Irritable bowel syndrome: diagnostic approaches in clinical practice

Figures & data

Figure 1 Laboratory and diagnostic tests commonly ordered, presented by physician type.³² More than 1 response could be chosen. A, Laboratory tests by practice type. “Other” laboratory tests (≤2%) are not represented. B, Diagnostic tests by practice type. “Other” diagnostic tests (4%–11%) and “no studies ordered” (34%–38%) are not represented. P values are shown.

Abbreviations: GI, gastrointestinal; CBC, complete blood count; ESR, erythrocyte sedimentation rate; LFT, liver function test; TFT, thyroid function test; FOBT, fecal occult blood test; EGD, esophagogastroduodenoscopy; SBFT, small bowel follow-through.

Table 1 Comparison of symptom-based criteria

Criteria/y	Symptoms, signs, and laboratory investigations included in criteria	Symptom duration required	Diagnostic performance
Manning et al^Citation39 1978	Abdominal pain relieved by defecation; more frequent stools with onset of pain; looser stools with onset of pain; passage of mucus per rectum; feeling of incomplete emptying; patient-reported visible abdominal distension	None	Sensitivity 78%, specificity 72%, positive LR 2.9 (95% CI, 1.3–6.4)^Citation31
Kruis et al^Citation40 1984	Symptoms (reported by patient using a form): abdominal pain, flatulence, or bowel irregularity; description of abdominal pain as burning, cutting, very strong, terrible, feeling of pressure, dull, boring, or “not so bad”	>2 yr	Sensitivity 77%, specificity 89%, positive LR 8.6 (95% CI, 2.9–26.0)^Citation31
	Signs (determined by physician): abnormal physical findings and/or history; pathognomonic for any diagnosis other than IBS; ESR >20 mm/2 h; leukocytosis >10,000 cells/μL; anemia (hemoglobin <12 g/dL for women, <14 g/dL for men); physician impression is that patient’s history suggests blood in the stools
Rome I criteria^Citation41 1990	Abdominal pain or discomfort relieved with defecation or associated with a change in stool frequency or consistency; any variation in defecation on ≥25% of occasions evidenced by 3 of the following: Altered stool frequency Altered stool form Altered stool passage Passage of mucus per rectum Bloating or distension	≥3 mo	Sensitivity 65%, specificity 100%, PPV 100%^Citation43
Rome II criteria^Citation13,Citation42 1999	Abdominal discomfort or pain that has 2 of 3 features: Relieved with defecation Onset associated with a change in stool frequency Onset associated with a change in stool form	≥12 wk (need not be consecutive in past year)	Not validated
Rome III criteria^Citation1 2006	Recurrent abdominal pain or discomfort ≥3 d/mo in the past 3 mo associated with ≥2 of the following: Improvement with defecation Onset associated with a change in stool frequency Onset associated with a change in stool form	Symptom onset: ≥6 mo before diagnosis	Not validated

Adapted with permission from Ford AC, Talley NJ, Veldhuyzen van Zanten SJ, Vakil NB, Simel DL, Moayyedi P. Will the history and physical examination help establish that irritable bowel syndrome is causing this patient’s lower gastrointestinal tract symptoms? JAMA. 2008;300(15):1793–1805.³¹ Copyright © 2008 American Medical Association. All rights reserved.

Abbreviations: Cl, confidence interval; LR, logistic regression; IBS, irritable bowel syndrome; ESR, erythrocyte sedimentation rate; PPV, positive predictive value.

Table 2 Comparison of traditional diagnostic methods

Tests	Advantages	Disadvantages
CBC, TSH, serum chemistries, FOBT	Inexpensive	Limited value in identifying organic disease in patients without alarm features^Citation2
Stool for ova and parasites	Noninvasive, inexpensive May be useful in patients with clinical features, symptom pattern, and geographic area suggestive of infection^Citation13	Limited value in identifying organic disease in patients without alarm features^Citation2
Hydrogen breath tests	May be useful when lactose maldigestion is suspected^Citation51,Citation56 Noninvasive	Need for specialized equipment, dedicated space, and technical support^Citation51 False-positive results possible in smokers and those with poor oral hygiene^Citation51 Limited value in identifying organic disease in patients without alarm features^Citation2
Celiac serologies (anti-tTG, EMA, AGA)	Routine use in IBS-D and IBS-M patients helpful in identifying celiac disease^Citation2,Citation58	–
Abdominal imaging	May be useful in excluding mechanical obstruction in patients with IBS-C and alarm features^Citation2	Expensive Low diagnostic yield in patients without alarm features^Citation29
Endoscopy/colonoscopy	Useful for identifying organic diseases (particularly IBD, colorectal cancer, and microscopic colitis) in patients with IBS-D and alarm features^Citation2 Can exclude mechanical obstruction in patients with IBS-C and alarm features^Citation2 Upper endoscopy with biopsies may be useful in detecting celiac disease or SIBO^Citation2	Expensive Low diagnostic yield in patients without alarm features^Citation3,Citation49 Normal findings not associated with improved HRQoL^Citation37

Abbreviations: CBC, complete blood count; TSH, thyroid-stimulating hormone; FOBT, fecal occult blood test; anti-tTG, antibodies to tissue transglutaminase; EMA, endomysial antibodies; AGA, antigliadin antibodies; IBS, irritable bowel syndrome; IBS-D, diarrhea-predominant IBS; IBS-M, mixed IBS; IBS-C, constipation-predominant IBS; IBD, inflammatory bowel disease; SIBO, small intestinal bacterial overgrowth; HRQoL, health-related quality of life.

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