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Single Patient Based Medicine: Irritable Bowel Syndrome.
(Sergio Stagnaro)
Introduction. ................................................................................................................................. 1
Clinical symptomatology of Irritable Bowel Syndrome. ............................................................. 2
Differential Diagnosis. ................................................................................................................. 2
Biophysical Semeiotics of Irritable Bowel Syndrome. ................................................................ 3
Conclusion. .................................................................................................................................. 3
References. ................................................................................................................................... 4
Introduction.
K.B. Holten and A. Wetherington’s excellent article (1) stimulated me to write this paper
aiming to demomstrate the usefulness of Biophysical Semeiotics knowledge of doctors, in general,
and particularly general practitioners, all around the world, who first examine patients suffering
from abdominal pain and intestinal motility abnormalities, that must be properly and rapidly
diagnosed, particularly in the interest of patient’s life.
Diagnosing a patient who presents with abdominal pain and altered bowel habits can be
challenging. As a matter of fact, family physicians frequently see patients who have abdominal pain
and altered bowel habits. It is, therefore, a challenge to properly evaluate these patients and
differentiate between irritable bowel syndrome (IBS) and life-threatening illnesses of the
gastrointestinal tract.
In reality, although serious organic illnesses can cause these symptoms, irritable bowel
syndrome is commonly responsible. The above-cited authors, I sincerely thank once again, state that
it can be difficult to properly evaluate these patients without overusing diagnostic tests and
consultation. A practical approach for diagnosing irritable bowel syndrome is suggested, using the
Rome II criteria and the presence of alarm symptoms such as weight loss, gastrointestinal bleeding,
anemia, fever, or frequent nocturnal symptoms as starting points (1).
If there are no alarm symptoms and the Rome II criteria are not met, it is acceptable to
reevaluate the patient at a later date. If there are no alarm symptoms and the Rome II criteria are
met, the patient should be categorized on the basis of age: patients 50 years or younger can be
evaluated on the basis of predominant symptoms, i.e., constipation, diarrhea, or abdominal pain.
Patients older than 50 years should be fully evaluated and considered for gastroenterology referral.
If alarm symptoms are present, a full evaluation should be performed (and gastroenterology referral
considered), regardless of the patient's age.
From the above remarks, it is easy to understand that IBS is one of the most common
chronic gastrointestinal illnesses. IBS traditionally has been a diagnosis of exclusion, based on
history, physical examination, and a negative battery of diagnostic studies (2). There are no
structural or chemical markers for IBS (3). Diagnostic tests are frequently overused because
physicians are concerned about missing a life-threatening illness.
In addition, IBS is a real economic problem for every NHS around the world, and absenteism
resulting from IBS significantly affects the work force. Studies have shown that IBS affects 3 to 22
percent of persons worldwide (4). Symptoms are reported by 12 percent of Americans and are the
cause of 20 to 50 percent of referrals to gastroenterology clinics. Most people with IBS do not seek
medical care. Finally, one half of patients develop symptoms before 35 years of age, and 40 percent
of patients develop symptoms between 35 and 50 years of age. Onset in elderly persons is rare (1).
Clinical symptomatology of Irritable Bowel Syndrome.
The most common symptoms of IBS include a change in the appearance or frequency of
stools, and abdominal pain that is relieved by defecation. Other associated symptoms include
bloating, distention, mucus in the stool, urgency, and a feeling of incomplete evacuation.
Based on stool-habit alteration, three subgroups of IBS have been described three different
IBS types: constipation-predominant IBS, diarrhea-predominant IBS, and IBS with alternating
bowel habits (also known as pain-predominant) (5). Although these groupings are useful for
research purposes, in day-to-day practice, symptom patterns may vary. Associated with IBS we can
observe a loth of other disorders, such as anxiety, stress, social phobia, somatization disorders,
depression (including dysthymia), panic disorder, fibromyalgia, chronic fatigue syndrome,
temporomandibular joint syndrome, intestinal allergy, a.s.o.
However, these factors do not enlighten IBS pathogenesis, which is still unknown.
Differential Diagnosis.
Numerous illnesses, many of them really severe, share some of the same symptoms as IBS..
Therefore, a differential diagnosis for patients who present with abdominal pain and altered bowel
habits is important (6, 7). One must consider in particular inflammatory bowel disease, bacterial and
viral in origine, Crohn's disease or ulcerative colitis, celiac disease, constipating medications,
laxatives, malabsorption syndromes, pancreatic insufficiency, endocrine disorders (diabetes, hyperand hypo-thyroidism, Addison’s disease), psychiatric disorders, anxiety, depression, gastrointestinal
carcinoma.
Nowadays, no gold standard or marker for IBS exists and then a cost-effective diagnostic
approach that uses the fewest tests and invasive studies is most desirable. In my opinion, it is
desirable that doctor can clinically utilize very few examinations, which allow to recognize the
disease as well as exclude other severe disorders, causing often mortality. At the present, in
diagnosing and differential diagnosing IBS, doctor follows some guide lines and score systems,
among them “Rome II criteria”, but no one is 100% of cases sensitive or specific (2). In fact,
several scoring systems for diagnosing IBS have been proposed (1). As regards this point, we must
take intoaccount that it is necessary a period of 12 weeks, at least, (not necessarily consecutive), of
three of following symptoms: abdominal pain or discomfort that is relieved with defecation,
associated with a change in frequency of stools, associated with a change in appearance of stools. In
other words, the proper diagnosis is possible after 12 weeks after symptoms begin: really, a time to
long.
On the other hand, blood studies are expensive and almost in normal range in case of IBS,
ad colon endoscopy. In addition, abdominal ultrasonography is not needed in patients with IBS
because it can lead to overaggressive diagnosis and treatment of minor findings (8). The
sophysticated semeiotics, referred above, are necessary, because they can point to organic causes
for pain and altered bowel habits (e.g., inflammatory bowel disease, colorectal carcinoma,
metabolic causes). Most authors suggest that all symptomatic patients have a complete blood cell
count. Determination of the erythrocyte sedimentation rate, thyroid-stimulating hormone (TSH)
level, and electrolyte levels is useful in patients with constipation-predominant and diarrheapredominant symptoms. Fecal occult blood testing and the testing of stool for ova and parasites are
useful in patients with diarrhea. Lactose-malabsorption studies have limited value except in patients
with diarrhea-predominant symptoms. No psychometric screening tools have high enough
specificity or sensitivity to warrant their use for diagnostic purposes. In some cases, a psychosocial
evaluation is recommended (3).
Certainly, if alarm symptoms (weight loss, gastrointestinal bleeding, anemia, fever, or
frequent nocturnal symptoms) are present, a full evaluation should be performed, regardless of the
patient's age. These symproms, however, occur usually to late.
Biophysical Semeiotics of Irritable Bowel Syndrome.
To understand what follows, reader must obviously have a good knowledge of Biophysical
Semeiotics, illustrated in both this site HONCode 233736, www.semeioticabiofisica, and in its large
Bibliography articles.
When a patient is suffering from abdominal pain, first of all doctor has to gather accurately
his (her) history, which is precious diagnostic tool. The diagnostic iter, starts looking for numerous
biophysical semeiotics signs of inflammation: Rethiculo-Endothelial System Hyperfunction
Syndrome, finger-pulp diagram, evaluation of Acute Phase Proteins, a.s.o., as described in Practical
Applications (9, 10). At this points, ascertaining “Oncological Terrain” in a “quantitative” way (11),
localizing it precisely, is unavoidable (12). If all these data are absent, doctor is allowed to exclude
inflammatory intestinal disorders, and obviously colon cancer.
On the contrary, if the patient is involved by oncological terrain, in order to corroborate the
possible intestinal site of malignancy, doctor can perform an useful and easy biophysical-semeiotic
manoeuvre, stimulating intestinal trigger-points by means of abdominal wall muscles: the subject,
to be examined, must push as during defecation, “simulated defecation test”. In presence of colon
cancer, e.g., it appears at first gastric aspecific reflex and, then, tonic gastric contraction. (It is
necessary to exclude both appendicitis and diverticulitis).
In case of IBS, wherein inflammation and intestinal malignancy signs are absent
(oncological terrain can however be present), doctor has to assess intestinal peristalsis, so-called
colon “velocimetry”, that sometime results increased or decreased (NN = 30 sec.) in relation to the
subtype of IS (See in this web site: Glossary).
As I referred above, patient with IBS present psycho-somatic disorders, anxiety, depression,
which can be now-a-days be recongized at the bed side by the aid of Biophysical Semeiotics (13,
14, 15).
As regards the evaluation of endocrine situation, necessary to exclude some diseases which
can notoriously bring about intestinal alterations, similar to those of IBS, and, therefore, are
challinging the diagnosing procedure (thyroid dysfunction, diabetes mellitus, Addison’s disease), I
ask, in a friendly way, reader to consult my former articles (14, 17, 18, 20, 21).
Conclusion.
Single patient based medicine, as illustrated in this article, show particularly efficacious
effects in applying in the singular case general knowledge, obtained by means of meta-analysis
researches on very large populations.
Notoriously, the main difficulty of EBM is transfering in one patient all knowledge gathered
in a large number of patients, whose social, ethnic, and racial conditions are not always the same.
Statistical data, certainly precious and interesting, can only partially be useful when applied
on a particular subject, suffering from a well-defined disorder. For instance, the fact that colon
cancer involves preferentially, i.e., mainly, the ascending tract, is not significant for the doctor who
examines a patient with oncological terrain, presenting with the complete biophysical-semeiotic
phenomenology of descending colon cancer, but without any risk of cancer elsewhere in the same
viscera.
Consequently, from the above remarks, in to-day-practice SPBM and EBM must interact
each other, improving themselves, because from such as co-operation the possibility originates to
overcome weak points of the medicine based on large number, all authors agree with (22).
References.
1) Holten K.B., Wetherington A. Diagnosing the Patient with Abdominal Pain and Altered Bowel
Habits: Is It Irritable Bowel Syndrome? Am Fam Physician 2003; 67:2157-62.
2) Longstreth GF. Irritable bowel syndrome: diagnosis in the managed care era. Dig Dis Sci
1997;42: 1105-11.
3) Fass R, Longstreth GF, Pimentel M, Fullerton S, Russak SM, Chiou CF, et al. Evidence- and
consensus-based practice guidelines for the diagnosis of irritable bowel syndrome. Arch Intern Med
2001; 161:2081-8.
4) Locke GR 3d, Zinsmeister AR, Talley NJ, Fett SL, Melton LJ. Risk factors for irritable bowel
syndrome: role of analgesics and food sensitivities. Am J Gastroenterol 2000;95:157-65.
5) Whitehead WE. Patient subgroups in irritable bowel syndrome that can be defined by symptom
evaluation and physical examination. Am J Med 1999;107:33S-40S.
6) Dalton CB, Drossman DA. Diagnosis and treatment of irritable bowel syndrome. Am Fam
Physician 1997;55:875-80, 883-5.
7) Sanders DS, Carter MJ, Hurlstone DP, Pearce A, Ward AM, McAlindon ME, et al. Association
of adult coeliac disease with irritable bowel syndrome: a case-control study in patients fulfilling
ROME II criteria referred to secondary care. Lancet 2001;358:1504-8.
8) Francis CY, Duffy JN, Whorwell PJ, Martin DF. Does routine abdominal ultrasound enhance
diagnostic accuracy in irritable bowel syndrome? Am J Gastroenterol 1996;91:1348-50.
9) Stagnaro S., Il Ruolo della Percussione Ascoltata nella “difficile Diagnosi” di Appendicite. Biol.
Med. 8, 71, 1986.
10) Stagnaro-Neri M., Stagnaro S., Appendicite. Min. Med. 87, 183, 1996 (Pub-Med indexed for
Medline)
11) Stagnaro S. Il Terreno Oncologico. Contributo alla prevenzione primaria di tumori maligni.
http://digilander.libero.it/semeioticabiofisica/oncologico.htm.( volume in stampa).
12 Stagnaro S. Oncogenesi: il punto di vista semeiotico-biofisico.
http://digilander.libero.it/piazzettamedici/professione/professione.htm
13) Stagnaro-Neri M, Stagnaro S., Valutazione clinica percusso-ascoltatoria del sistema nervoso
vegetativo e del sistema renina-angiotensina, circolatorio e tessutale. Arch. Med. Int. XLIV, 3, 173178, 1992. (Infotrieve)
14) Stagnaro S., Stagnaro-Neri M. Semeiotica Biofisica: valutazione clinica del picco precoce della
secrezione insulinica di base e dopo stimolazione tiroidea, surrenalica, con glucagone endogeno e
dopo attivazione del sistema renina-angiotesina circolante e tessutale – Acta Med. Medit. 13, 99,
1997.
15) Stagnaro S. Bed-side diagnosing acute appendicitis and gastrointestinal diseases.
(17 July 2003) Gut.j.on line: http://gut.bmjjournals.com/cgi/eletters/52/5/770-a#100.
16) Stagnaro S. Depression, Anxiety and Psychosis. B C Medical Journal, Volume 43, Number 6,
page 321, July-August, 2001
17) Stagnaro S., Diet and Risk of Type 2 Diabetes. N Engl J Med. 2002 Jan 24;346(4):297-298.
letter [PubMed –indexed for MEDLINE].
18) Stagnaro S., Stagnaro-Neri M. Valutazione percusso-ascoltatoria del Diabete Mellito. Aspetti
teorici e pratici. Epat. 32, 131, 1986.
19) Stagnaro-Neri M., Stagnaro S., Il diagramma linfatico dell’arto superiore nella diagnosi clinica
percusso-ascoltatoria del diabete mellito. III Congr. Intern. Di Flebolinfologia. Ferrara-San Marino,
18-21 Settembre, 1991. Atti 21-11.
20) Stagnaro-Neri M., Stagnaro S., Sindrome di Reaven, classica e variante, in evoluzione
diabetica. Il ruolo della Carnitina nella prevenzione del diabete mellito. Il Cuore. 6, 617, 1991
(Pub-Med indexed for Medline)
21) Stagnaro-Neri M., Stagnaro S., Il Segno di Bilancini-Lucchi nella diagnosi clinica del diabete
mellito. The Pract. Ed. It. 176, 30.
22) Trisha G. Evidence Based Medicine. Le basi. Infomedica S.r.l. Sigma Tau. Pianezza (Torino)
1998.