Irritable Bowel Syndrome (IBS) : Mnemonic Approach

Rome IV Criteria for IBS

Mnemonic: 1, 2, 3

Recurrent abdominal pain on average:

• ≥1 day/week associated with
• ≥2 of the following in
• last 3 months:
  • Related to defecation
  • Associated with a change in stool frequency
  • Associated with a change in stool form (appearance)

Criteria fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis

Alarm findings (Red flags)

Mnemonic: ALARMING

1. Age 50 or more
2. Loss of weight (unintentional), Lymphadenopathy
3. Anemia
4. Recent change in bowel habit
5. Mass (abdominal)
6. Intestinal bleeding (melena, hematochezia, FOBT positive)
7. Night diarrhea
8. Genealogy (family) history of Colon carcinoma, Inflammatory Bowel Disease or Celiac disease

Additional diagnostic testing

Mnemonic: Rule out 4 “C”
1. Carcinoma
2. Celiac disease
3. Colitis
4. Carbohydrate (lactose) intolerance

Additional diagnostic testing is not indicated if the patient meets the Rome IV diagnostic criteria in the absence of alarm features. Some recommended additional diagnostic tests are:

1. All patients ≥ 50 years old or those with alarm features: Colonoscopy for Colorectal carcinoma screening
2. IBS with Diarrhea or Mixed: Serologic tests for celiac disease
3. IBS with Diarrhea: Colonoscopy with random biopsies (to rule out microscopic colitis)
4. When no response to diet and still suspicious: Breath testing for lactose intolerance

Management

Mnemonic: BCDEF

1. Cognitive Behavioral therapy

2. Drugs:

	Constipation predominant	Diarrhea predominant
1st line	Constipation: Osmotic laxatives Pain: Antispasmodics	Diarrhea: Loperamide, Cholestyramine (Bile acid sequestrants) Pain: Antispasmodics
2nd line	Secretagogues: Linaclotide Lubiprostone	Rifaximin Low dose TCA Eluxadoline (mixed opioid receptor agonist)
3rd line	Tegaserod (Serotonin-4 agonist)	Alosetron (Serotonin-3 antagonist)

3. Education and reassurance (most important)

4. Food modifications:

• Lactose restriction
• Gluten restriction
• Fiber supplementation
• Low-FODMAP diet