Abdominal Pain? Before Jumping to IBS…

It struck me, when talking to Dr Wang, just how much of this has to do with stretch. You have these muscle layers that are being stretched out, and that can be very irritating to certain people who are hypersensitive to that. It's one of the reasons they're so uncomfortable. So it makes sense to treat constipation aggressively — to decrease that stress and keep things moving along so that you don't have that kind of constant irritation. In primary care, we should be reasonably comfortable doing this.
https://www.medscape.com/viewarticle/1000228?src=soc_yt

-- TRANSCRIPT --
Matthew F. Watto, MD: Welcome back to The Curbsiders. I'm Dr Matthew Frank Watto, here with my great friend and America's primary care physician, Dr Paul Nelson Williams. We are about to drop some knowledge on irritable bowel syndrome (IBS) from our podcast with Dr Iris Wang.

Most people know that IBS is when people are having recurrent abdominal pain and a change in their stool; it can be diarrhea, constipation, or both. What kind of workup do we need to do for this? Most of the time in these disorders of gut-brain interaction (of which IBS is one), testing is going to be negative, and we expect it to be negative. But what testing should we do for a patient with IBS with diarrhea (IBS-D)?

Paul N. Williams, MD: If we're looking at the diarrhea-predominant type, you don't want to miss the obvious stuff first and jump right to the diagnosis. It's worthwhile to review the patient's medications to make sure there's no causative etiology — some sneaky metformin causing problems or what have you. You want to make sure they've had thyroid testing so that you're not missing that as a cause of diarrhea. Thinking about malabsorption, has the patient had previous gut surgery of some kind or a cholecystectomy? It's worth exploring possible causative etiologies before jumping right to IBS.

Dr Wang often tests for celiac disease with serology, and maybe with fecal calprotectin in the right patients, to see if this is potentially an inflammatory bowel disease. In patients who warrant it (for example, they are avid campers or have risk for C diff exposure), she will do more guided testing, but it's really a fairly broad initial workup in the absence of something pointing you in a specific direction. This is what we should all feel fairly comfortable doing in the first place.

Watto: Fortunately, you don't have to mess around with 48-hour stool collection for bile acids, fat, and things like that. Let the GI doctors do that. It's a pretty basic workup that you can definitely send off in primary care.

If the patient has the constipation type of IBS (IBS-C), it's even easier. You pretty much look for an obvious cause, like something going on metabolically or any medications that are causing constipation. If you don't find anything, really all you have to do is a trial of laxatives and make sure they're up to date with colon cancer screening. But otherwise, you don't have to do much. And if a trial of laxatives isn't successful, they might see GI and get motility testing such as anal manometry. But it's not really necessary for most people.

Dr Wang mentioned that she always asks about incomplete emptying and having to strain, because some of these people have dyssynergy of the muscles in their pelvis, and that can be worked on. And she recommends a Squatty Potty for them.

Williams: Right. And she's a big fan of pelvic physical therapy, which can help a lot of people.

Watto: One of the treatments for IBS that unfortunately is not widely available, but hopefully online versions will pop up that are good and evidence based, is gut-directed cognitive-behavioral therapy or gut-directed hypnotherapy. These actually have a number needed to treat as low as 4, which is just crazy. But they're going to be difficult to access.

In primary care, should we just start recommending the low-FODMAP diet? Is this a good thing to remain on for the rest of your life?

Williams: No. The point that Dr Wang made is that the low-FODMAP diet is a short-term thing. You don't have patients on this diet endlessly. Six weeks is the number that she gave us, and then you start reintroducing food back into the diet. That's a key element, because if you do not do that, then it can lead to micronutrient deficiencies, which are bad, or the patient can develop food intolerances as a result of the diet, which are even worse. You've just exacerbated the problem. So the low-FODMAP diet is not meant to be permanent. It is a way to help figure out what's bothering someone and what's not, and make sure that you are down the right diagnostic path.

Watto: In primary care, why is it important for us? Let's say the patient has IBS-C. Why is it important for us to treat their constipation? How does that help the bowel?

Transcript in its entirety can be found by clicking here: https://www.medscape.com/viewarticle/1000228?src=soc_yt

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