Evaluation of Irritable Bowel Syndrom in AL-Diwanyia

Irritable bowel syndrome (IBS) is the most commonly diagnosed gastrointestinal condition that comprises 25-50% of all referral to gastroenterologists. IBS causes a great deal of discomfort and distress, but it does not permanently harm the intestines and does not lead to a serious disease, such as cancer. To study the epidemiological aspect, clinical varieties and the response the available treatment in patients whom complaining of irritable bowel syndrome according to Rome criteria in al Diwaniya province in Iraq. Two hundreds sixty four patients with variable clinical presentation of irritable bowel syndrome of different age groups and sexes were fully examined and investigated to exclude the organic disease. We used the chi square calculation in statistical analysis


Introduction
Irritable bowel syndrome (IBS) is a gastrointestinal syndrome characterized by chronic abdominal pain and altered bowel habits in the absence of any organic cause.It is the most commonly diagnosed gastrointestinal condition.The prevalence of IBS in North America estimated from population-based studies is approximately 10 to 15 percent [1][2][3][4][5][6].A population based study in Europe found an overall prevalence of 11.5 percent (a value similar to that noted in reports in the United States); however, the prevalence varied widely among countries [7] and we don't have an estimate about the prevalence of this syndrome in Iraq because of paucity of studies conducted in this regard in our society.
IBS affects men and women, young patients and the elderly.However, younger patients and women are more likely to be diagnosed with IBS.A systematic review estimated that there is an overall 2:1 female predominance in North America [3].Only 15 percent of those affected actually seek medical attention [1, 2, 8, 9].Nevertheless, the absolute number of patients is still so large that IBS comprises 25 to 50 percent of all referrals to gastroenterologists [10].IBS also accounts for a significant number of visits to primary care physicians, and is the second highest cause of work absenteeism after the common cold [11].One estimate suggests that the total direct cost of IBS (including inpatient and outpatient health services) was greater than $1.7 billion in the United States in 2000 [12].Patients with IBS can present with a wide array of symptoms which include both gastrointestinal and extra intestinal complaints.However, the symptom complex of chronic abdominal pain and altered bowel habits remains the nonspecific yet primary characteristic of IBS [13].
Most people can control their symptoms with diet, stress management, and prescribed medications.For some people, however, IBS can be disabling.They may be unable to work, attend social events, , or even travel short distances(14,15).

IBS is characterized by the presence of abdominal discomfort or pain associated with disturbed defecation (16). Bloating or visible abdominal distention often are present in patients with IBS but are not considered essential for diagnosis (16).
In a classic study from the United Kingdom, Manning and associates first reported that six symptoms were more frequent in those subsequently documented to have IBS (abdominal pain that is relieved after bowel movement, looser stool at pain onset, more frequent stools at pain onset, visible abdominal distention, sensation of incomplete rectal evacuation and passage of mucus)(17).laterstudies showed that these studies were specific, but not sensitive, for identifying IBS and were of greater diagnostic value in women.( 18   disease is distributed among the educated group more than non educated group.More than 80% of female and more than 75% of male had the secondary degree or more.The P value assessment was <0.05 that is consider significant.

Discussion
The mean age in our study population is 26.1±1.2 years pointing to crucial fact proved by other population -based studies that IBS has higher prevalence in younger age group .generallyits believed that IBS is uncommon in the elderly, but it seems likely that IBS in the elderly is often under diagnosed or misclassified as diverticular disease for example (26).Female patients appeared to get higher prevalence in this study than males , a result which seems compatible with other population-based studies that all pointed to female predominance (16-28).
In clinical practice in the United States, women outnumber men, which is partly explained by increased health care-seeking behavior among women; this appeared to be culturally derived, because data from India indicate more men than women present for care for IBS; this does not mean that more men than women have IBS in India (28).Probably this explanation holds true in Iraqi society as well because women often seek medical care more frequent than men.
Healthy women have greater rectal sensitivity, slower colonic transit, and smaller stool output than do men, which may explain why certain symptoms, such as straining and passage of hard stools, seems to be more common in women ( 29

Conclusions and Recommendations
1. Irritable bowel syndrome is a common gastrointestinal disorder of high prevalence and a great impact on the society &patients life.2. the disorder mainly affects the young age group of both sexes, so it has an adverse effect on the performance & the productive power of the whole country.3. The different clinical varieties are present in nearly even distribution in our society & there seems to be an influence of different life stressors on the prevalence of the disease.4.the response to the available treatment is often un satisfactory and more advanced treatment modalities adopted in developed countries need to be evaluated & applied in Iraq.
,19).In an effort to build up the diagnostic utility of the Manning criteria, the Rome (I&II)were created following a formal consensus process to provide a standard for a clinical research (16).Supportive symptoms that are not part of the Rome III criteria include: abnormal stool frequency (3 bowel movements per week or >3 bowel movements per day); abnormal stool form (lumpy/hard or loose/watery), defecation straining, urgency, or a feeling of incomplete bowel movement, passing mucus and bloating.Four subtypes of IBS were also recognized: 1. IBS with constipation (hard or lumpy stools≥ 25 percent and loose (mushy) or watery stools <25 percent of bowel movements).2. IBS with diarrhea (loose (mushy) or water stools≥ 25 percent and hard or lumpy stools <25 percent of bowel movements).3. Mixed IBS (hard or lumpy stools 25 percent and loose (mushy) or watery stools 25 percent of bowel movements.4. Un sub typed IBS (insufficient abnormality of stool consistency to meet the above subtypes).The Rome criteria have been criticized for overemphasis on abdominal pain and failure to emphasize postprandial urgency, abdominal pain, and/or diarrhea (20).As a result, some investigators continue to use the Manning criteria or a combination of both.Other criteria have also been proposed (such as the Kruis criteria) but are uncommonly used (21-23).A number of studies have assessed the accuracy of the Rome and Manning criteria in a variety of practice settings (18).Although the overall sensitivity and specificity are high, results in individual studies have been variable, providing a rationale for ongoing studies that are attempting to further refine these criteria (24).Furthermore, the predictive values of the criteria depend upon the prevalence of IBS and organic disease in the individual practice setting.Considering the available data and the above limitations, a consensus statement issued by the American Gastroenterological Association recommends that the diagnosis of IBS should be based upon the identification of positive symptoms consistent with the condition (as summarized by the Rome criteria) and excluding in a cost-effective manner other conditions with similar clinical presentations.Rome II criteria At least 12 weeks (which need not to be consecutive) in the past 12 months of abdominal discomfort or pain associated with two of the following three features: Relieved with defecation; and/or Onset associated with pain and a change in frequency of stool; and/or onset associated with change in form (appearance) of stool (25).Patients and Method During the period between April to October 2007, patients who attending the outpatient clinic for internal diseases in Al-Diwaniya teaching hospital, with chronic(≥year) symptoms of : (abdominal pain, altered bowel motion in the form of diarrhea, constipation, or mixture of both, abdominal bloating & distention with or without mucus rectal discharge) were subjected to formal questioner and physical examination.All patients whose enter the study undergo full examination , chest X ray , ultrasound of abdomen , general stool examination, hematological tests including hemoglobin ,WBC count and differential, and ESR , thyroid function test, and biochemical tests including blood sugar, liver enzymes and serum amylase.Upper endoscopy and/or sigmoidoscopy were done to some patients were normal.Patients who had symptoms or signs pointing to organic disease were fully investigated to detect the cause.Patients who fulfilled Rome II criteria were included in the study, and those who had alarming symptoms ( gastrointestinal bleeding, anorexia, significant weight loss, nocturnal diarrhea)or those who were discovered during physical examination or diagnostic investigations to have an organic cause for their symptoms were excluded from the study.Two hundred sixty four patients from both sexes were included in this study with age ranging from sixteen to sixty five years with a ,30).In this study it's obvious that most patients are of intermediate social class and the most prevalent level of education was the intermediate level (secondary school &college graduates) however, these facts mostly reflects the normal economic &educational distribution of the Iraqi society rather than pointing to specific etiologic relation.The bigger size of the urban group can be explained in two ways: either by better access to medical care in urban area or by increased exposure to stressful events imposed by civilized society in cities reflected functionally as IBS like symptoms.This also may explain the higher percentage of married versus single patients reflecting the impact of pregnancy, child raising and marital problems on the bowel since it's a well established fact that a history of sexual, emotional & physical abuse is reported more often in patients with IBS than in those without this illness.(31,32)and sustained stress could be an important factor in both onset and persistence of IBS by enhancing visceral pain perception , by activating the area of midcingular cortex, an area that process visceral signals.(33,34)Theclinical subtypes of IBS are seen to be equally represented in the study sample population. in a study from Olmsted county, Minnesota, the shares were also nearly equal (35).However its unclear if those with predominant symptom (i.e.diarrhea or constipation),if followed long enough, eventually will develop the other(i.e.constipation or diarrhoea),but some data from primary care support this assumption (36).In addition, the definitions of IBS groups are still arbitrary and to some extent subjective.The response to treatment has been unsatisfactory in the great majority of patients.The drugs that were assessed are drugs available in the Iraqi market and include: anti spasmodic (cholinergic & non cholinergic), anti diarrhoeal,, laxatives, prokinetic drugs and antidepressant & anxiolytics in addition to simple no pharmacologic measures such as dietary modifications and simple psychological support.However the treatment of IBS is challenging and the results of the available studies regarding their efficacy are conflicting, while a meta-analysis of 23 randomized controlled trials concluded that antispasmodics were superior to placebo in the treatment of IBS (37),they have not been shown to more effective than placebo in other studies.Moreover, the effect of other drugs not widely available in Iraq such as serotonin receptor drugs and other treatment modalities such as psychotherapy, hypnotherapy & and behavioral cognitive therapy (CBT) have not been assessed in this study.