{a b} Yawn BP, Lydick E, Locke GR, Wollan PC, Bertram SL, Kurland MJ (2001). "Do published guidelines for evaluation of Irritable Bowel Syndrome reflect practice?". BMC gastroenterology 1: 11. doi:10.1186/1471-230X-1-11. PMC 59674. PMID 11701092. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=59674. 
43. ^ C. Hauser (29 August 2005). Mayo Clinic Gastroenterology and Hepatology Board Review. CRC Press. p. 225–. ISBN 9780203502747. http://books.google.com/books?id=nStxzRQlNaAC&pg=PA225. Retrieved 24 October 2010. 
44. ^ ^{a b} Fass R, Longstreth GF, Pimentel M, et al. (2001). "Evidence- and consensus-based practice guidelines for the diagnosis of irritable bowel syndrome". Arch. Intern. Med. 161 (17): 2081–8. doi:10.1001/archinte.161.17.2081. PMID 11570936. 
45. ^ Talley NJ (2006). "A unifying hypothesis for the functional gastrointestinal disorders: really multiple diseases or one irritable gut?". Reviews in gastroenterological disorders 6 (2): 72–8. PMID 16699476. 
46. ^ Spiegel BM, DeRosa VP, Gralnek IM, Wang V, Dulai GS (2004). "Testing for celiac sprue in irritable bowel syndrome with predominant diarrhea: a cost-effectiveness analysis". Gastroenterology 126 (7): 1721–32. doi:10.1053/j.gastro.2004.03.012. PMID 15188167. 
47. ^ Su YC, Wang WM, Wang SY, et al. (August 2000). "The association between Helicobacter pylori infection and functional dyspepsia in patients with irritable bowel syndrome". Am. J. Gastroenterol. 95 (8): 1900–5. doi:10.1111/j.1572-0241.2000.02252.x. PMID 10950033. 
48. ^ Gerards C, Leodolter A, Glasbrenner B, Malfertheiner P (2001). "H. pylori infection and visceral hypersensitivity in patients with irritable bowel syndrome". Dig Dis 19 (2): 170–3. doi:10.1159/000050673. PMID 11549828. 
49. ^ Grazioli B, Matera G, Laratta C, et al. (March 2006). "Giardia lamblia infection in patients with irritable bowel syndrome and dyspepsia: a prospective study". World J. Gastroenterol. 12 (12): 1941–4. PMID 16610003. http://www.wjgnet.com/1007-9327/12/1941.asp. 
50. ^ Vernia P, Ricciardi MR, Frandina C, Bilotta T, Frieri G (1995). "Lactose malabsorption and irritable bowel syndrome. Effect of a long-term lactose-free diet". The Italian journal of gastroenterology 27 (3): 117–21. PMID 7548919. 
51. ^ American College of Gastroenterology Task Force on Irritable Bowel Syndrome (January 2009). "An Evidence-Based Systematic Review on the Management of Irritable Bowel Syndrome". Am J Gastroenterology 104 (Supplement 1): S1–S35. doi:10.1038/ajg.2008.122. PMID 19521341. http://www.nature.com/ajg/journal/v104/n1s/pdf/ajg2008122a.pdf. 
52. ^ Wedlake, L; A'Hern, R, Russell, D, Thomas, K, Walters, JR, Andreyev, HJ (2009). "Systematic review: the prevalence of idiopathic bile acid malabsorption as diagnosed by SeHCAT scanning in patients with diarrhoea-predominant irritable bowel syndrome". Alimentary pharmacology & therapeutics 30 (7): 707–17. doi:10.1111/j.1365-2036.2009.04081.x. PMID 19570102.. 
53. ^ Professor C Heather Ashton (1987). "Benzodiazepine Withdrawal: Outcome in 50 Patients". British Journal of Addiction 82: 655–671. http://www.benzo.org.uk/ashbzoc.htm. 
54. ^ Cole JA, Rothman KJ, Cabral HJ, Zhang Y, Farraye FA (2006). "Migraine, fibromyalgia, and depression among people with IBS: a prevalence study". BMC gastroenterology 6: 26. doi:10.1186/1471-230X-6-26. PMC 1592499. PMID 17007634. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=1592499. 
55. ^ Corazziari E, Attili AF, Angeletti C, De Santis A (2008). "Gallstones, cholecystectomy and irritable bowel syndrome (IBS) MICOL population-based study". Dig Liver Dis. 40 (12): 944–50. doi:10.1016/j.dld.2008.02.013. PMID 18406218. 
56. ^ Cole JA, Yeaw JM, Cutone JA, et al. (2005). "The incidence of abdominal and pelvic surgery among patients with irritable bowel syndrome". Dig. Dis. Sci. 50 (12): 2268–75. doi:10.1007/s10620-005-3047-1. PMID 16416174. 
57. ^ Longstreth GF, Yao JF (2004). "Irritable bowel syndrome and surgery: a multivariable analysis". Gastroenterology 126 (7): 1665–73. doi:10.1053/j.gastro.2004.02.020. PMID 15188159. 
58. ^ Tietjen GE, Bushnell CD, Herial NA, Utley C, White L, Hafeez F (2007). "Endometriosis is associated with prevalence of comorbid conditions in migraine". Headache 47 (7): 1069–78. doi:10.1111/j.1526-4610.2007.00784.x. PMID 17635599. 
59. ^ "Interstitial cystitis: Risk factors". Mayo Clinic. January 20, 2009. http://www.mayoclinic.com/health/interstitial-cystitis/DS00497/DSECTION=4. 
60. ^ Ford AC, Talley NJ, Spiegel BM, et al. (2008). "Effect of fibre, antispasmodics, and peppermint oil in the treatment of irritable bowel syndrome: systematic review and meta-analysis". BMJ 337: a2313. doi:10.1136/bmj.a2313. PMC 2583392. PMID 19008265. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=2583392. 
61. ^ ^{a b c d e f g} Ducrotté, P. (Nov 2007). "[Irritable bowel syndrome: current treatment options]". Presse Med 36 (11 Pt 2): 1619–26. doi:10.1016/j.lpm.2007.03.008. PMID 17490849. 
62. ^ Böhmer CJ, Tuynman HA (August 2001). "The effect of a lactose-restricted diet in patients with a positive lactose tolerance test, earlier diagnosed as irritable bowel syndrome: a 5-year follow-up study". Eur J Gastroenterol Hepatol 13 (8): 941–4. doi:10.1097/00042737-200108000-00011. PMID 11507359. 
63. ^ http://www.gastro.org/wmspage.cfm?parm1=5549 American Gastroenterological Association
64. ^ ^{a b} Atkinson W, Sheldon TA, Shaath N, Whorwell PJ (2004). "Food elimination based on IgG antibodies in irritable bowel syndrome: a randomised controlled trial". Gut 53 (10): 1459–64. doi:10.1136/gut.2003.037697. PMC 1774223. PMID 15361495. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=1774223. 
65. ^ Longstreth GF, Thompson WG, Chey WD, Houghton LA, Mearin F, Spiller RC (2006). "Functional bowel disorders". Gastroenterology 131 (2): 688. doi:10.1053/j.gastro.2006.06.027. 
66. ^ Sjölund K, Ekman R, Lindgren S, Rehfeld J (1996). "Disturbed motilin and cholecystokinin release in the irritable bowel syndrome". Scand J Gastroenterol 31 (11): 1110–4. doi:10.3109/00365529609036895. PMID 8938905. 
67. ^ ^{a b c d e f g h i j} Shen, YH.; Nahas, R. (Feb 2009). "Complementary and alternative medicine for treatment of irritable bowel syndrome". Can Fam Physician 55 (2): 143–8. PMC 2642499. PMID 19221071. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=2642499. 
68. ^ ^{a b} Bijkerk C, Muris J, Knottnerus J, Hoes A, de Wit N (2004). "Systematic review: the role of different types of fiber in the treatment of irritable bowel syndrome". Aliment Pharmacol Ther 19 (3): 245–51. doi:10.1111/j.0269-2813.2004.01862.x. PMID 14984370. 
69. ^ Bijkerk C, de Wit N, Muris JW, et al. (2009). "Systematic Soluble or insoluble fiber in irritable bowel syndrome in primary care? Randomised placebo controlled trial". BMJ 339 (b): 3154–. doi:10.1136/bmj.b3154. PMID 19713235. 
70. ^ Prior A, Whorwell P (1987). "Double blind study of ispaghula in irritable bowel syndrome". Gut 28 (11): 1510–3. doi:10.1136/gut.28.11.1510. PMC 1433676. PMID 3322956. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=1433676. 
71. ^ Jalihal A, Kurian G (1990). "Ispaghula therapy in irritable bowel syndrome: improvement in overall well-being is related to reduction in bowel dissatisfaction". J Gastroenterol Hepatol 5 (5): 507–13. doi:10.1111/j.1440-1746.1990.tb01432.x. PMID 2129822. 
72. ^ Kumar A, Kumar N, Vij J, Sarin S, Anand B (1987). "Optimum dosage of ispaghula husk in patients with irritable bowel syndrome: correlation of symptom relief with whole gut transit time and stool weight". Gut 28 (2): 150–5. doi:10.1136/gut.28.2.150. PMC 1432983. PMID 3030900. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=1432983. 
73. ^ Francis CY, Whorwell PJ (1994). "Bran and irritable bowel syndrome: time for reappraisal". Lancet 344 (8914): 39–40. doi:10.1016/S0140-6736(94)91055-3. PMID 7912305. 
74. ^ Cann P, Read N, Holdsworth C, Barends D (1984). "Role of loperamide and placebo in management of irritable bowel syndrome (IBS)". Dig Dis Sci 29 (3): 239–47. doi:10.1007/BF01296258. PMID 6365490. 
75. ^ Cann P, Read N, Holdsworth C (1984). "What is the benefit of coarse wheat bran in patients with irritable bowel syndrome?". Gut 25 (2): 168–73. doi:10.1136/gut.25.2.168. PMC 1432266. PMID 6319244. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=1432266. 
76. ^ ^{a b} Quartero A, Meineche-Schmidt V, Muris J, Rubin G, de Wit N (2005). Quartero, A Otto. ed. "Bulking agents, antispasmodic and antidepressant medication for the treatment of irritable bowel syndrome". Cochrane Database Syst Rev (2): CD003460. doi:10.1002/14651858.CD003460.pub2. PMID 15846668. 
77. ^ Lesbros-Pantoflickova D, Michetti P, Fried M, Beglinger C, Blum A (2004). "Meta-analysis: The treatment of irritable bowel syndrome". Aliment Pharmacol Ther 20 (11–12): 1253–69. doi:10.1111/j.1365-2036.2004.02267.x. PMID 15606387. 
78. ^ Jailwala J, Imperiale T, Kroenke K (2000). "Pharmacologic treatment of the irritable bowel syndrome: a systematic review of randomized, controlled trials". Ann Intern Med 133 (2): 136–47. PMID 10896640. 
79. ^ Talley N (2001). "Serotoninergic neuroenteric modulators". Lancet 358 (9298): 2061–8. doi:10.1016/S0140-6736(01)07103-3. PMID 11755632. 
80. ^ Joo J, Ehrenpreis E, Gonzalez L, Kaye M, Breno S, Wexner S, Zaitman D, Secrest K (1998). "Alterations in colonic anatomy induced by chronic stimulant laxatives: the cathartic colon revisited". J Clin Gastroenterol 26 (4): 283–6. doi:10.1097/00004836-199806000-00014. PMID 9649012. 
81. ^ Tack J, Broekaert D, Fischler B, Oudenhove L, Gevers A, Janssens J (2006). "A controlled crossover study of the selective serotonin reuptake inhibitor citalopram in irritable bowel syndrome". Gut 55 (8): 1095–103. doi:10.1136/gut.2005.077503. PMC 1856276. PMID 16401691. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=1856276. 
82. ^ Vahedi H, Merat S, Rashidioon A, Ghoddoosi A, Malekzadeh R (2005). "The effect of fluoxetine in patients with pain and constipation-predominant irritable bowel syndrome: a double-blind randomized-controlled study". Aliment Pharmacol Ther 22 (5): 381–5. doi:10.1111/j.1365-2036.2005.02566.x. PMID 16128675. 
83. ^ Creed F, Fernandes L, Guthrie E, Palmer S, Ratcliffe J, Read N, Rigby C, Thompson D, Tomenson B (2003). "The cost-effectiveness of psychotherapy and paroxetine for severe irritable bowel syndrome". Gastroenterology 124 (2): 303–17. doi:10.1053/gast.2003.50055. PMID 12557136. 
84. ^ Tabas G, Beaves M, Wang J, Friday P, Mardini H, Arnold G (2004). "Paroxetine to treat irritable bowel syndrome not responding to high-fiber diet: a double-blind, placebo-controlled trial". Am J Gastroenterol 99 (5): 914–20. doi:10.1111/j.1572-0241.2004.04127.x. PMID 15128360. 
85. ^ "UpToDate Inc." (subscription required). http://www.uptodate.com/online/content/topic.do?topicKey=gi_dis/5811&selectedTitle=1~148&source=search_result#9. 
86. ^ Jackson J, O'Malley P, Tomkins G, Balden E, Santoro J, Kroenke K (2000). "Treatment of functional gastrointestinal disorders with antidepressant medications: a meta-analysis". Am J Med 108 (1): 65–72. doi:10.1016/S0002-9343(99)00299-5. PMID 11059442. 
87. ^ Drossman D, Toner B, Whitehead W, Diamant N, Dalton C, Duncan S, Emmott S, Proffitt V, Akman D, Frusciante K, Le T, Meyer K, Bradshaw B, Mikula K, Morris C, Blackman C, Hu Y, Jia H, Li J, Koch G, Bangdiwala S (2003). "Cognitive-behavioral therapy versus education and desipramine versus placebo for moderate to severe functional bowel disorders". Gastroenterology 125 (1): 19–31. doi:10.1016/S0016-5085(03)00669-3. PMID 12851867. 
88. ^ Sharara AI, Aoun E, Abdul-Baki H, Mounzer R, Sidani S, Elhajj I (2006). "A randomized double-blind placebo-controlled trial of rifaximin in patients with abdominal bloating and flatulence". Am J Gastroenterol 101 (2): 326–33. doi:10.1111/j.1572-0241.2006.00458.x. PMID 16454838. 
89. ^ Quigley EM (2006). "Germs, gas and the gut; the evolving role of the enteric flora in IBS". Am J Gastroenterol 101 (2): 334–5. doi:10.1111/j.1572-0241.2006.00445.x. PMID 16454839. 
90. ^ Raahave D, Christensen E, Loud FB, Knudsen LL. Correlation of bowel symptoms with colonic transit, length, and faecal load in functional faecal retention 2009;56:83-8
91. ^ Warfield, Carol A.; Zahid H. Bajwa (2003). Principles and Practice of Pain Medicine. McGraw-Hill Professional. ISBN 0071443495. 
92. ^ Kennedy T, Jones R, Darnley S, Seed P, Wessely S, Chalder T (2005). "Cognitive behaviour therapy in addition to antispasmodic treatment for irritable bowel syndrome in primary care: randomised controlled trial". BMJ 331 (7514): 435. doi:10.1136/bmj.38545.505764.06. PMC 1188111. PMID 16093252. http://bmj.bmjjournals.com/cgi/content/full/331/7514/435. 
93. ^ Heymann-Mönnikes I, Arnold R, Florin I, Herda C, Melfsen S, Mönnikes H (2000). "The combination of medical treatment plus multicomponent behavioral therapy is superior to medical treatment alone in the therapy of irritable bowel syndrome". Am J Gastroenterol 95 (4): 981–94. doi:10.1111/j.1572-0241.2000.01937.x. PMID 10763948. 
94. ^ van der Veek PP, van Rood YR, Masclee AA (2007). [www3.interscience.wiley.com/cgi-bin/fulltext/117987882/HTMLSTART "Clinical trial: short- and long-term benefit of relaxation training for irritable bowel syndrome"]. Aliment. Pharmacol. Ther. 26 (6): 943–52. doi:10.1111/j.1365-2036.2007.03437.x. PMID 17767479. www3.interscience.wiley.com/cgi-bin/fulltext/117987882/HTMLSTART. 
95. ^ Halpert AD, Thomas AC, Hu Y, Morris CB, Bangdiwala SI, Drossman DA (2006). "A survey on patient educational needs in irritable bowel syndrome and attitudes toward participation in clinical research". J Clin Gastroenterol 40 (1): 37–43. doi:10.1097/01.mcg.0000190759.95862.08. PMID 16340632. 
96. ^ ^{a b} http://www.nhs.uk/Conditions/Irritable-bowel-syndrome/Pages/Treatment.aspx
97. ^ Nikfar S, Rahimi R, Rahimi F, Derakhshani S, Abdollahi M (December 2008). "Efficacy of probiotics in irritable bowel syndrome: a meta-analysis of randomized, controlled trials". Dis. Colon Rectum 51 (12): 1775–80. doi:10.1007/s10350-008-9335-z. PMID 18465170. 
98. ^ Niedzielin K, Kordecki H, Birkenfeld B (2001). "A controlled, double-blind, randomized study on the efficacy of Lactobacillus plantarum 299V in patients with irritable bowel syndrome". Eur J Gastroenterol Hepatol 13 (10): 1143–7. doi:10.1097/00042737-200110000-00004. PMID 11711768. 
99. ^ "New Studies Examine the Evidence on Probiotics in IBS" (PDF) (Press release). American College of Gastroenterology. October 31, 2005. http://www.acg.gi.org/media/releases/ACG05Release_ProbioticsinIBS.pdf. 
100. ^ Brenner DM, Moeller MJ, Chey WD, Schoenfeld PS (April 2009). "The utility of probiotics in the treatment of irritable bowel syndrome: a systematic review". Am. J. Gastroenterol. 104 (4): 1033–49; quiz 1050. doi:10.1038/ajg.2009.25. PMID 19277023. 
101. ^ "IBS diet: Can yogurt ease symptoms?". Mayo Clinic. May 21, 2008. http://www.mayoclinic.com/health/ibs-diet/AN01346. 
102. ^ Hadley SK, Gaarder SM (2005). "Treatment of irritable bowel syndrome". Am Fam Physician 72 (12): 2501–6. PMID 16370407. http://www.aafp.org/afp/20051215/2501.html. 
103. ^ Ford, A. C.; Talley, N. J.; Spiegel, B. M. R.; Foxx-Orenstein, A. E.; Schiller, L.; Quigley, E. M. M.; Moayyedi, P. (2008). "Effect of fibre, antispasmodics, and peppermint oil in the treatment of irritable bowel syndrome: Systematic review and meta-analysis". BMJ 337: a2313–a2313. doi:10.1136/bmj.a2313. PMC 2583392. PMID 19008265. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=2583392.  edit
104. ^ Madisch A, Holtmann G, Plein K, Holz J (2004). "Treatment of irritable bowel syndrome with herbal preparations: results of a double-blind, randomized, placebo-controlled, multi-centre trial". Aliment Pharmacol Ther 19 (3): 271–9. doi:10.1111/j.1365-2036.2004.01859.x. PMID 14984373. 
105. ^ Wald K., Kelber O., Weiser D., Laufer S., Heinle H."Effects of STW 5 and its single extracts on ileal oxygen radical production induced by histamine" Planta Medica 2009 75:9
106. ^ Izzo, A. A.; Sharkey, K. A. (2010). "Cannabinoids and the gut: New developments and emerging concepts". Pharmacology & Therapeutics 126 (1): 21–38. doi:10.1016/j.pharmthera.2009.12.005. PMID 20117132.  edit
107. ^ Printz, C. (2010). "A "natural" in the hunt for anticancer compounds. Researcher spans the globe in quest for cancer-fighting plants". Cancer 116 (23): 5341–5342. doi:10.1002/cncr.25779. PMID 21171231.  edit
108. ^ ^{a b} Rahimi, R.; Shams-Ardekani, M.; Abdollahi, M. (2010). "A review of the efficacy of traditional Iranian medicine for inflammatory bowel disease". World journal of gastroenterology : WJG 16 (36): 4504–4514. PMC 2945480. PMID 20857519. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=2945480.  edit
109. ^ Lim B, Manheimer E, Lao L, Ziea E, Wisniewski J, Liu J, Berman B (2006). Manheimer, Eric. ed. "Acupuncture for treatment of irritable bowel syndrome". Cochrane Database Syst Rev (4): CD005111. doi:10.1002/14651858.CD005111.pub2. PMID 17054239. 
110. ^ ^{a b c} Quigley EM, Locke GR, Mueller-Lissner S, Paulo LG, Tytgat GN, Helfrich I, Schaefer E (July 2006). "Prevalence and management of abdominal cramping and pain: a multinational survey". Aliment. Pharmacol. Ther. 24 (2): 411–9. doi:10.1111/j.1365-2036.2006.02989.x. PMID 16842469. 
111. ^ Ehlin AG, Montgomery SM, Ekbom A, Pounder RE, Wakefield AJ (August 2003). "Prevalence of gastrointestinal diseases in two British national birth cohorts". Gut 52 (8): 1117–21. doi:10.1136/gut.52.8.1117. PMC 1773740. PMID 12865268. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=1773740. 
112. ^ Hungin AP, Chang L, Locke GR, Dennis EH, Barghout V (June 2005). "Irritable bowel syndrome in the United States: prevalence, symptom patterns and impact". Aliment. Pharmacol. Ther. 21 (11): 1365–75. doi:10.1111/j.1365-2036.2005.02463.x. PMID 15932367. 
113. ^ Jafri W, Yakoob J, Jafri N Islam M, Ali QM (June 2007). "Irritable bowel syndrome and health seeking behaviour in different communities of Pakistan". J Pak Med Assoc 57 (6): 285–7. PMID 17629228. 
114. ^ Jafri W, Yakoob J, Jafri N, Islam M, Ali QM (2005). "Frequency of irritable bowel syndrome in college students". J Ayub Med Coll Abbottabad. 4 (17): 9–11. PMID 16599025. 
115. ^ Tuteja AK, Talley NJ, Gelman SS, Alder SC, Adler SC, Thompson C, Tolman K, Hale DC (January 2008). "Development of Functional Diarrhea, Constipation, Irritable Bowel Syndrome, and Dyspepsia During and After Traveling Outside the USA". Dig. Dis. Sci 53 (1): 271–6. doi:10.1007/s10620-007-9853-x. PMID 17549631. 
116. ^ Brown PW (1950). "The irritable bowel syndrome". Rocky Mountain medical journal 47 (5): 343–6. PMID 15418074. 
117. ^ Levy RL, Von Korff M, Whitehead WE, Stang P, Saunders K, Jhingran P, Barghout V, Feld AD. (2001). "Costs of care for irritable bowel syndrome patients in a health maintenance organization". Am J Gastroenterol 96 (11): 3122–9. doi:10.1111/j.1572-0241.2001.05258.x. PMID 11721759. 
118. ^ Nyrop KA, Palsson OS, Levy RL, Korff MV, Feld AD, Turner MJ, Whitehead WE (2007). [www3.interscience.wiley.com/cgi-bin/fulltext/117987809/HTMLSTART "Costs of health care for irritable bowel syndrome, chronic constipation, functional diarrhoea and functional abdominal pain"]. Aliment Pharmacol Ther 26 (2): 237–48. doi:10.1111/j.1365-2036.2007.03370.x. PMID 17593069. www3.interscience.wiley.com/cgi-bin/fulltext/117987809/HTMLSTART. 
119. ^ Leong SA, Barghout V, Birnbaum HG, et al. (2003). "The economic consequences of irritable bowel syndrome: a US employer perspective". Arch. Intern. Med. 163 (8): 929–35. doi:10.1001/archinte.163.8.929. PMID 12719202. 
120. ^ Martin B, Ganguly R, Pannicker S, Feride F, Barghout V (2003). "Utilization Patterns and Net Direct Medical Costs Medicaid of Irritable Bowel Syndrome". Curr Med Res Opin 19 (8): 771–80. doi:10.1185/030079903125002540. PMID 14687449. http://www.medscape.com/viewarticle/465472. 
121. ^ Gibson PR, Shepherd SJ. (Feb 2010). "Evidence-based dietary management of functional gastrointestinal symptoms: The FODMAP approach". J Gastroenterol Hepatol. 25 (2): 252–8.. doi:10.1111/j.1440-1746.2009.06149.x. PMID 20136989. http://www.medscape.com/viewarticle/716634. 

External links

• UNC Center for Functional GI & Motility Disorders
• Irritable bowel syndrome at the Open Directory Project