IRRITABLE BOWEL SYNDROME (IBS)

1) DEFINITION
• Irritable bowel syndrome (IBS) is a disorder of altered intestinal motility in which the
colon does not contract in a normal pattern.
• Irritable bowel syndrome (IBS) or functional bowel syndrome is a disorder of the large
bowel that results in altered bowel habits, abdominal pain and absence of structural
of biochemical abnormalities.
• Irritable bowel syndrome (IBS) is a symptom complex characterized by intermittent
and recurrent abdominal pain and stool pattern irregularities.
• Rarely does IBS required hospitalization. It is classified as IBS with diarrhea, IBS with
constipation, and IBS with mixed diarrhea and constipation.

2) PATOPHYSIOLOGY

Stress, psychologic factors, prior gastroenteritis, and specific food intolerances.

The abdominal pain or discomfort associated with IBS is most likely due to increased
visceral sensitivity

That is, the presence of stool or gas in the GI tract stimulates visceral fibres, which results in
perception of discomfort or pain.

Several neurochemicals, including serotonin, are likely involved in bowel symptoms of

diarrhea, constipation, and pain sensitivity.
3) CLINICAL MANIFESTATION
• Abdominal distension,
• Excessive flatulence,
• Bloating,
• A continual defecation urge,
• Constipation
• Depression
• Anxiety
• Palpitation

GENDER DIFFERENCES IN IBS

MEN WOMEN
• More men report manifestations • More women report manifestations of
of diarrhea. constipation.
• Less likely to admit to symptoms or • Affects women 2-2.5 times as often as
seek help for them than women. men.
• More women report extraintestinal
manifestations(e.g.migraine headache,
insomnia, fibromyalgia).
• Alosetron (Lotronex) (antidiarrheal) and
tegaserod (Zelnorm) (anticonstipation)
are approved for treating IBS only in
women.

4) DIAGNOSTIC TEST
1) Biopsy : to rule out other disorder not helpful in diagnosing IBS
2) Stool test for guaiac : To rule out inflammatory bowel diseases and malignancy
3) Stool stains : TO rule out motile amebic trophozoites, leukocytes and mucus
4) Stool cultures : To rule out ova and parasites, specialy giardia
5) Complete blood count : To rule out anemia and inflammation
6) Differential blood cell count (eosinophilia) : To rule out paracytosis, cytosis (suggest
tuberculosis) and vacuolated cells ( suggest inflammation)
 7) Three – day trial on lactose – free diet, lactose tolerance test, or breath hydrogen
test. To rule out lactose insufiency in patients with distantion and bloating or diarrhea.
8) Double – contrast barrium anema : exaggerated housetral contraction or absence or
houstration, narrow lumen with pellet stones lumen easily dilated, rule out colon
cancer polyps diver ticulosis
9) Cholecystogram or ultrosound graphy of gall bladder : To rule out gallbladder disease
presence of dyspepsia
10) Small bowel series : To rule out obstruction of bowel, in diarrhea and symptoms
suggest obstruction
11) Colonoscopy : Tp rule out inflammatory bowel disease, polyps, diverticulosis or colon
cancer when clinically justified as in change in symptoms in patients with long
standing IBS uncontrol level exacerbation of IBS

5) Treatment
1. Surgery – rare
2. Medications :
a. Bulk – forming laxatives : psyllium preparations (metamucil, consyl, metrolan )
taken at meal times in obese patient before meals and in thin patient after
meals ( hydrophilic properties bind water, preventing excessive dehydration of
stool and excess liquidity) may inprove symptoms.
b. Antidiarrheal agents –
i. loperamide ( emodium ) to mg 6-8 hours ( preferred, doest not cross
blood – brain barrier )
ii. diphenoxylate ( lomotil ) 2.5 to 5 mg 4 – 6 hours
iii. dependency on antidiarrheals can develop, slow with drawel of
medicine as coping abilities are develop is recommended may
improve symptoms
c. anti-spasmodic agents
i. anti cholinergics
1. dicyclomine ( bentyl ) 20mg 30 – 45 minutes before meals
2. propantheline ( pro.banthine ) 15 mg 30 – 40 minutes before
meals
3. hyoscyamine ( levsin ) 1 – u tablets 4 hours as needed, not
before meals.
 ii. Calcium channel blockers : currently under incestigation for treatment
of IBS based on smooth muscle relaxants properties and in hibitory
effects on gastrocolonic responses.

6) NURSING DIAGNOSIS

6.1: Disturbance bowel elimination (constipation) related to decrease motility of

gastrointestinal tract.

Aim : the patient will mantain passage of soft, formed stool every 1 to 3 days without
straining.

Interventions

1. Assess usual pattern of elimination; compare with present pattern. Include size,
frequency, color, and quality. "Normal" frequency of passing stool varies from
twice daily to once every third or fourth day. It is important to ascertain what is
"normal" for each individual.
2. Evaluate fear of pain. Hemorrhoids, anal fissures, or other anorectal disorders
that are painful can cause ignoring the urge to defecate, which over time results
in a dilated rectum that no longer responds to the presence of stool.
3. Encourage daily fluid intake of 2000 to 3000 ml/day, if not contraindicated
medically. Patients, especially elderly patients, may have cardiovascular
limitations, which require that less fluid is taken.
4. Encourage increased fiber in diet (e.g., raw fruits, fresh vegetables); a minimum
of 20 g of dietary fiber per day is recommended. Fiber passes through the
intestine essentially unchanged. When it reaches the colon, it absorbs water and
forms a gel, which adds bulk to the stool and makes defecation easier.
5. Encourage patient to consume prunes, prune juice, cold cereal, and bean
products. These are "natural" cathartics because of their high-fiber content.
6. Encourage physical activity and regular exercise. Ambulation and/or abdominal
exercises strengthen abdominal muscles that facilitate defecation.
7. Teach use of pharmacological agents as ordered, as in the following:
a. Bulk fiber (Metamucil and similar fiber products). These increase fluid,
gaseous, and solid bulk of intestinal contents.
 b. Stool softeners (e.g., Colace). These soften stool and lubricate intestinal
mucosa.
c. Chemical irritants (e.g., castor oil, cascara, Milk of Magnesia). These
irritate the bowel mucosa and cause rapid propulsion of contents of small
intestines.
d. Suppositories. These aid in softening stools and stimulate rectal mucosa;
best results occur when given 30 minutes before usual defecation time or
after breakfast.
e. Oil retention enema. This softens stool.
8.
Outcome : Patient can bowel open regularly without straining.

6.2 disturbance bowel elimination (diarrheal) is related to irregular motility in

gastrointestinal tract.

Aim : to maintain electrolyte balance in the body that have been loss by the diarrhea.

Interventions:

1. Assess for abdominal pain, cramping, frequency, urgency, loose or liquid stools,
and hyperactive bowel sensations.
2. Assess hydration status, as in the following:
a. Input and output. Diarrhea can lead to profound dehydration and
electrolyte imbalance.
b. Skin turgor
c. Moisture of mucous membrane
3. Encourage fluids; consider nutritional support. Fluids compensate for
malabsorption and loss of nutrients.
4. Check for fecal impaction by digital examination. Liquid stool (apparent diarrhea)
may seep past a fecal impaction.
5. Teach patient or caregiver the following dietary factors that can be controlled:
a. Avoid spicy, fatty foods.
b. Broil, bake, or boil foods; avoid frying.
c. Avoid foods that are disagreeable.
6. Teach patient or caregiver the importance of fluid replacement during diarrheal
episodes. Fluids prevent dehydration.
 7. Teach patient or caregiver the importance of good perianal hygiene after each
bowel open. Hygiene controls perianal skin excoriation and minimizes risk of
spread of infectious diarrhea
8. Give antidiarrheal drugs as ordered. Most antidiarrheal drugs suppress GI
motility, thus allowing for more fluid absorption.
9. Provide the following dietary alterations as allowed:
a. Bulk fiber (e.g., cereal, grains, Metamucil)
b. "Natural" antidiarrheals (e.g., pretzels, matzos, cheese)
c. Avoidance of stimulants (e.g., caffeine, carbonated beverages) Stimulants
may increase Gastrointestinal motility and worsen diarrhea.

Outcome : electrolyte balance in the body is normal and diarrhea is reduced.

7) Conclusions
Irritable bowel syndrome (IBS) is a symptom complex characterized by intermittent
and recurrent abdominal pain and stool pattern irregularities. It is classified as IBS with
diarrhea, IBS with constipation, and IBS with mixed diarrhea and constipation. Other
common symptoms include abdominal distension, excessive flatulence, bloating, a
continual defecation urge, urgency, and sensation of incomplete evacuation. The abdominal
pain or discomfort associated with IBS is most likely due to increased visceral sensitivity.
That is, the presence of stool or gas in the GI tract stimulates visceral afferent fibers, which
results in perception of discomfort or pain. Several neurochemicals, including serotonin, are
likely involved in bowel symptoms of diarrhea, constipation, and pain sensitivity. The health
care provider should establish a trusting relationship at onset of treatment. The patient
should be encouraged to verbalize concerns and anxiety. The patient whose primary
symptoms are abdominal distention and increased flatulence should be advised to eliminate
common gas-producing foods (e.g.broccoli, cabbage) from the diet and to substitute yogurt
for milk products to help determine if there is lactose intolerance. Other therapies include
cognitive-behavioral therapy, relaxation and stress management techniques, acupuncture,
hypnosis, and Chinese herbs. No single therapy has been found to be effective for all
patients with IBS.
8) REFERENCES
1) Bucher, O’Brien, Dirksen, Heitkemper & Lewis.(2007). Irritable bowel
syndrome (IBS).Medical Surgical Nursing, Assessment and Management of
Clinical Problems, seventh edition, international edition.
2) Tucker, Hirsch, McFarland & Thompson. (2002). Irritable bowel syndrome
(IBS). Mosby’s Clinical Nursing, fifth edition.
3) Mike Walsh. Watson’s Clinical Nursing and Related Sciences. 6th edition.