Irritable Bowel Syndrome: The Most Common Presentation, Severity Ranking and Therapeutic Regimens among Patients Attending Outpatient

www.jkmc.uobaghdad.edu.iq 10 Al-kindy College Medical Journal 2020:16 No.1 ABSTRACT Background: Irritable bowel syndrome (IBS) is one of the most common GI disorders in people under 50 years of age. Objective: To Formulate an overview about demographics of IBS and patterns of presentation, to determine IBS patients severity ranking, and to recognize the main regimens with their patient satisfaction. Methods: This is a cross sectional clinical study that is conducted in Outpatient Consultant Internal Medicine Clinic in Al-Kindy Teaching Hospital from 11/12/2017 to 24/12/2017. The patients suffering from IBS are diagnosed by a consultant according to the symptom-based Rome criteria for functional GI disorders, by implementing a questionnaire collecting thorough information. 77 cases of IBS patients were collected (24 male and 53 female). Results: This study revealed that majority of patients were female (68.8%). Most of the patients were married, employees and housewives, aged between (20-30 yrs). Most patients use anxiolytics, muscle relaxants and proton pump inhibitor. There is a high IBS prevalence among low educational level (high school graduates and non-school graduates). Most patients in our study had constipation. Aggravating factors Psychological factors (stress) are intrinsically associated with IBS and symptoms in a large percentage of patients. Antispasmodics usage in our study show high effectiveness for IBS patients especially those with crampy abdominal pain and diarrhea. Conclusions: Diagnosing and managing IBS can be a big challenge since many drugs used to reduce symptoms and severity, but also, they could be unnecessary medication that could aggravate bowel symptoms and have adverse effects on the long term.

prevalence among low educational level (high school graduates and non-school graduates). Most patients in our study had constipation. Aggravating factors Psychological factors (stress) are intrinsically associated with IBS and symptoms in a large percentage of patients. Antispasmodics usage in our study show high effectiveness for IBS patients especially those with crampy abdominal pain and diarrhea. Conclusions: Diagnosing and managing IBS can be a big challenge since many drugs used to reduce symptoms and severity, but also, they could be unnecessary medication that could aggravate bowel symptoms and have adverse effects on the long term. Keywords: IBS, diarrhea, constipation, anxiolytic, antispasmodics.

INTRODUCTION
Irritable bowel syndrome (IBS) is an episodic gastrointestinal (GI) disorder that is affecting a significant proportion of population, with a calculated approximate prevalence of 11.2% (1) . IBS has a strong impact on health-related quality of life, with its consequences in reduced work productivity, increased absenteeism and elevated health care use and costs. The cardinal symptoms of IBS include bloating and abdominal pain/discomfort associated with changes in bowel habits (2). Several risk factors for IBS have been identified including: Female gender, psychological problems, stress, food intolerance, bacterial overgrowth of the small intestine. Incidence and epidemiology IBS is common with a prevalence of 14% to 24% in females and 5% to 19% in males. Most individuals meeting diagnostic criteria for IBS will not seek treatment (3) . However, it constitutes 12% of visits to primary care physicians and 28% of visits to gastroenterologist.
Data documented between 2.4 and 3.5 million yearly visits to physicians by patients with IBS and more than 2.2 million medications prescribed. Rates were highest among those aged 30-50 years (4) . Recent epidemiological studies from Middle East countries demonstrated rise in the burden of IBS in the Arab world (5) . In Iraq, IBS is one of the most common gastro-intestinal disorders with prevalence estimated between 10% and 20% (6).

Pathophysiology:
is complex and found to be due to combination of several factors (7)

Clinical diagnosis
It depends on complete medical history, physical exam and tests to rule out other conditions and specific diagnostic criteria to IBS which is Rome III criteria (8) Rome criteria III: These criteria state that in order for a diagnosis of IBS to be given, patients must satisfy the following: Recurrent abdominal pain or discomfort at least once/week, on average, in the past 3 months with onset at least 6 months previously of recurrent abdominal pain or discomfort associated with 2 or more of the following: (1) It is relieved with defecation.
(2) Onset is associated with a change in frequency of stool. (3) Onset associated with a change in form (appearance) of stool. Diagnostics tests to exclude other pathologies (9) (1) .

Pharmacologic management:
Treatment of IBS is based on the main symptoms of the disease such as diarrhoea, constipation, abdominal pain or bloating. Determination of disease severity and the patient's major symptoms are deemed as being the main goals of treatment (10) . The aim of the study: Satisfaction with drug therapy (using IBS severity score: Figure 1) (11) :Includes the following questions with the answers ranking from: None, not very severe, quite severe, severe, very severe ( with a relevant score for each question ranging from 0-100).

DISCUSSION
Regarding the sex distribution of patients, there was female predominance, this predominance goes with international epidemiological studies (5) . Several studies have reported that higher prevalence in women is related with biobehavioural stress response, sex-related differences in psychosocial factor, autonomic responses, gender role, hormonal factors because hormones rise and fall throughout the menstrual cycle (12) . Regarding the age distribution, the highest prevalence of IBS was recorded in the (20-30) years age group. This finding is similar to a study from New Zealand which found that 50% of patients with IBS report having first symptoms before age of 35 years, this may be due to high anxiety among this age group, workload, and among females, estrogen therapy before or after menopause also play a role in this age group (13) . There is a high IBS prevalence among low educational level (high school graduates and non-school graduates). The finding is supported by the theory that lower education level and income is associated with poorer health care outcomes, lower overall quality of life, and increased life stressors, and this is similar to findings from a study in U.S (14) . In respect to the marital status, most of the patients were married. This is due to recent conflict circumstances in our country and the greater responsibilities of marriage in such difficult lifestyle which may precipitate psychosocial stress that predispose and/or exacerbate IBS. This finding is similar to that of Patrick (15) . Most patients were housewives and employees. This could be attributed to that an employee with the stress of his work and a housewife with the burden of her home responsibilities, also since it is hard nowadays to find a job, they are under stress because of unemployment stress at home. These results coincide with that of Toner, et al who found that psychosocial stress are important triggers for symptoms of IBS (16) . Considering past medical history, most of our sample had no medical history and also high percentages of patients with anxiety. These results are in agreement with that of Labus, Jennifer S., et al (17) , who found that anxiety is the key explanatory variable of IBS diagnostic status. Most patients in our study had constipation. This differs from a study in China in which the most common type was diarrhea 66.3%, then constipation 14.7% (18) . In our society, the predominance of constipation may be due to: dietary choices such as insufficient dietary fiber, or behavioural causes such as decreased physical activity, inadequate fluid intake, side effects of medications such as tricyclic

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antidepressant ,other medical condition such as hypothyroidism and obstruction by colorectal cancer, and also may be due to high weather temperature and dehydration, (19) . Our result also showed that (55.84%) of patients had a family history of IBS and this is supported by a previous study (20) . Aggravating factors: Psychological factors (stress) are intrinsically associated with IBS and symptoms in a large percentage of patients. Two studies have explored the relationship between IBS severity and psychosocial factors. In the study by Drossman et al this study agrees with ours showing the stress is highly attributed to severity (21) . Relieving factors in the present study, we found that drugs are superior to other remedies because patients seek fastest way for symptomatic relieve. Although a dietary control is also high but still drug is superior because some patients may not follow a balanced IBS suitable diet. Still a great number of patients follow some dietary control due to self-education after repeated attacks of IBS to avoid some kinds of food as spicy, gluten containing and even milk sometimes, also others seek for food with high fibers as vegetables and fruits especially if they have constipation predominant IBS (22) . Treatment: Anxiolytics are most commonly used for IBS attacks (27.27%) followed by proton pump inhibitors (PPI) (22.07%). Proton pump inhibitors (PPI) usage is an example of wrong usage by taking it without a prescription. Patients think that pain of IBS is the same as gastric or duodenal ulcer pain which reflects patients education level that is explored in our study. Some doctors may prescribe it because some IBS patient may have concurrent ulcer so will give it in a combination with other drugs and that's why some patients may be satisfied with PPI or antacids, although some research shows adverse effects in long term usage (increased risk of infection , reduced intestinal absorption of vitamins, minerals and renal damage) (23) .
Antimicrobial drugs may be used in IBS patients as intestinal bacterial overgrowth is one of the pathophysiological causes of IBS. It is especially beneficial for those with diarrhoea and bloating. Patients still use the antimicrobials as treatment despite the risk of emergence of opportunistic bacterial infections and bacterial resistance (24) . Antispasmodics usage in our study show high effectiveness for IBS patients especially those with crampy abdominal pain and diarrhoea but the most important limitation is the anticholinergic properties of these agents (25) . Although antispasmodics are widely used as shown also in the present study, some researches show that herbal remedies have effect that is superior to antispasmodics, this was shown in a study where treatment with Anthem graveolens show significant P≤0.05 improvement in total score percent 78.13%, compared to mebeverine 53.13% (26) . Muscle relaxants also show high usage (19.48%) in the present study. This is supported by meta-analysis by Jailwala et al. which confirms the efficacy of muscle relaxants in the treatment of IBS. These drugs showed significant efficacy on the global assessment despite a high placebo effect (38% global improvement) (23) . There is also high usage of laxatives (11.68%) as they are helpful to control bowel motion and management of constipation. Regarding patient's satisfaction in the present study, most patients are satisfied as they have IBS from relatively long time and now they learnt how to live with such pain, or maybe they have mild type that doesn't affect their daily life performance as it is mild pain and that can be managed by usage of drugs. Those who are not satisfied maybe they don't take their medication regularly or they use drugs without medical prescription also their stressful life events may play a role. When severity is "mild," patients have lowintensity infrequent symptoms and good health-related quality of life and may not seek health care, and epidemiological studies of individuals with mild IBS indicate that many have never been to a physician (27) . When severity is "moderate," there is more persistent and discomforting symptoms with some impaired health-related quality of life, reduced socializing, and some work absenteeism. Health-care visits occur, often to primary care physicians with perhaps occasional referrals to GI specialists. When IBS is "severe," the symptoms are more frequent, even persistent, and of greater intensity, and associated with marked function impairment, psychosocial comorbidities, and health-care referrals to specialists (28) . In conclusion: Diagnosing and managing IBS can be challenging due to the lack of a definitive diagnostic marker and effective treatment options. Data about the natural history of IBS is quite sparse. We believe that the scoring system is a very robust way of monitoring the severity of IBS.