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