Abstract
Abbreviations and Acronyms:
DD (defecatory disorder), GI (gastrointestinal), 5-HT (5-hydroxytryptamine), IBS (irritable bowel syndrome), NBS (narcotic bowel syndrome), OBD (opioid bowel dysfunction), OIC (opioid-induced constipation), SNRI (serotonin and norepinephrine reuptake inhibitor), SSRI (selective serotonin reuptake inhibitor), TCA (tricyclic antidepressant)- 1.Read the activity.
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Methods
Epidemiology and Natural Course
Relevant Anatomy, Physiology, and Pathophysiology
Clinically Oriented Introduction to GI Motor and Sensory Functions

Pathogenesis of Symptoms
Luminal Irritants
Increased Visceral Sensitivity
Normal and Disordered GI Motility
Hormonal and Other Chemical Mediators
Abdominal Wall Accommodation
Psychosocial Factors
Clinical Features
Characteristics of Pain, Physical Examination, and Associated Conditions
Other Conditions
Musculoskeletal Abdominal Pain
Opioid Bowel Dysfunction, Opioid-Induced Constipation, and Narcotic Bowel Syndrome
Structural Diseases
Diagnostic Testing

Management
Establishing an Effective Patient-Physician Relationship
Empathy
Goal | Prefer | Avoid |
---|---|---|
Express empathy | Acknowledge patient suffering (eg, “I am sorry you feel this way…I can see that the pain has really affected your life. I will do my best to help you.”) | Dismissing symptoms (eg, “There is nothing wrong with you.”) |
Assess the patient's insight into the functional nature of the pain | Ask open-ended questions (eg, “Can you tell me what you think is causing your symptoms?” or “Tell me about what concerns you the most about your symptoms.”) | Closed-ended questions (eg, “Do you think your pain is caused by eating?”) |
Understand the patient's expectation from the physician | Ask open-ended questions (eg, “Tell me a little about what you were expecting from this consultation” or “I see that you have been suffering from pain for many years. Could you tell me a little bit about what made you come to see me today?”) | Judgmental statements (eg, “I am not sure I can help you. You have been to so many doctors already.”) |
Understand the patient's expectations from treatment(s) | Ask probing, open-ended questions (eg, “If I asked you what would be a reasonably tolerable pain level that we can try to achieve, what would you say?”) | Imposing a treatment plan (eg, “My plan is to refer you to the psychiatrist and the pain specialist.”) |
Assess the patient's understanding of education provided by the physician | “I provided you with quite a bit of information today and want to make sure you understood what I said. Can you tell me what you have understood so far?” | Unilateral flow of information (eg, “I hope you understood all the things we discussed today and implement the suggestions I gave you.”) |
Help the patient take responsibility for the illness | Suggest that the patient keep a diary of symptoms for 3-4 wk | Prescribing treatments in which the patient is a passive recipient |
Education
Helping the Patient Take Responsibility
Designing a Treatment Strategy on the Basis of Severity of Symptoms
Dietary Measures
Treatment | NNT (95% CI) | Benefits and suggestions for use |
---|---|---|
Over-the-counter agents | ||
Fiber: psyllium | 4.5, NA 45 , | Begin with low dose and increase gradually. Effects are not as pronounced as for laxatives and manifest over time |
Laxatives: polyethylene glycol | NA, 3 (2-4) 45 , | More evidence for CC than IBS-C. Improved bowel symptoms but not abdominal pain in IBS-C 57 |
Antidiarrheals: loperamide | NA | Beneficial for diarrhea, but not abdominal pain in IBS-D |
Probiotics | 7 (4-12.5) 58 | Studies used different species, strains, preparations, and doses in various patient populations; therefore, results are challenging to interpret. Possibly beneficial for bloating and flatulence |
Antispasmodics: peppermint oil | 3 (2-4) 58 | Improves abdominal pain and global symptom relief |
Prescription medications | ||
Antidepressants: TCAs, SSRIs, and SNRIs | 4 (3-6) 58 | Use TCAs for IBS-D and SSRIs for IBS-C |
Linaclotide | 7 (5-8), 6 (5-8) 59 , 60 , 61 | Improves abdominal pain, bloating, and global IBS symptoms in IBS-C |
Lubiprostone | 13, 4 (3-7) 45 | Improves abdominal bloating, discomfort, constipation severity in opioid-induced constipation 62 Spierings EL, Rauck R, Brewer R, Marcuard S, Vallejo R. Long-term safety and efficacy of lubiprostone in opioid-induced constipation in patients with chronic noncancer pain [published online ahead of print August 29, 2015]. Pain Pract doi:10.1111/papr.12347. |
Prucalopride | NA, 6 (5-9) 45 | Not approved for use in the United States |
Antibiotics: rifaximin | 9 (6-12.5) 58 | Improves global symptoms, bloating, and abdominal pain in IBS |
Clonidine | NA 63 | Improves bowel symptoms in IBS-D |
Other therapies | ||
Psychological and behavioral therapies | 4 (35) 64 | Cognitive behavioral therapy, hypnotherapy, dynamic psychotherapy, relaxation training, and multicomponent psychological therapy all improved global symptoms in IBS |
Pharmacotherapy for Symptoms
Visceral Pain
Constipation
Diarrhea
Abdominal Wall Pain
Narcotic Bowel Syndrome
Nausea and Vomiting
Psychological and Behavioral Interventions
Multidisciplinary Pain Treatment Centers
Conclusion
Supplemental Online Material
References
- Functional gastrointestinal disorders: history, pathophysiology, clinical features and Rome IV.Gastroenterology. 2016; 150: 1262-1279
- The epidemiology of irritable bowel syndrome in North America: a systematic review.Am J Gastroenterol. 2002; 97: 1910-1915
- Functional dyspepsia.N Engl J Med. 2015; 373: 1853-1863
- Functional abdominal pain syndrome.Gastroenterology. 2006; 130: 1492-1497
- Incidence of a clinical diagnosis of the irritable bowel syndrome in a United States population.Aliment Pharmacol Ther. 2004; 19: 1025-1031
- Overlap of gastrointestinal symptom complexes in a US community.Neurogastroenterol Motil. 2005; 17: 29-34
- Systemic review: natural history of irritable bowel syndrome.Aliment Pharmacol Ther. 2004; 19: 861-870
- Natural history of functional gastrointestinal disorders: a 12-year longitudinal population-based study.Gastroenterology. 2007; 133: 799-807
- Change over time of bowel habit in irritable bowel syndrome: a prospective, observational, 1-year follow-up study (RITMO study).Aliment Pharmacol Ther. 2007; 25: 323-332
- An update on post-infectious irritable bowel syndrome: role of genetics, immune activation, serotonin and altered microbiome.J Neurogastroenterol Motil. 2012; 18: 258-268
- Integrated upper gastrointestinal response to food intake.Gastroenterology. 2006; 131: 640-658
- Characteristics of vagal esophageal tension-sensitive afferent fibers in the opossum.J Neurophysiol. 1989; 61: 1001-1010
- Mechanisms and management of functional abdominal pain.J R Soc Med. 2014; 107: 347-354
- Peripheral mechanisms in irritable bowel syndrome.N Engl J Med. 2013; 368: 578-579
- The proximal colonic motor response to rectal mechanical and chemical stimulation.Am J Physiol Gastrointest Liver Physiol. 2002; 282: G443-G449
- Principles and clinical implications of the brain-gut-enteric microbiota axis.Nat Rev Gastroenterol Hepatol. 2009; 6: 306-314
- Fibromyalgia and Related Conditions.Mayo Clin Proc. 2015; 90: 680-692
- American Gastroenterological Association technical review on constipation.Gastroenterology. 2013; 144: 218-238
- Serotonin signalling in the gut—functions, dysfunctions and therapeutic targets.Nat Rev Gastroenterol Hepatol. 2013; 10 ([published correction appears in Nat Rev Gastroenterol Hepatol. 2013;10(10):564]): 473-486
- Abdominal accommodation induced by meal ingestion: differential responses to gastric and colonic volume loads.Neurogastroenterol Motil. 2013; 25 (339-e253)
- Abdominal distention results from caudo-ventral redistribution of contents.Gastroenterology. 2009; 136: 1544-1551
- Abdominothoracic mechanisms of functional abdominal distension and correction by biofeedback.Gastroenterology. 2015; 148: 732-739
- Early life risk factors that contribute to irritable bowel syndrome in adults: a systematic review.Am J Gastroenterol. 2008; 103 (quiz 775): 765-774
- Psychosocial distress and somatic symptoms in community subjects with irritable bowel syndrome: a psychological component is the rule.Am J Gastroenterol. 2009; 104: 1772-1779
- Abuse, trauma, and GI illness: is there a link?.Am J Gastroenterol. 2011; 106: 14-25
- The potential role of behavioral therapies in the management of centrally mediated abdominal pain.Neurogastroenterol Motil. 2015; 27: 313-323
- Review article: the functional abdominal pain syndrome.Aliment Pharmacol Ther. 2011; 33: 514-524
- Irritable bowel syndrome: a clinical review.JAMA. 2015; 313: 949-958
- AGA technical review on irritable bowel syndrome.Gastroenterology. 2002; 123: 2108-2131
- Physical and emotional functioning of adult patients with chronic abdominal pain: comparison with patients with chronic back pain.J Pain. 2005; 6: 75-83
- Health-related quality of life and health care costs in severe, refractory irritable bowel syndrome.Ann Intern Med. 2001; 134: 860-868
- Disease management produces limited quality-of-life improvements in patients with congestive heart failure: evidence from a randomized trial in community-dwelling patients.Am J Manag Care. 2005; 11: 701-713
- Health-related quality of life is related to COPD disease severity.Health Qual Life Outcomes. 2005; 3: 56
- Treating depressed primary care patients improves their physical, mental, and social functioning.Arch Intern Med. 1997; 157: 1113-1120
- Translation, validation, and norming of the Dutch language version of the SF-36 Health Survey in community and chronic disease populations.J Clin Epidemiol. 1998; 51: 1055-1068
- Chronic abdominal wall pain: clinical features, health care costs, and long-term outcome.Clin Gastroenterol Hepatol. 2004; 2: 395-399
- Chronic abdominal wall pain. Diagnostic validity and costs.Dig Dis Sci. 1994; 39: 1935-1941
- Is abdominal wall tenderness a useful sign in the diagnosis of non-specific abdominal pain?.Ann R Coll Surg Engl. 1988; 70: 233-234
- Diagnosis and treatment of narcotic bowel syndrome.Nat Rev Gastroenterol Hepatol. 2014; 11: 410-418
- Evidence against routine testing of patients with functional gastrointestinal disorders for celiac disease: a population-based study.Clin Gastroenterol Hepatol. 2015; 13: 1937-1943
- The yield of colonoscopy in patients with non-constipated irritable bowel syndrome: results from a prospective, controlled US trial.Am J Gastroenterol. 2010; 105: 859-865
- Microscopic colitis or functional bowel disease with diarrhea: a French prospective multicenter study.Am J Gastroenterol. 2014; 109: 1461-1470
- Irritable bowel syndrome and risk of colorectal cancer: a Danish nationwide cohort study.Br J Cancer. 2011; 104: 1202-1206
- Association between irritable bowel syndrome and colorectal cancer: a nationwide population-based study.Eur J Intern Med. 2014; 25: 82-86
- American Gastroenterological Association medical position statement on constipation.Gastroenterology. 2013; 144: 211-217
- ACG clinical guideline: management of benign anorectal disorders.Am J Gastroenterol. 2014; 109 (quiz 1058): 1141-1157
- Epidemiology and prevention of postsurgical adhesions revisited.Ann Surg. 2016; 263: 12-19
- Clinical practice: hereditary angioedema.N Engl J Med. 2008; 359: 1027-1036
- Clinically important features of porphyrin and heme metabolism and the porphyrias.Metabolites. 2014; 4: 977-1006
- Patients with chronic pelvic pain: endometriosis or interstitial cystitis/painful bladder syndrome?.JSLS. 2007; 11: 182-189
- Functional abdominal pain syndrome.Clin Gastroenterol Hepatol. 2004; 2: 353-365
- A comparison of a short nurse-based and a long multidisciplinary version of structured patient education in irritable bowel syndrome.Eur J Gastroenterol Hepatol. 2012; 24: 950-957
- Structured patient education is superior to written information in the management of patients with irritable bowel syndrome: a randomized controlled study.Eur J Gastroenterol Hepatol. 2010; 22: 420-428
- New and emerging treatment options for irritable bowel syndrome.Gastroenterol Hepatol (N Y). 2015; 11: 1-19
- Diets that differ in their FODMAP content alter the colonic luminal microenvironment.Gut. 2015; 64: 93-100
- Diet low in FODMAPs reduces symptoms of irritable bowel syndrome as well as traditional dietary advice: a randomized controlled trial.Gastroenterology. 2015; 149: 1399-1407.e1392
- Randomized clinical trial: macrogol/PEG 3350 plus electrolytes for treatment of patients with constipation associated with irritable bowel syndrome.Am J Gastroenterol. 2013; 108: 1508-1515
- American College of Gastroenterology monograph on the management of irritable bowel syndrome and chronic idiopathic constipation.Am J Gastroenterol. 2014; 109 (quiz S27): S2-S26
- AGA practice guideline on constipation: technical review.Gastroenterology. 2013; 144: 218-238
- Effects of linaclotide in patients with irritable bowel syndrome with constipation or chronic constipation: a meta-analysis.Clin Gastroenterol Hepatol. 2013; 11 (quiz e1068): 1084-1092.e1083
- Effect of linaclotide in irritable bowel syndrome with constipation (IBS-C): a systematic review and meta-analysis.Neurogastroenterol Motil. 2014; 26: 499-509
Spierings EL, Rauck R, Brewer R, Marcuard S, Vallejo R. Long-term safety and efficacy of lubiprostone in opioid-induced constipation in patients with chronic noncancer pain [published online ahead of print August 29, 2015]. Pain Pract doi:10.1111/papr.12347.
- A randomized, controlled exploratory study of clonidine in diarrhea-predominant irritable bowel syndrome.Clin Gastroenterol Hepatol. 2003; 1: 111-121
- Efficacy of antidepressants and psychological therapies in irritable bowel syndrome: systematic review and meta-analysis.Gut. 2009; 58: 367-378
- A randomized controlled trial of a probiotic, VSL#3, on gut transit and symptoms in diarrhoea-predominant irritable bowel syndrome.Aliment Pharmacol Ther. 2003; 17: 895-904
- A randomized controlled trial of a probiotic combination VSL# 3 and placebo in irritable bowel syndrome with bloating.Neurogastroenterol Motil. 2005; 17: 687-696
- Lactobacillus and bifidobacterium in irritable bowel syndrome: symptom responses and relationship to cytokine profiles.Gastroenterology. 2005; 128: 541-551
- Centrally targeted pharmacotherapy for chronic abdominal pain.Neurogastroenterol Motil. 2015; 27: 455-467
- Bulking agents, antispasmodics and antidepressants for the treatment of irritable bowel syndrome.Cochrane Database Syst Rev. 2011; : CD003460
- Cognitive-behavioral therapy versus education and desipramine versus placebo for moderate to severe functional bowel disorders.Gastroenterology. 2003; 125: 19-31
- Not all side effects associated with tricyclic antidepressant therapy are true side effects.Clin Gastroenterol Hepatol. 2009; 7: 446-451
- Selective effects of serotonergic psychoactive agents on gastrointestinal functions in health.Am J Physiol Gastrointest Liver Physiol. 2003; 284: G130-G137
- Duloxetine for treating painful neuropathy, chronic pain or fibromyalgia.Cochrane Database Syst Rev. 2014; : CD007115
- Effect of linaclotide on severe abdominal symptoms in patients with irritable bowel syndrome with constipation.Clin Gastroenterol Hepatol. 2014; 12: 616-623
- Current and emerging drug options in the treatment of diarrhea predominant irritable bowel syndrome.Expert Opin Pharmacother. 2015; 16: 2781-2792
- Increased colonic bile acid exposure: a relevant factor for symptoms and treatment in IBS.Gut. 2015; 64: 84-92
- Eluxadoline for irritable bowel syndrome with diarrhea.N Engl J Med. 2016; 374: 242-253
- Adrenergic modulation of human colonic motor and sensory function.Am J Physiol. 1997; 273: G997-G1006
- Randomized clinical trial of trigger point infiltration with lidocaine to diagnose anterior cutaneous nerve entrapment syndrome.Br J Surg. 2013; 100: 217-221
- Early experience with lidocaine patch for postoperative pain control after laparoscopic ventral hernia repair.Int J Surg. 2009; 7: 36-38
- The narcotic bowel syndrome: clinical features, pathophysiology, and management.Clin Gastroenterol Hepatol. 2007; 5 (quiz 1121-1122): 1126-1139
- Tapering long-term opioid therapy in chronic noncancer pain: evidence and recommendations for everyday practice.Mayo Clin Proc. 2015; 90: 828-842
- Self-administered cognitive behavior therapy for moderate to severe irritable bowel syndrome: clinical efficacy, tolerability, feasibility.Clin Gastroenterol Hepatol. 2008; 6: 899-906
- Short-term and long-term efficacy of psychological therapies for irritable bowel syndrome: a systematic review and meta-analysis.Clin Gastroenterol Hepatol. 2016; 14: 937-947
- Diaphragmatic breathing for rumination syndrome: efficacy and mechanisms of action.Neurogastroenterol Motil. 2016; 28: 384-391
- Teaching diaphragmatic breathing for rumination syndrome.Am J Gastroenterol. 2006; 101: 2449-2452
- A rehabilitation approach to chronic pain in rheumatologic practice.Curr Opin Rheumatol. 1996; 8: 163-168
- Chronic noncancer pain rehabilitation with opioid withdrawal: comparison of treatment outcomes based on opioid use status at admission.Mayo Clin Proc. 2004; 79: 759-768
Article Info
Footnotes
Grant Support: The work was supported in part by USPHS NIH Grant R01 DK78924 from the National Institutes of Health .
Potential Competing Interests: Dr Bharucha has received personal fees from Allergan Inc, Johnson & Johnson Inc, Medspira, Ironwood Pharmaceuticals, Inc., GI Care Pharma, the National Center for Pelvic Pain Research, Salix, Macmillan Medical Communications, and FORUM Pharmaceuticals, outside the submitted work. In addition, Dr Bharucha has a patent on the anorectal manometry device, with royalties paid to Medspira, and a pending patent on the anorectal manometry probe fixation device licensed to Medtronic.
Individual reprints of this article and a bound reprint of the entire Symposium on Pain Medicine will be available for purchase from our website www.mayoclinicproceedings.org.
The Symposium on Pain Medicine will continue in an upcoming issue.
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