Irritable bowel syndrome (IBS) is a gastrointestinal (GI) disorder characterized

by altered bowel habits and abdominal pain in the absence

of detectable structural abnormalities
IBS is a disorder of the young, with most new patients
presenting before age 45. Women are
diagnosed with IBS two to three times as often as men.
Rome I I Criteria for the Diagnosis of I BS
At least 12 weeks, which need not be consecutive, in the preceding 12
months of abdominal discomfort or pain that has two of following three
features:
1. Relieved by defecation
2. Onset associated with changes in stool frequency
3. Onset associated with changes in stool form
Abdominal Pain According to the Rome II criteria, abdominal pain or
discomfort is a prerequisite clinical feature of IBS. Abdominal pain in
IBS is highly variable in intensity and location; it is localized to the
hypogastrium in 25%, the right side in 20%, to the left side in 20%,
and the epigastrium in 10% of patients. It is frequently episodic and
crampy, but it may be superimposed on a background of constant ache.
However, patients with severe IBS often wake repeatedly during the
night, and, hence, nocturnal pain is a poor discriminating factor between
organic and functional bowel disease. Pain is often exacerbated
by eating or emotional stress and relieved by passage of flatus or stools.
Altered Bowel Habits Alteration in bowel habits is the most consistent
clinical feature in IBS. It usually begins in adult life. The most common
pattern is constipation alternating with diarrhea, usually with one
of these symptoms predominating. At first, constipation may be episodic,
but eventually it becomes continuous and increasingly intractable
to treatment with laxatives. Stools are usually hard with narrowed
caliber, possibly reflecting excessive dehydration caused by prolonged
colonic retention and spasm. Most patients also experience a sense of
incomplete evacuation, leading to repeated attempts at defecation in a
short time span. Patients whose predominant symptom is constipation
may have weeks or months of constipation interrupted with brief periods
of diarrhea. In other patients, diarrhea may be the predominant
symptom. Diarrhea resulting from IBS usually consists of small volumes
of loose stools. Most patients have stool volumes of <200 mL. Diarrhea may be aggravated
by emotional stress or eating. Stool may be accompanied by passage
of large amounts of mucus;
Upper Gastrointestinal Symptoms Between 25 and 50% of patients with
IBS complain of dyspepsia, heartburn, nausea, and vomiting
Because IBS is a disorder for which no pathognomonic abnormalities
have been identified, its diagnosis relies on recognition of
positive clinical features and elimination of other organic diseases.
A careful history and physical examination are frequently helpful
in establishing the diagnosis. Clinical features suggestive of IBS
include the following: recurrence of lower abdominal pain with
altered bowel habits over a period of time without progressive deterioration,
onset of symptoms during periods of stress or emotional
upset, absence of other systemic symptoms such as fever and
weight loss, and small-volume stool without any evidence of blood.
On the other hand, the appearance of the disorder for the first
time in old age, a progressive course from time of onset, persistent
diarrhea after a 48-h fast, and presence of nocturnal diarrhea or
steatorrheal stools argue against the diagnosis of IBS.
Thus, a younger individual with mild symptoms requires a minimal
diagnostic evaluation, while an older person or an individual with
rapidly progressive symptoms should undergo a more thorough
exclusion of organic disease. Most patients should have a complete
blood count and sigmoidoscopic examination; in addition, stool
specimens should be examined for ova and parasites. In those older
than 40 years, an air-contrast barium enema or colonoscopy should
also be performed. If the main symptoms are diarrhea and increased
gas, the possibility of lactase deficiency should be ruled out with
a hydrogen breath test or with evaluation after a 3-week lactosefree
diet. In patients with concurrent symptoms of dyspepsia, upper
GI radiographs or esophagogastroduodenoscopy may be advisable.
In patients with postprandial right upper quadrant pain, an ultrasonogram
of the gallbladder should be obtained. Laboratory features
that argue against IBS include evidence of anemia, elevated
sedimentation rate, presence of leukocytes or blood in stool, and
stool volume <200 to 300 mL/d. These findings would necessitate
other diagnostic considerations.
The following may be useful in providing an objective assessment of psychological features:
Hospital Anxiety and Depression Scale (HADS). This is a simple 14-item
questionnaire to measure the level of anxiety and depression.
The Sense of Coherence (SOC) test can be used to identify patients with a low SOC
who respond to cognitive behavioral therapy.
The Patient Health Questionnaire (PHQ-15). This is a 15-item questionnaire that helps
identify the presence of multiple somatic symptoms (somatization). The PHQ-15 should be
validated in a given country before it is used in clinical practice in that location


The prevalence of IBS in Europe and North America is estimated to be 1015%. In Sweden,
the most commonly cited figure is 13.5%.
The prevalence of IBS is increasing in countries in the AsiaPacific region, particularly in
countries with developing economies. Estimates of the prevalence of IBS (using the Rome II
diagnostic criteria) vary widely in the AsiaPacific region. Studies from India show that the
Rome I criteria for IBS identify more patients than the Rome II criteria. Reported prevalences
include 0.82% in Beijing, 5.7% in southern China, 6.6% in Hong Kong, 8.6% in Singapore,
14% in Pakistan, and 22.1% in Taiwan. A study in China found that the prevalence of IBS as
defined by the Rome III criteria in outpatient clinics was 15.9%.
Generally, data from South America are scarce; in Uruguay, for example, there is only one
study, and the overall prevalence was 10.9% (14.8% in women and 5.4% in men); 58% with
IBS-C and 17% with IBS-D. In 72% of the cases, the age of onset was < 45 years.
Data from Africa are even more scanty. A study in a Nigerian student population based on
the Rome II criteria found a 26.1% prevalence. A study among outpatients in the same
country, based on the same criteria, reported a 33% prevalence


Patient Counseling and Dietary Alterations Reassurance and careful explanation
of the functional nature of the disorder and of how to avoid
obvious food precipitants are important first steps in patient counseling
and dietary change. Occasionally, a meticulous dietary history may
reveal substances (such as coffee, disaccharides, legumes, and cabbage)
that aggravate symptoms. As a therapeutic trial, patients should
be encouraged to eliminate any foodstuffs that appear to produce
symptoms.
Antispasmodics Clinicians have observed that anticholinergic drugs
may provide temporary relief for symptoms such as painful cramps
related to intestinal spasm. Physiologic studies demonstrate that
anticholinergic drugs inhibit the gastrocolic reflex; hence, postprandial
pain is best managed by giving antispasmodics 30 min before meals
so that effective blood levels are achieved shortly before the anticipated
onset of pain. Most anticholinergics contain natural belladonna
alkaloids, which may cause xerostomia, urinary hesitancy and retention,
blurred vision, and drowsiness. Some physicians prefer to use
synthetic anticholinergics such as dicyclomine that have less effect on
mucous membrane secretions and therefore produce fewer undesirable
side effects
Most IBS patients have mild symptoms. They
are usually cared for in primary care practices and have little or no
psychosocial difficulties and do not seek health care often. Treatment
usually involves education, reassurance, and dietary/lifestyle changes.
A smaller proportion have moderate symptoms that are usually intermittent
and correlate with altered gut physiology, such as worsening
with eating or stress and relieved by defecation. Treatments include
gut-acting pharmacologic agents such as antispasmodics, antidiarrheals,
fiber supplements, and the newer gut serotonin modulators
(Fig. 277-1). A small proportion of IBS patients have severe and refractory
symptoms. They are usually seen in referral centers and frequently
have constant pain and psychosocial difficulties (Fig. 277-1).
This group of patients are best managed with antidepressants and other
psychological treatments
Prognosis
For most patients with IBS, symptoms are likely to persist, but not worsen. A smaller
proportion will deteriorate, and some will recover completely. For example, a recent study
found that while 18% of a random sample of 1021 people in the general (U.S.) population
had IBS, 38% had no complaints 1220 months later.
Factors that may negatively affect the prognosis include:
Avoidance behavior related to IBS symptoms
Anxiety about certain medical conditions
Impaired function as a result of symptoms
A long history of IBS symptoms
Chronic ongoing life stress
Psychiatric comorbidity
Approaches by the physician that positively affect the treatment outcome:
Acknowledging the disease
Educating the patient about IBS
Reassuring the patient

Chronic fatigue syndrome (CFS) is the current name for a
disorder characterized by debilitating fatigue and several associated
physical, constitutional, and neuropsychological complaints
TABLE 370-2 CDC Criteria for Diagnosis of Chronic Fatigue Syndrome
A case of chronic fatigue syndrome is defined by the presence of:
1. Clinically evaluated, unexplained, persistent or relapsing fatigue that is
of new or definite onset; is not the result of ongoing exertion; is not
alleviated by rest; and results in substantial reduction of previous levels
of occupational, educational, social, or personal activities; and
2. Four or more of the following symptoms that persist or recur during six
or more consecutive months of illness and that do not predate the fatigue:
Self-reported impairment in short-term memory or concentration
Sore throat
Tender cervical or axillary nodes
Muscle pain
Multijoint pain without redness or swelling
Headaches of a new pattern or severity
Unrefreshing sleep
Postexertional malaise lasting >= 24 h
Severe chronic fatigue of 6 months or longer that is not explained by any medical or
psychiatric diagnosis
Symptom Percentage
Fatigue 100
Difficulty concentrating 90
Headache 90
Sore throat 85
Tender lymph nodes 80
Muscle aches 80
Joint aches 75
Feverishness 75
Difficulty sleeping 70
Psychiatric problems 65
Allergies 55
Abdominal cramps 40
Weight loss 20
Rash 10
Rapid pulse 10
Weight gain 5
Chest pain 5
Night sweats
Patients with CFS are twice as likely to be women as
men and are generally 25 to 45 years old, Community-based
studies find that 100 to 300 individuals per 100,000 population in the
United States meet the current CDC case definition.
A thorough history, physical examination, and judicious
use of laboratory tests are required to exclude other causes of the
patients symptoms. Prominent abnormalities argue strongly in favor
of alternative diagnoses. No laboratory test, however, can diagnose
this condition or measure its severity. In most cases, elaborate, expensive
workups are not helpful. Early claims that magnetic resonance
imaging or single photon emission computed tomography can identify abnormalities in the
brain of CFS patients have not withstood further
study. The dilemma for patient and clinician alike is that CFS has no
pathognomonic features and remains a constellation of symptoms and
a diagnosis of exclusion. Often the patient presents with features that
also meet criteria for other subjective disorders such as fibromyalgia
and irritable bowel syndrome.
These tests should usually be done:
l urinalysis for protein, blood and glucose
l full blood count
l urea and electrolytes
l liver function
l thyroid function
l erythrocyte sedimentation rate or plasma
viscosity
l C-reactive protein
l random blood glucose
l serum creatinine
l screening blood tests for gluten sensitivity
l serum calcium
l creatine kinase
l assessment of serum ferritin levels (children
and young people only).

Many symptoms of CFS respond to treatment. Non-steroidal antiinflammatory
drugs alleviate headache, diffuse pain, and feverishness.
Allergic rhinitis and sinusitis are common; antihistamines or decongestants
may be helpful. Although the patient may be averse to psychiatric
diagnoses, depression and anxiety are often prominent and
should be treated. Expert psychiatric assessment is sometimes advisable.
Nonsedating antidepressants improve mood and disordered sleep
and may attenuate the fatigue. Even modest improvements in symptoms
can make an important difference in the patients degree of selfsufficiency
and ability to appreciate lifes pleasures.
Practical advice should be given regarding life-style. Sleep disturbances are common;
consumption of heavy meals with alcohol and
caffeine at night can make sleep even more elusive, compounding
fatigue. Total rest leads to further deconditioning and the self-image
of being an invalid, whereas overexertion may worsen exhaustion and
lead to total avoidance of exercise. A moderate, carefully graded regimen
should be encouraged and has been proven to relieve symptoms
and enhance exercise tolerance. The physician should promote the patients efforts to recover.
Controlled trials in the United Kingdom, in Australia, and in the Netherlands
showed cognitive-behavioral therapy to be helpful. This approach
aims to dispel misguided beliefs and fears about CFS that can
contribute to inactivity and despair. For CFS, as for many other conditions,
a comprehensive approach to physical, psychological, and social
aspects of well-being is in order.
ME/CFS patients were most disadvantaged in terms of vitality,
recreation, social interaction, home management and work. There
is a general tendency for the clinical course to plateau from between six
months and six years. In a nine-year study of 177 patients, 12% of patients
reported recovery (68). The patients with the least severe symptomology
at the beginning of the study were the most likely to recover
but there were no demographic characteristics associated with recovery.
Patient with comorbid fibromyalgia syndrome demonstrated greater
symptom severity and functional impairment than individuals with CFS
alone (69). Other studies (70,71,72,73,37) suggest that less than 10% of
patients return to premorbid levels of functioning. As the criteria become
more stringent the prognosis appears to worsen (74). Chronic
sleep loss [< 7 hours per night] may shorten longevity (75). Infrequent
deaths have been reported in the acute stage due to orthostatic cardiac
irregularity (32). The chronic, incurable and poorly understood nature
of this illness reduces the quality of medical and social support and may
increase the risk of suicide.
The prognosis for children is better. In a 13 year follow-up of 46 children
and adolescence diagnosed with chronic fatigue syndrome, 80%
had satisfactory outcomes although most had mild to moderate persisting
symptoms, and 20% remained ill with significant symptoms and activity
limitations (76).
Conditions of autonomic system evaluation
Multiple factors influence autonomic function
body position, emotional state, ingested food and
medicines, as well as other substances [6]. Caffeine
and nicotine should be withheld for at least 3-4 h
before testing, alcohol for 8 h. If possible, sympathomimetic
drugs should be stopped for 24-48 h
before testing, and anticholinergics for 48 h [23].
Moreover, standardization of test conditions is
crucial in order to make them comparable,
especially during the assessment of cardiovascular
reflexes. Directly before testing, the patient should
be laid down or seated for about 30 min in a quiet
room with neutral temperature and humidity
Some Psychosomatic Disorders
Acne
Allergic reactions Migraine
Mucous colitis
Nausea
Neurodermatitis
Obesity
Painful menstruation
Pruritus ani
Pylorospasm
Regional enteritis
Rheumatoid arthritis
Sacroiliac pain
Skin diseases, such as psoriasis
Spastic colitis
Tachycardia
Tension headache
Tuberculosis
Ulcerative colitis
Urticaria
Vomiting
Warts
Angina pectoris
Angioneurotic edema
Arrhythmia
Asthmatic wheezing
Bronchial asthma
Cardiospasm
Chronic pain
syndromes
Coronary heart disease
Diabetes mellitus
Duodenal ulcer
Essential hypertension
Gastric ulcer
Headache
Herpes
Hyperinsulinism
Hyperthyroidism
Hypoglycemia
Immune diseases
Irritable colon


Nutrient Effects
Vitamin A Improves gut barrier function
Maintains production of mucosal secretions
Protects against oxidative damage (in -carotene form)
Improves immune response to antigens
Deficiency: increased morbidity and mortality, increased severity of infections,
reduced number of lymphocytes, reduced lymphoid organ weight
Vitamin C Protects against oxidative damage
Deficiency: decreased resistance to infection and cancer; decreased delayed-type
hypersensitivity response; impaired wound healing
Vitamin B6 Required for nucleic acid and protein synthesis (with implications for rapid
immune cell response to antigens)
Deficiency: lymphocytopenia; reduced lymphoid tissue weight; reduced responses
to mitogens; general deficiencies in cell-mediated immunity; lowered antibody
responses
Vitamin B12* Required for nucleic acid and protein synthesis
Mediates a variety of immune responses, including cell-mediated
and humoral immunity
Deficiency: depressed immune responses, including delayed-type
hypersensitivity response and T-cell proliferation
Vitamin E Acts as a strong antioxidant, reduces cell membrane peroxidation
Deficiency: rare in humans (except as secondary to fat malabsorption); reduced
immune response, anemia, fetal resorption in experimentally induced deficiency
Folate* Required for nucleic acid and protein synthesis
Mediates a variety of immune responses, including cell-mediated
and humoral immunity
Deficiency: depressed immune responses, including delayed-type
hypersensitivity response and T-cell proliferation
Iron Is fundamental for normal immune system development
Allows proper functioning of enzymes involved in nucleic acid
synthesis and cell replication
Mediates components of inflammatory response
Deficiency: reduced capacity for an adequate immune response, as measured by:
decreased delayed-type hypersensitivity response, mitogen responsiveness, and
NK cell activity; decreased lymphocyte bactericidal activity; lower IL-6 levels
Selenium Allows proper functioning of enzymes involved in drug/chemical
metabolism and other processes
Acts as an antioxidant; protects cells from oxidative damage
Deficiency: suppression of immune function; increased cancer incidence and
cardiomyopathy in populations with chronic Se deficiency
Zinc Allows proper functioning of enzymes involved in nucleic acid
synthesis and cell replication
Improves intestinal barrier function
Mediates unspecific immunity, such as neutrophils and NK cells
Has a role in balance of T helper cell functions
Deficiency: increased susceptibility to infectious diarrhea, increased
diarrheal and respiratory morbidity

What is the Valsalva Maneuver?
The Valsalva maneuver is one of the most important clinical physiological tests for
autonomic failure. It consists of blowing against a resistance for several seconds, then
relaxing. The instant a person begins to blow, the sudden increase in chest and abdominal
pressure forces blood out of the chest and down the arms. This increases blood pressure
briefly (phase I). Soon afterwards, the amount of blood ejected by the heart with each beat
(stroke volume) plummets, because the straining decreases entry of blood from the veins
into the heart. Blood pressure progressively falls (phase II). The brain senses this fall and a
rapid decrease in outflow in the parasympathetic nervous system to the heart. The increase
in nerve traffic leads to more release of norepinephrine, which tightens blood vessels
throughout the body. When the patient relaxes at the end of the maneuver (phase III),
briefly, the blood pressure falls, but then blood rushes back into the chest and within a few
heartbeats, the heart ejects this blood. The blood pressure increases (phase IV) and since
the blood vessels are constricted, produces an overshoot of blood pressure, outflow to
blood vessels falls and in response to this increase in blood pressure the heart rate falls.
The pattern of these various perturbations gives physicians important information about
both sympathetic and parasympathetic function.
In patients with autonomic dysfunction, the blood vessels fail to constrict reflexively
(during phase II) and so blood pressure falls progressively and does not increase toward
baseline at the end of phase II. During phase IV, because of the lack of tightening of blood
vessels, there is no rapid increase in blood pressure and no phase IV overshoot of pressure.
Instead, the blood pressure gradually increases slowly back to the baseline value
What is a tilt table test?
The tilt table is done to see if standing up provokes a sudden fall in blood pressure
(neurally mediated hypotension), an excessive increase in pulse rate (Postural tachycardia
syndrome) or fainting (neurally mediated syncope). The patient lies on a stretcher-like
support. Straps like seatbelts are attached around the abdomen and legs and the patient is
tilted upright at an angle. The exact angle varies and may be from 60 to 90 degrees. The
tilting goes on for up to 45 minutes. The patient is gradually tilted to an upright position
until systolic blood pressure drops to 70 mm Hg or the appearance of orthostatic symptoms
such as dizziness, lightheadedness or faintness. The purpose is to hopefully reproduce the
patients problem in a controlled laboratory setting. It may not be performed on all
patients, such as patients with a persistent fall in blood pressure each time they stand up
(orthostatic hypotension) because the blood pressure will fall progressively beginning as
soon as the tilting starts.
What is a sweat test?
Sweat tests evaluate a particular part of the autonomic nervous system. The brain increases
sweating by directing an increase in sympathetic nervous system traffic to sweat glands in
the skin. The chemical messenger, acetylcholine, is released, which acts on the sweat
glands to stimulate the production of sweat. The QSART is a special form of sweat test. It
tests the ability of sympathetic nerve terminals in the skin to release acetylcholine and
increase sweat production. A drug is applied to a nearby patch of skin. This evokes
sweating at the site, but it also allows the body to release its own acetylcholine, resulting in
sweat production. If a person had a loss of sympathetic nerve terminals that release
acetylcholine, applying the patches would not lead to increased sweating. By this sort of
neuropharmacologic test, doctors can distinguish sympathetic cholinergic failure due to
loss of cholinergic terminals from failure due to abnormal regulation of sympathetic nerve
traffic to intact cholinergic terminals.
What is a cold pressor test?
In this test, the patient dunks a hand into ice-cold water for 1-2 minutes. This rapidly
increases the blood pressure by increasing activity of the sympathetic nervous system.