Empowering Patients: Strategies for Managing Irritable Bowel Syndrome With Constipation

HRQOL has become an important topic in medical research, but the impact of IBS on patients’ quality of life (QOL) has often been underestimated by physicians and researchers. Carol Antequera, MMS, DMSc, PA-C, is a physician assistant in the Division of Gastroenterology and Motility Disorders (hospital affiliations: Sylvester Comprehensive Cancer Center, University of Miami Hospital and Clinics) and cochair of the Advanced Practice Provider Council at the University of Miami, Florida. She collaborates with the chair and executive sponsor to promote professional excellence and education advancement with the goal of providing accessible, evidence-based, and cost-effective health care to patients. In this article, Ms Antequera discusses best practices for managing care and improving HRQOL for patients with IBS.

Several disease-specific tools for QOL measurement are designed to detect HRQOL changes in IBS. They include the Irritable Bowel Syndrome Quality of Life (IBSQOL) questionnaire, the Irritable Bowel Syndrome Questionnaire (IBSQ), and the IBS-36. The Functional Digestive Disorders Quality of Life (FDDQL) questionnaire is designed to be used for both IBS and functional dyspepsia. More general instruments include the Sickness Impact Profile (SIL) and Medical Outcomes Study Short Form-36 (SF-36). Which scales do you typically employ, if any? What are the advantages and disadvantages of using these scales? Are any other scales routinely used?

IBS is a chronic condition characterized by recurrent abdominal pain or change in bowel symptoms but without any structural or biochemical abnormalities.^1,2 It can hinder daily activities, impair QOL, and impose a social and economic burden. An estimated 5% to 10% of the world population is affected by IBS, and approximately 20% to 40% of all visits to gastroenterologists are due to IBS symptoms. In the United States alone, between 2.4 and 3.5 million annual physician visits are for IBS.¹
 
In my practice, after establishing the diagnosis of IBS, we use the IBS Severity Scoring System (IBS-SSS). This tool is used to assess primarily the intensity of IBS symptoms during a 10-day period, including severity of abdominal pain, frequency of abdominal pain, distention, dissatisfaction with bowel habits, and interference with life in general. Each item is scored on a visual analog scale from 0 to 100, and the IBS-SSS calculates the sum of these 5 scores.³

Other than these tools, what other methods are available to measure HRQOL? How do you initiate conversations with patients related to QOL?

Open and trusting communication is a key part of the relationship between a health care provider and a patient. As practitioners of modern Western medicine, we diagnose and manage patients by ordering increasingly expensive and often unnecessary tests that lead to higher health care costs. I have found this to be particularly true with chronic or functional gastrointestinal (GI) conditions. This may be occurring because we are no longer comfortable with our clinical judgment and diagnostic skills — we often feel compelled to “rule out organic disease” before accepting a disease as “functional.” Testing has become easy to obtain and is perceived as clinically helpful, and we also succumb to practicing defensive medicine in a litigious society.
 
Douglas Drossman, MD, has published numerous papers and conducted considerable research on the patient-physician relationship and its effects on health, and he discusses 15 core concepts and recommendations to improve communication skills and physician-patient relationships.⁴ These concepts can be applied by asking questions to understand the patient’s agenda. For example, with chronic illness, there can be many reasons for a visit: symptoms are worse, major psychological stress is occurring, the patient is worrying about cancer or insurance issues, or they are being urged to come by family. Knowing the reason for the visit can help gauge the necessary conduct. I begin every patient visit by asking, “What brings you in today?” This simple question gives the patient the opportunity to start talking and thus begins a dialogue. Patients have access to a large body of information, which is not always accurate and may cause more anxiety. All too often patients present to my clinic with a stack of articles they have found on the internet and even a diagnosis for what they believe they have, and they need to be understood and acknowledged before any re-education is attempted.
 
Setting realistic goals for patients with chronic conditions is crucial to their QOL. It is estimated that more than 40% of patients experience IBS symptoms for up to 5 years before diagnosis is made, and patients may be frustrated by the lack of answers and lack of relief of their condition.² Many patients present for the first visit and expect answers and a cure, and it is important for the practitioner to be clear and explain to them that this is a chronic disorder requiring ongoing management, like migraine headaches or arthritis. If the goals are not articulated at the first visit, the patient may leave dissatisfied and then return several months later feeling their goals were not met.

These are all reasons it helps to clarify the patient’s goals and reconcile them to achieve a consensus for care. This can be done by telling them something to this effect: “I can understand how much you want these long-standing symptoms to go away, but realistically we need to find better ways to manage them, just like arthritis or migraine headaches. If you could reduce your symptoms by 30% or 40%, would that help?” This way, the patient is introduced to the ideas of managing a chronic illness and setting realistic goals.

HRQOL is a metric to consider when assessing treatment decisions. How often do you reassess IBS symptom burden in patients, in particular those with constipation-predominant IBS?

In my practice, I reassess symptom burden at every visit, whether they have constipation-predominant IBS or diarrhea-predominant IBS. The burden of IBS can range from mild to severe in both cases, so it is important to reassess all IBS patients at every visit. This also helps me understand the patterns of their condition and to continue our open communication about any contributing psychosocial factors that may trigger flares. We also know that food and nutrients play a major role in IBS; in many patients with meal-related GI symptoms, diet manipulation is a natural first step in the treatment plan. During follow-up visits, I always ask patients about any changes in diet that may be helping or worsening their symptoms, as patients with bowel disorders often identify food as an important trigger of their GI symptoms. For example, a survey was conducted in Sweden that included roughly 200 patients with IBS, and 84% of them said food was a key trigger of their GI symptoms.⁵ For patients with persistent symptoms of IBS, a low-FODMAP diet (which is a diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) may be recommended with the guidance of a dietician.

IBS can be divided into 4 subtypes: IBS-constipation (IBS-C), IBS-diarrhea (IBS-D), IBS-mixed (IBS-M), and IBS-unspecified (IBS-U).⁶ Are any HRQOL components specific to constipation-predominant IBS?

Management of IBS-D and IBS-C is generally based on symptoms reported by patients, but limited information on the severity of symptoms exists. This highlights the need for a validated severity scale to guide treatment decisions. Several studies on the assessment of symptom severity, patient burden, and health care professional attitudes toward IBS have been conducted, though no single study has validated any single tool. One study found that out of 679 health care professionals, only one-third routinely classified patients by severity of symptoms.⁷ The researchers looked more closely at the burden of IBS-D and concluded that severe IBS-D was associated with increased medication use compared with milder symptoms, leading to a negative perspective of IBS-D.
 
In 2 large surveys measuring the impact of IBS on daily life, respondents reported high rates of impairment in areas such as going out with friends, eating outside the home, traveling, and visiting new or unfamiliar places. However, these studies did not distinguish between IBS subtypes.⁸

Some research suggests that patients who seek treatment for IBS have high rates of comorbidity with psychiatric disorders.⁹ How do coexisting medical conditions affect HRQOL in those with IBS?

Coexisting medical and psychiatric conditions can affect patients with IBS; there is plenty of research to suggest the significance of the brain-gut interaction in IBS. Recent studies have indicated that the majority of people (50% to 90%) who seek treatment for IBS have a lifetime history of, or currently have 1 or more, common psychiatric conditions, including major depressive disorder, generalized anxiety disorder, panic disorder, social phobia, and post-traumatic stress disorder.⁹ Patients with IBS have triple the odds of experiencing either anxiety or depression, compared with healthy subjects.¹⁰ It is recommended that physicians treating patients with anxiety and depression assess them for IBS as well. Diagnosing and treating a coexisting GI disorder could speed the improvement of the psychiatric comorbidities. This is where a multidisciplinary approach is essential to the treatment of these patients; health care practitioners should treat patients holistically to address these comorbid conditions.

This Q&A was edited for clarity and length.

References

1. IBS facts and statistics. International Foundation for Gastrointestinal Disorders. Accessed April 10, 2023. https://aboutibs.org/what-is-ibs/facts-about-ibs/
 
2. Burbige EJ. Irritable bowel syndrome: diagnostic approaches in clinical practice. Clin Exp Gastroenterol. 2010;3:127-137. doi:10.2147/CEG.S12596
 
3. Lembo A, Ameen VZ, Drossman DA. Irritable bowel syndrome: toward an understanding of severity. Clin Gastroenterol Hepatol. 2005;3(8):717-725. doi:10.1016/s1542-3565(05)00157-6
 
4. Drossman DA. 2012 David Sun lecture: helping your patient by helping yourself—how to improve the patient-physician relationship by optimizing communication skills. Am J Gastroenterol. 2013;108(4):521-528. doi:10.1038/ajg.2013.56
 
5. Singh P, Tuck C, Gibson PR, Chey WD. The role of food in the treatment of bowel disorders: focus on irritable bowel syndrome and functional constipation. Am J Gastroenterol. 2022;117(6):947-957. doi:10.14309/ajg.0000000000001767
 
6. Singh P, Staller K, Barshop K, et al. Patients with irritable bowel syndrome-diarrhea have lower disease-specific quality of life than irritable bowel syndrome-constipation. World J Gastroenterol. 2015;21(26):8103-8109. doi:10.3748/wjg.v21.i26.8103
 
7. Emmanuel A, Goosey RW, Wiseman G, Baker S, Törnblom H. Impact of symptom severity in patients with diarrhoea-predominant irritable bowel syndrome (IBS-D): results from two separate surveys of HCPs and patients with IBS-D. BMC Gastroenterol. 2020;20(1):127. doi:10.1186/s12876-020-01252-9
 
8. Ballou S, McMahon C, Lee HN, et al. Effects of irritable bowel syndrome on daily activities vary among subtypes based on results from the IBS in America Survey. Clin Gastroenterol Hepatol. 2019;17(12):2471-2478.e3. doi:10.1016/j.cgh.2019.08.016
 
9. Lydiard RB. Irritable bowel syndrome, anxiety, and depression: what are the links? J Clin Psychiatry. 2001;62(suppl8):38-47.
 
10. Zamani M, Alizadeh-Tabari S, Zamani V. Systematic review with meta-analysis: the prevalence of anxiety and depression in patients with irritable bowel syndrome. Aliment Pharmacol Ther. 2019;50(2):132-143. doi:10.1111/apt.15325

Posted by Haymarket’s Clinical Content Hub. The editorial staff of Clinical Advisor had no role in this content’s preparation.