Elsevier

Medical Hypotheses

Volume 76, Issue 1, January 2011, Pages 97-99
Medical Hypotheses

Diarrhea Predominant Irritable Bowel Syndrome (IBS-D): Fact or fiction

https://doi.org/10.1016/j.mehy.2010.08.040Get rights and content

Summary

Diarrhea Predominant Irritable Bowel Syndrome IBS (IBS-D) and functional diarrhea constitute 50% of cases treated by gastroenterology specialists and a significant proportion of those treated in a primary physicians practice. The size of the problem and the difficulty in successfully addressing these entities has frustrated patients and physicians alike.

The presented data delineates work-up, final diagnoses and clinical outcomes in the largest single clinical retrospective study of 303 patients with an initial presentation of IBS-D and functional diarrhea. Results indicate that 298 (98%) patients were found to have a diagnosis different from the initial presentation of IBS-D, and 204 (68%) of the patients studied had conditions related to treatable bile acid abnormalities.

After identifying these clinical diagnoses and instituting appropriate therapy, 98% of these patients had a favorable response, as measured by a decrease in the number of bowel movements to less than three per day and a significant change in the consistency of the stools. This finding is dramatically different from the poor response generally experienced from conventional therapy for IBS-D and functional chronic diarrhea. The data presented in this study substantiates the hypothesis that IBS-D and functional diarrhea do not exist as true clinical entities and explains the previous lack of satisfactory therapeutic response.

Symptoms experienced by these patients were caused by a collection of different clinical conditions bunched up under this “umbrella” diagnosis of IBS-D. Once these separate entities were identified and appropriately addressed, the clinical response was quite impressive and encouraging. The implication of this hypothesis could be of vital importance because of the number of those suffering from these symptoms.

Introduction

Criteria and diagnostic work-up for irritable bowel syndrome (IBS) has evolved through many phases in search of defining an entity that affects up to 15% of the population in the United States [1], [2], [3]. The opacity of the etiology has lead to far reaching explanations for such entities, none of which has been satisfactory. This study was initiated to analyze 303 patients, frequently seen by more than one physician, diagnosed with chronic diarrhea and presented to this gastroenterologist practice as “diarrhea predominant IBS”.

Symptoms at the time of initial presentation satisfied the established Rome criteria for irritable bowel syndrome [4]. Although pain is fundamental in the diagnosis of IBS, abdominal discomfort and pain may be difficult to differentiate by patients and physicians. As a result, differentiating true IBS-D from functional diarrhea is difficult, and physicians frequently lump chronic diarrhea with negative work-up as “diarrhea predominant-IBS”. Many feel that Manning/Rome criteria are too restrictive [5], [6], [7].

The patients in this study presented with more than three bowel movements per day for a minimum of 2 months associated with urgency, and at times, incontinence. All shared a common characteristic of “bathroom mapping” which is the anxious search for a bathroom in all venues.

Analysis of the data in this study was revealing. The favorable response, as defined by less than three bowel movements per day, lead to a different fundamental understanding and approach to patients with chronic diarrhea and supports the proposed hypothesis.

Section snippets

Hypothesis

This hypothesis contends that Diarrhea Predominant Irritable Bowel Syndrome (IBS-D) and functional diarrhea are not true clinical entities as previously thought, but a collection of different, separate medical conditions. Once these conditions are identified and appropriately addressed, the clinical response is very impressive compared to the poor response and frustration currently experienced by both the patient and the physician. This explains the lack of clarity in understanding the cause of

Methods

Five hundred and seventy-five patients over the age of 18 with chronic diarrhea were reviewed retrospectively in a solo gastroenterology private practice over a period of 8 years. Only 303 patients completed the work-up necessary to be included in this publication. Chronic diarrhea is defined by at least three loose bowel movements per day over a minimum period of 2 months [9]. The bowel movements vary from semi-solid, to explosive, watery movements with urgency as well as occasional fecal

Results

Bile acid induced diarrhea (Habba Syndrome, post-cholecystectomy and Empiric Bile Acid Therapy patients) constituted the majority of patients in this study 204 (68%). This finding is similar to previous studies [12]. The female: male ratio was 5:1 which is not surprising since gallbladder dysfunction is more common in females. Of interest, 124 (41%) total patients in this study had diarrhea caused by a relatively new entity relating dysfunctional gallbladder with chronic diarrhea “Habba

Discussion

Chronic diarrhea is a devastating illness causing a significant impact, which hinders basic functioning in a person’s life. Patients commonly try to address this issue with their primary physicians who may suggest simple dietary measures and anti-diarrheal agents without avail, frequently resulting in referral to a specialist who performs certain investigative tests with inconclusive diagnosis. They are then tagged with “Diarrhea Predominant Irritable Bowel Syndrome”, given an array of

Conflicts of interest statement

None declared.

References (18)

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    2012, American Journal of Medicine
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    Therapy with a bile acid binder resulted in 96% improvement in the 10% of patients with severe bile acid malabsorption (SeHCAT <5%), 80% improvement in the 32% with moderate (75SeHCAT <10%), and 70% improvement in the 26% with mild malabsorption (75SeHCAT <15%).64 Habba65 reported a 68% improvement in diarrhea with bile acid sequestrant therapy among patients labeled as having irritable bowel syndrome-diarrhea. The bile acid sequestrant, colesevelam, reduces the accelerated ascending colon transit in patients with irritable bowel syndrome-diarrhea;66 the transit rate in the ascending colon is a determinant of stool consistency.

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