Do you get irritated when people say that someone’s abdominal pain is “just from anxiety”? What IS a FODMAP, anyways? Join our guest Hannibal Person who is trained in both psychiatry and pediatric gastroenterology as he describes his approach to diagnosing, explaining, and treating irritable bowel syndrome.
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Note: Most research in IBS is in adults, please apply accordingly in clinical practice. Studies have been cited accordingly and pediatric data was cited when available. More research needs to be done for IBS in general, and especially for our pediatric patients.
Old framework: Organic vs. functional as “diagnosis of exclusion”. This divide promotes stigma, and also overlooks the fact that these “functional disorders” have pathophysiologic underpinnings. Instead, call them “disorders of gut-brain interaction” (DGBIs).
The pathophysiology of IBS is complex and not fully understood, but involves visceral hypersensitivity to normal gut stretch and peristalsis (fMRI studies showing uptick of pain networks/emotional regulations); microbiome changes; sub-clinical inflammatory processes (study on injecting food allergen into colonic lining resulting on co-localization of mast cells).
Officially, the criteria for diagnosing IBS are the Rome IV criteria, outlined below:
The stool pattern can be mainly constipation, mainly diarrhea, or mixed/alternating – a patient can also have normal bowel movements in between.
However, while the official criteria are useful for standardizing research populations, they may lead to under-diagnosis and delay in treatment in clinical practice. Recognizing this, the Rome Foundation released modified clinical guidelines for use in practice.
In short, while the qualitative features of the Rome IV criteria must be met:
Expert pearl: Be aware of language barriers if using an interpreter. Some symptoms, like “bloating”, may not interpret well across languages and/or cultures, so symptoms may be missed.
Expert opinion: Like in all conditions, there exists significant racial inequities in the diagnosis and treatment of IBS.
What else, besides bowel habits, should you screen for?
IBS is not a diagnosis of exclusion – one could make the diagnosis with a history and physical exam. However, any of the following alarm symptoms should trigger a further workup for other GI conditions:
Currently, the ACG strongly recommends testing for Celiac in patients you suspect of having IBS. However, little evidence exists for pediatrics and our expert guest tends to not test in the absence of alarm symptoms and family history.
Expert practice: If your patient is having chronic diarrhea, even without alarm symptoms it would be reasonable to get a stool calprotectin, infectious studies, malabsorption if losing weight, and H. Pylori antigen if pertinent family or travel/residential history.
Expert opinion: For those with significant family histories of celiac, IBD, and other GI disorders, some basic workup can go a long way to reassure families. However, not all negative testing will provide similar reassurance.
Fun fact: A small, proof-of-concept study found that a device that records bowel sounds was accurate in predicting IBS.
General Goals of Treatment
Explaining IBS to Patient & Family
There are many, non-stigmatizing ways to explain the diagnosis and management of IBS to your patient and their family. Although there isn’t a one-size-fits-all model, our expert guest had some wise advice:
Expert practice: Start low, go slow. Before deciding to treat symptoms, elucidate stool pattern and rate of “switching” between constipation and diarrhea if applicable. This is helpful for directing treatment and prevents you from flipping the patient into the other bothersome stool pattern. A poop diary isn’t a bad idea either!
Expert pearl: A lot of kids with IBS are labeled as having “functional constipation”. But if you are effectively managing constipation and they still have pain, it’s time to put IBS on your differential.
Behavioral and Integrative Therapies
Listeners will learn a framework for the pathophysiology, diagnosis, and management of irritable bowel syndrome for optimal outpatient treatment.
After listening to this episode listeners will…
Dr. Person reports no relevant financial disclosures. The Cribsiders report no relevant financial disclosures.
Zhang AY, Person H, Masur S, Chiu C, Berk J. “#74 IBS: More Than A Gut Feeling”. The Cribsiders Pediatric Podcast. https:/www.thecribsiders.com/74/ 12/6/22
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