From the Journals

IBS complaints differ with diarrhea versus constipation

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Providers should seek to manage symptoms with minimal adverse events

Irritable bowel syndrome (IBS) patients experience frequent symptoms of abdominal pain and changes in bowel function, often on a weekly basis.

Dr. Gregory S. Sayuk

Intuitively, these bowel disturbances translate into considerable emotional and social burdens. This study by Ballou and colleagues provides important insight into the impact of IBS on affected individuals. As with other studies, they found that IBS patients report decreased work productivity and greater absenteeism. The investigators also observed that symptoms affect the IBS subtypes (constipation- and diarrhea-predominant) differently. Interestingly, constipation-predominant IBS patients struggled more with internal and interpersonal issues (e.g., self-consciousness and sex avoidance), while diarrheal-predominant patients were more preoccupied by social and external concerns (e.g., bathroom availability, leaving the house).

Both IBS subtypes expressed a willingness to go to considerable lengths in a theoretical “trade-off” to obtain symptom relief. A remarkable percentage of patients were willing to forgo both primitive drives (sex in 40% of respondents) and modern conveniences (cellphones and Internet in more than 20% of respondents) in exchange for IBS relief.

In light of these findings, it is not surprising that previous surveys observed considerable IBS patient acceptance of treatments with higher risks of serious adverse events in return for better symptom control. In recent years, several novel therapies have emerged as effective options for the management of IBS. Of course, these newer IBS medications are more costly, and some have recognized rare, yet potentially serious adverse events. In balance, gastroenterology providers must recall the substantial effect of IBS symptoms on the well-being and daily functioning of the individual and account for this major burden when making IBS treatment recommendations.

Gregory S. Sayuk, MD, MPH, is an associate professor, department of medicine, division of gastroenterology, and department of psychiatry, and associate program director, gastroenterology training, Washington University in St. Louis; and a staff physician, John Cochran VA Medical Center, St. Louis. He has no relevant conflicts.



At least 50% of patients with irritable bowel syndrome (IBS) described their condition as “extremely bothersome” based on survey data from 3,254 individuals. However, differences in the nature of other symptoms among IBS subtypes, namely IBS with diarrhea (IBS-D) and IBS with constipation (IBS-C), have not been well studied, wrote Sarah Ballou, PhD, of Beth Israel Deaconess Medical Center, Boston, and colleagues.

Source: American Gastroenterological Association

In a study published in Clinical Gastroenterology and Hepatology, the researchers reviewed survey results from 1,587 individuals with IBS-D and 1,667 with IBS-C. The average age of the patients was 47 years, 81% were female, and 90% were white.

Approximately 84% of patients with IBS-C and 93% of those with IBS-D reported abdominal pain, the most common symptom in both groups. Overall, 36% of the 1,885 patients employed or in school reported decreased productivity in those settings.

IBS-C patients were significantly more likely to report that their symptoms caused them to avoid sex, feel self-conscious about their bodies, have trouble concentrating, and feel “not like myself,” compared with IBS-D patients (P less than .004 for all).

IBS-D patients were significantly more likely to report that their symptoms caused them to avoid traveling in general, avoid places without bathrooms, avoid leaving the house, and have trouble making plans, compared with IBS-C patients (P less than .004 for all).

The survey also asked respondents what they would give up for 1 month in exchange for 1 month of relief from IBS symptoms. Overall, approximately 60% said they would give up alcohol, 55% said they would give up caffeine, 40% would give up sex, 24.5% would give up their cell phones, and 21.5% would give up the internet, the researchers wrote.

The study findings were limited by several factors, including the absence of survey respondents with mixed-type IBS, the reliance on self-reports, and the potential for recall bias. Also, the study was not designed to assess the impact of other comorbidities and did not include non-IBS controls, the researchers noted.

However, the results suggest that patients with different IBS subtypes struggle differently in areas of daily function, which has implications for treatment, they wrote.

“This study highlights important differences between IBS-C and IBS-D, which could impact the development and refinement of mind-body therapies for IBS, with tailored treatment goals for each IBS subtype. For example, treatment tailored specifically for IBS-D may be more behaviorally focused (e.g., exposure to specific situations outside the home) while treatment for IBS-C may be more cognitively focused (e.g., evaluating self-esteem and beliefs about self and others) in addition to targeting the bowel dysfunction and pain,” they concluded.

The researchers had no financial conflicts to disclose.

SOURCE: Ballou S et al. Clin Gastroenterol Hepatol. 2019 Aug 13. doi: 10.1016/j.cgh.2019.08.016.

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