18 Indeed, direct care costs are considerable, estimated to be between £90 and £316 per patient per year in the UK, 19 and close to $1 billion per annum in the USA. In preference, making an early and positive diagnosis of IBS following cogent use of limited investigations, together with a clear explanation, may help patients better accept the diagnosis and facilitate earlier treatment, 17 as well as minimise associated healthcare costs. 16 Although undertaking extensive testing may offer both the physician and the patient some reassurance, repeatedly normal investigations may instead make the patient feel that the cause of their symptoms remains elusive, or that organic disease has been ‘missed’. 14 15 Nevertheless, and due in part to the potential uncertainty that may surround the diagnosis, many physicians still consider IBS to be a diagnosis of exclusion. ![]() Guidelines for the management of IBS advocate that a diagnosis is made on clinical grounds, without the need for exhaustive investigations in an attempt to rule out all possible organic pathology. 13 This highlights the importance of implementing a logical and evidenced-based approach to investigation and diagnosis. 8 Consequently, patients with IBS account for between 10% and 25% of a gastroenterologist’s workload in the outpatient clinic. Up to 80% will consult in primary care, 10 11 the majority of whom will be managed in this setting, 12 but some will be referred for a specialist opinion. 7 This, in conjunction with other factors, 8–11 such as the severity and chronicity of symptoms and fear of underlying organic disease, make individuals with IBS likely to seek the advice of a doctor. Nonetheless, whatever uncertainties exist in our understanding of IBS, what is clear is that this disorder has a substantial impact on patients, many of whom report considerable impairment of quality of life as a consequence of their symptoms, 5 and face daily challenges with working 6 and socialising. 4 Although the identification of these potential pathophysiological mechanisms has yet to yield any useful diagnostic strategies for clinical practice, it does cast doubt on the concept that IBS is a purely functional condition. 3 The aetiology remains unclear, but a variety of factors have been implicated, including genetics, visceral hypersensitivity, disordered gastrointestinal motility, abnormalities of the brain–gut axis, and alterations in the gut microbiome. 1 Patients with IBS experience abdominal pain in association with a change in the frequency or form of their stools, and are subdivided according to their predominant stool form into IBS with diarrhoea (IBS-D), constipation or a mixed stool pattern. Irritable bowel syndrome (IBS) is a common chronic functional gastrointestinal disorder, with an estimated population prevalence of 10%, 1 which more commonly affects women 2 and younger individuals. There is no role for routine hydrogen breath tests for lactose malabsorption or small intestinal bacterial overgrowth. A 23-seleno-25-homotaurocholic acid (SeHCAT) scan should be considered in patients with IBS-D, a third of whom may actually have bile acid diarrhoea. Colonoscopy should be considered in any patient with alarm features for colorectal cancer, and in those whose clinical features are suggestive of microscopic colitis. Beyond this, the need for investigations should be made on a case-by-case basis, contingent on the reporting of known risk factors for organic pathology. ![]() Patients with diarrhoea should have a faecal calprotectin measured, and should proceed to colonoscopy to exclude inflammatory bowel disease (IBD) if this is positive. All patients should have coeliac serology tested, regardless of their predominant stool form. Routine blood tests in suspected IBS have low yield, but are an acceptable part of routine practice. Exhaustive investigation to exclude all organic pathology is unnecessary, and may be counterproductive. Making an early diagnosis, based on a clinical assessment of symptoms, while limiting use of investigations, are key tenets of this process. Consequently, there have been calls for the care of patients with IBS to be standardised, a process which aims to promote high-quality and high-value care. ![]() Many patients express disappointment over the lack of a patient-centred approach. However, there is variability in approaches to diagnosis and investigation between physicians, dependent on expertise. ![]() Irritable bowel syndrome (IBS) is a common functional gastrointestinal disorder which accounts for a substantial proportion of a gastroenterologist’s time in the outpatient clinic.
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