Irritable bowel syndrome laboratory findings: Difference between revisions

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__NOTOC__
__NOTOC__
{{Irritable bowel syndrome}}
{{Irritable bowel syndrome}}
{{CMG}}; {{AE}}  
{{CMG}}; {{AE}} {{Cherry}}


==Overview==
==Overview==
An elevated/reduced concentration of serum/blood/urinary/CSF/other [lab test] is diagnostic of [disease name].
The diagnosis of irritable bowel syndrome (IBS) is based on clinical [[Symptom|symptoms]] and elimination of other organic [[Gastrointestinal tract|gastrointestinal]] diseases. This is due to lack of definitive [[Radiologic sign|radiologic]] or [[Medical laboratory|laboratory]] diagnostic tests in [[Irritable bowel syndrome|IBS]]. If the history and [[physical examination]] are suggestive of [[Irritable bowel syndrome|IBS]] in the absence of alarm features, [[complete blood count]], occult [[blood test]], complete metabolic panel and [[Erythrocyte sedimentation rate|ESR]] are usually normal. Additional tests may be costly and harmful in young patients with typical [[Irritable bowel syndrome|IBS]] [[symptoms]], in the absence of alarm features. To determine the aggressiveness of the diagnostic evaluation, the American Gastroenterological Association has defined certain factors that must be considered such as degree of psychosocial impairment, age and sex of the patient, [[family history]] of [[colorectal cancer]] etc. In patients that require aggressive diagnostic evaluation, additional diseases such as [[Celiac disease]], [[Inflammatory bowel disease|IBD]], [[Clostridium difficile infection|''Clostridium difficile'' infection]], [[giardiasis]], [[Lactose intolerance|lactase deficiency]], [[Bile salts|bile salt]] [[malabsorption]] and [[Colorectal cancer|colon cancer]] should be ruled out.
 
OR
 
Laboratory findings consistent with the diagnosis of [disease name] include [abnormal test 1], [abnormal test 2], and [abnormal test 3].
 
OR
 
[Test] is usually normal among patients with [disease name].
 
OR
 
Some patients with [disease name] may have elevated/reduced concentration of [test], which is usually suggestive of [progression/complication].
 
OR
 
There are no diagnostic laboratory findings associated with [disease name].


==Laboratory Findings==
==Laboratory Findings==
* The diagnosis of [[Irritable bowel syndrome|IBS]] is based on clinical [[Symptom|symptoms]] and elimination of other organic [[Gastrointestinal tract|gastrointestinal]] diseases. This is due to lack of definitive [[Radiologic sign|radiologic]] or [[Medical laboratory|laboratory]] diagnostic tests in [[Irritable bowel syndrome|IBS]].<ref name="pmid16678561">{{cite journal |vauthors=Longstreth GF, Thompson WG, Chey WD, Houghton LA, Mearin F, Spiller RC |title=Functional bowel disorders |journal=Gastroenterology |volume=130 |issue=5 |pages=1480–91 |year=2006 |pmid=16678561 |doi=10.1053/j.gastro.2005.11.061 |url=}}</ref><ref name="pmid12454866">{{cite journal |vauthors=Drossman DA, Camilleri M, Mayer EA, Whitehead WE |title=AGA technical review on irritable bowel syndrome |journal=Gastroenterology |volume=123 |issue=6 |pages=2108–31 |year=2002 |pmid=12454866 |doi=10.1053/gast.2002.37095 |url=}}</ref><ref name="pmid17488783">{{cite journal |vauthors=Spiller R, Aziz Q, Creed F, Emmanuel A, Houghton L, Hungin P, Jones R, Kumar D, Rubin G, Trudgill N, Whorwell P |title=Guidelines on the irritable bowel syndrome: mechanisms and practical management |journal=Gut |volume=56 |issue=12 |pages=1770–98 |year=2007 |pmid=17488783 |pmc=2095723 |doi=10.1136/gut.2007.119446 |url=}}</ref><ref name="pmid12425586">{{cite journal |vauthors=Brandt LJ, Bjorkman D, Fennerty MB, Locke GR, Olden K, Peterson W, Quigley E, Schoenfeld P, Schuster M, Talley N |title=Systematic review on the management of irritable bowel syndrome in North America |journal=Am. J. Gastroenterol. |volume=97 |issue=11 Suppl |pages=S7–26 |year=2002 |pmid=12425586 |doi= |url=}}</ref><ref name="YAWN_2001">{{cite journal |author=Yawn BP, Lydick E, Locke GR, Wollan PC, Bertram SL, Kurland MJ|title=Do published guidelines for evaluation of irritable bowel syndrome reflect practice? |journal=BMC gastroenterology |volume=1|issue= |pages=11 |year=2001 |pmid=11701092 |doi=}}</ref>  
* The diagnosis of irritable bowel syndrome ([[Irritable bowel syndrome|IBS]]) is based on clinical [[Symptom|symptoms]] and elimination of other organic [[Gastrointestinal tract|gastrointestinal]] diseases. This is due to lack of definitive [[Radiologic sign|radiologic]] or [[Medical laboratory|laboratory]] diagnostic tests in [[Irritable bowel syndrome|IBS]].<ref name="pmid16678561">{{cite journal |vauthors=Longstreth GF, Thompson WG, Chey WD, Houghton LA, Mearin F, Spiller RC |title=Functional bowel disorders |journal=Gastroenterology |volume=130 |issue=5 |pages=1480–91 |year=2006 |pmid=16678561 |doi=10.1053/j.gastro.2005.11.061 |url=}}</ref><ref name="pmid12454866">{{cite journal |vauthors=Drossman DA, Camilleri M, Mayer EA, Whitehead WE |title=AGA technical review on irritable bowel syndrome |journal=Gastroenterology |volume=123 |issue=6 |pages=2108–31 |year=2002 |pmid=12454866 |doi=10.1053/gast.2002.37095 |url=}}</ref><ref name="pmid17488783">{{cite journal |vauthors=Spiller R, Aziz Q, Creed F, Emmanuel A, Houghton L, Hungin P, Jones R, Kumar D, Rubin G, Trudgill N, Whorwell P |title=Guidelines on the irritable bowel syndrome: mechanisms and practical management |journal=Gut |volume=56 |issue=12 |pages=1770–98 |year=2007 |pmid=17488783 |pmc=2095723 |doi=10.1136/gut.2007.119446 |url=}}</ref><ref name="pmid12425586">{{cite journal |vauthors=Brandt LJ, Bjorkman D, Fennerty MB, Locke GR, Olden K, Peterson W, Quigley E, Schoenfeld P, Schuster M, Talley N |title=Systematic review on the management of irritable bowel syndrome in North America |journal=Am. J. Gastroenterol. |volume=97 |issue=11 Suppl |pages=S7–26 |year=2002 |pmid=12425586 |doi= |url=}}</ref><ref name="YAWN_2001">{{cite journal |author=Yawn BP, Lydick E, Locke GR, Wollan PC, Bertram SL, Kurland MJ|title=Do published guidelines for evaluation of irritable bowel syndrome reflect practice? |journal=BMC gastroenterology |volume=1|issue= |pages=11 |year=2001 |pmid=11701092 |doi=}}</ref><ref name="pmid28657875">{{cite journal |vauthors=Ford AC, Lacy BE, Talley NJ |title=Irritable Bowel Syndrome |journal=N. Engl. J. Med. |volume=376 |issue=26 |pages=2566–2578 |year=2017 |pmid=28657875 |doi=10.1056/NEJMra1607547 |url=}}</ref><ref name="pmid28541989">{{cite journal |vauthors=Weaver KR, Melkus GD, Henderson WA |title=Irritable Bowel Syndrome |journal=Am J Nurs |volume=117 |issue=6 |pages=48–55 |year=2017 |pmid=28541989 |doi=10.1097/01.NAJ.0000520253.57459.01 |url=}}</ref><ref name="pmid15361507">{{cite journal |vauthors=De Ponti F |title=Pharmacology of serotonin: what a clinician should know |journal=Gut |volume=53 |issue=10 |pages=1520–35 |year=2004 |pmid=15361507 |pmc=1774227 |doi=10.1136/gut.2003.035568 |url=}}</ref>  


* If the history and physical exam are suggestive of IBS in the absence of alarm features, the following tests rule out organic causes by 97 percent:  
* If the history and [[physical examination]] are suggestive of [[Irritable bowel syndrome|IBS]] in the absence of alarm features, the following tests rule out organic causes:<ref name="pmid25732419">{{cite journal |vauthors=Menees SB, Powell C, Kurlander J, Goel A, Chey WD |title=A meta-analysis of the utility of C-reactive protein, erythrocyte sedimentation rate, fecal calprotectin, and fecal lactoferrin to exclude inflammatory bowel disease in adults with IBS |journal=Am. J. Gastroenterol. |volume=110 |issue=3 |pages=444–54 |year=2015 |pmid=25732419 |doi=10.1038/ajg.2015.6 |url=}}</ref><ref name="pmid10601059">{{cite journal |vauthors=Thompson WG, Heaton KW, Smyth GT, Smyth C |title=Irritable bowel syndrome in general practice: prevalence, characteristics, and referral |journal=Gut |volume=46 |issue=1 |pages=78–82 |year=2000 |pmid=10601059 |pmc=1727778 |doi= |url=}}</ref><ref name="pmid19521341">{{cite journal |vauthors=Brandt LJ, Chey WD, Foxx-Orenstein AE, Schiller LR, Schoenfeld PS, Spiegel BM, Talley NJ, Quigley EM |title=An evidence-based position statement on the management of irritable bowel syndrome |journal=Am. J. Gastroenterol. |volume=104 Suppl 1 |issue= |pages=S1–35 |year=2009 |pmid=19521341 |doi=10.1038/ajg.2008.122 |url=}}</ref><ref name="pmid4169512">{{cite journal |vauthors=Vargues R |title=[The determination of complement] |language=French |journal=Transfusion (Paris) |volume=10 |issue=3 |pages=277–92 |year=1967 |pmid=4169512 |doi= |url=}}</ref><ref name="pmid23357491">{{cite journal |vauthors=Begtrup LM, Engsbro AL, Kjeldsen J, Larsen PV, Schaffalitzky de Muckadell O, Bytzer P, Jarbøl DE |title=A positive diagnostic strategy is noninferior to a strategy of exclusion for patients with irritable bowel syndrome |journal=Clin. Gastroenterol. Hepatol. |volume=11 |issue=8 |pages=956–62.e1 |year=2013 |pmid=23357491 |doi=10.1016/j.cgh.2012.12.038 |url=}}</ref><ref name="pmid27436200">{{cite journal |vauthors=Lacy BE, Moreau JC |title=Diarrhea-predominant irritable bowel syndrome: Diagnosis, etiology, and new treatment considerations |journal=J Am Assoc Nurse Pract |volume=28 |issue=7 |pages=393–404 |year=2016 |pmid=27436200 |doi=10.1002/2327-6924.12387 |url=}}</ref>
** CBC- normal in IBS  
** [[Complete blood count|CBC]]- normal in [[Irritable bowel syndrome|IBS]]
** Occult blood test- normal in IBS  
** [[Occult blood]] test- normal in [[Irritable bowel syndrome|IBS]]
** Complete metabolic panel- normal  
** Complete metabolic panel- normal  
** ESR- normal 
** [[ESR]]- normal 
* Additional tests may be costly and harmful in young patients with typical IBS symtoms, in the absence of alarm features.
* Additional tests may be costly and harmful in young patients with typical [[Irritable bowel syndrome|IBS]] [[symptoms]], in the absence of alarm features.<ref name="pmid11570936">{{cite journal |vauthors=Fass R, Longstreth GF, Pimentel M, Fullerton S, Russak SM, Chiou CF, Reyes E, Crane P, Eisen G, McCarberg B, Ofman J |title=Evidence- and consensus-based practice guidelines for the diagnosis of irritable bowel syndrome |journal=Arch. Intern. Med. |volume=161 |issue=17 |pages=2081–8 |year=2001 |pmid=11570936 |doi= |url=}}</ref><ref name="pmid20179696">{{cite journal |vauthors=Chey WD, Nojkov B, Rubenstein JH, Dobhan RR, Greenson JK, Cash BD |title=The yield of colonoscopy in patients with non-constipated irritable bowel syndrome: results from a prospective, controlled US trial |journal=Am. J. Gastroenterol. |volume=105 |issue=4 |pages=859–65 |year=2010 |pmid=20179696 |pmc=2887227 |doi=10.1038/ajg.2010.55 |url=}}</ref><ref name="pmid19521341">{{cite journal |vauthors=Brandt LJ, Chey WD, Foxx-Orenstein AE, Schiller LR, Schoenfeld PS, Spiegel BM, Talley NJ, Quigley EM |title=An evidence-based position statement on the management of irritable bowel syndrome |journal=Am. J. Gastroenterol. |volume=104 Suppl 1 |issue= |pages=S1–35 |year=2009 |pmid=19521341 |doi=10.1038/ajg.2008.122 |url=}}</ref>
* To determine the aggressiveness of the diagnostic evaluation, the American Gastroenterological Association has defined certain factors that must be considered:
* To determine the aggressiveness of the diagnostic evaluation, the American Gastroenterological Association has defined certain factors that must be considered:<ref name="pmid10588169">{{cite journal |vauthors=Schmulson MW, Chang L |title=Diagnostic approach to the patient with irritable bowel syndrome |journal=Am. J. Med. |volume=107 |issue=5A |pages=20S–26S |year=1999 |pmid=10588169 |doi= |url=}}</ref><ref name="pmid4023607">{{cite journal |vauthors=Svendsen JH, Munck LK, Andersen JR |title=Irritable bowel syndrome--prognosis and diagnostic safety. A 5-year follow-up study |journal=Scand. J. Gastroenterol. |volume=20 |issue=4 |pages=415–8 |year=1985 |pmid=4023607 |doi= |url=}}</ref><ref name="pmid28586906">{{cite journal |vauthors=Sultan S, Malhotra A |title=Irritable Bowel Syndrome |journal=Ann. Intern. Med. |volume=166 |issue=11 |pages=ITC81–ITC96 |year=2017 |pmid=28586906 |doi=10.7326/AITC201706060 |url=}}</ref>
** Degree of psychosocial impairment
** Degree of psychosocial impairment
** Age and sex of the patient
** Age and sex of the [[patient]]
** Family history of colorectal cancer
** [[Family history]] of [[colorectal cancer]]
** Prior diagnostic studies
** Prior [[Diagnosis|diagnostic]] studies
** Duration of symptoms
** Duration of [[Symptom|symptoms]]
** Change in symptoms over time
** Change in [[Symptom|symptoms]] over time


* In patients that require aggressive diagnostic evaluation, additional diseases need to be ruled out:
* In patients that require aggressive diagnostic evaluation, additional diseases need to be ruled out:<ref name="pmid21762658">{{cite journal |vauthors=Cash BD, Rubenstein JH, Young PE, Gentry A, Nojkov B, Lee D, Andrews AH, Dobhan R, Chey WD |title=The prevalence of celiac disease among patients with nonconstipated irritable bowel syndrome is similar to controls |journal=Gastroenterology |volume=141 |issue=4 |pages=1187–93 |year=2011 |pmid=21762658 |pmc=3186819 |doi=10.1053/j.gastro.2011.06.084 |url=}}</ref><ref name="pmid26913568">{{cite journal |vauthors=Guagnozzi D, Arias Á, Lucendo AJ |title=Systematic review with meta-analysis: diagnostic overlap of microscopic colitis and functional bowel disorders |journal=Aliment. Pharmacol. Ther. |volume=43 |issue=8 |pages=851–862 |year=2016 |pmid=26913568 |doi=10.1111/apt.13573 |url=}}</ref><ref name="pmid27796144">{{cite journal |vauthors=Hilpüsch F, Johnsen PH, Goll R, Valle PC, Sørbye SW, Abelsen B |title=Microscopic colitis: a missed diagnosis among patients with moderate to severe irritable bowel syndrome |journal=Scand. J. Gastroenterol. |volume=52 |issue=2 |pages=173–177 |year=2017 |pmid=27796144 |doi=10.1080/00365521.2016.1242025 |url=}}</ref><ref name="pmid12425553">{{cite journal |vauthors=Cash BD, Schoenfeld P, Chey WD |title=The utility of diagnostic tests in irritable bowel syndrome patients: a systematic review |journal=Am. J. Gastroenterol. |volume=97 |issue=11 |pages=2812–9 |year=2002 |pmid=12425553 |doi=10.1111/j.1572-0241.2002.07027.x |url=}}</ref><ref name="pmid6724251">{{cite journal |vauthors=Kruis W, Thieme C, Weinzierl M, Schüssler P, Holl J, Paulus W |title=A diagnostic score for the irritable bowel syndrome. Its value in the exclusion of organic disease |journal=Gastroenterology |volume=87 |issue=1 |pages=1–7 |year=1984 |pmid=6724251 |doi= |url=}}</ref>
** Celiac disease: Serological screening(antiendomysial antibodies)  
** [[Celiac disease]]: [[Serological]] [[Screening (medicine)|screening]] (antiendomysial [[antibodies]]) <ref name="pmid11705563">{{cite journal |vauthors=Sanders DS, Carter MJ, Hurlstone DP, Pearce A, Ward AM, McAlindon ME, Lobo AJ |title=Association of adult coeliac disease with irritable bowel syndrome: a case-control study in patients fulfilling ROME II criteria referred to secondary care |journal=Lancet |volume=358 |issue=9292 |pages=1504–8 |year=2001 |pmid=11705563 |doi=10.1016/S0140-6736(01)06581-3 |url=}}</ref><ref name="pmid19364994">{{cite journal |vauthors=Ford AC, Chey WD, Talley NJ, Malhotra A, Spiegel BM, Moayyedi P |title=Yield of diagnostic tests for celiac disease in individuals with symptoms suggestive of irritable bowel syndrome: systematic review and meta-analysis |journal=Arch. Intern. Med. |volume=169 |issue=7 |pages=651–8 |year=2009 |pmid=19364994 |doi=10.1001/archinternmed.2009.22 |url=}}</ref><ref name="pmid23826010">{{cite journal |vauthors=Mehdi Z, Sakineh E, Mohammad F, Mansour R, Alireza A |title=Celiac disease: Serologic prevalence in patients with irritable bowel syndrome |journal=J Res Med Sci |volume=17 |issue=9 |pages=839–42 |year=2012 |pmid=23826010 |pmc=3697208 |doi= |url=}}</ref><ref name="pmid23609613">{{cite journal |vauthors=Rubio-Tapia A, Hill ID, Kelly CP, Calderwood AH, Murray JA |title=ACG clinical guidelines: diagnosis and management of celiac disease |journal=Am. J. Gastroenterol. |volume=108 |issue=5 |pages=656–76; quiz 677 |year=2013 |pmid=23609613 |pmc=3706994 |doi=10.1038/ajg.2013.79 |url=}}</ref><ref name="pmid27753436">{{cite journal |vauthors=Irvine AJ, Chey WD, Ford AC |title=Screening for Celiac Disease in Irritable Bowel Syndrome: An Updated Systematic Review and Meta-analysis |journal=Am. J. Gastroenterol. |volume=112 |issue=1 |pages=65–76 |year=2017 |pmid=27753436 |doi=10.1038/ajg.2016.466 |url=}}</ref><ref name="pmid19364994">{{cite journal |vauthors=Ford AC, Chey WD, Talley NJ, Malhotra A, Spiegel BM, Moayyedi P |title=Yield of diagnostic tests for celiac disease in individuals with symptoms suggestive of irritable bowel syndrome: systematic review and meta-analysis |journal=Arch. Intern. Med. |volume=169 |issue=7 |pages=651–8 |year=2009 |pmid=19364994 |doi=10.1001/archinternmed.2009.22 |url=}}</ref><ref name="pmid21762658">{{cite journal |vauthors=Cash BD, Rubenstein JH, Young PE, Gentry A, Nojkov B, Lee D, Andrews AH, Dobhan R, Chey WD |title=The prevalence of celiac disease among patients with nonconstipated irritable bowel syndrome is similar to controls |journal=Gastroenterology |volume=141 |issue=4 |pages=1187–93 |year=2011 |pmid=21762658 |pmc=3186819 |doi=10.1053/j.gastro.2011.06.084 |url=}}</ref>
** IBD:  
** IBD: <ref name="pmid25732419">{{cite journal |vauthors=Menees SB, Powell C, Kurlander J, Goel A, Chey WD |title=A meta-analysis of the utility of C-reactive protein, erythrocyte sedimentation rate, fecal calprotectin, and fecal lactoferrin to exclude inflammatory bowel disease in adults with IBS |journal=Am. J. Gastroenterol. |volume=110 |issue=3 |pages=444–54 |year=2015 |pmid=25732419 |doi=10.1038/ajg.2015.6 |url=}}</ref><ref name="pmid20634346">{{cite journal |vauthors=van Rheenen PF, Van de Vijver E, Fidler V |title=Faecal calprotectin for screening of patients with suspected inflammatory bowel disease: diagnostic meta-analysis |journal=BMJ |volume=341 |issue= |pages=c3369 |year=2010 |pmid=20634346 |pmc=2904879 |doi= |url=}}</ref><ref name="pmid24286461">{{cite journal |vauthors=Waugh N, Cummins E, Royle P, Kandala NB, Shyangdan D, Arasaradnam R, Clar C, Johnston R |title=Faecal calprotectin testing for differentiating amongst inflammatory and non-inflammatory bowel diseases: systematic review and economic evaluation |journal=Health Technol Assess |volume=17 |issue=55 |pages=xv–xix, 1–211 |year=2013 |pmid=24286461 |pmc=4781415 |doi=10.3310/hta17550 |url=}}</ref><ref name="pmid25732419">{{cite journal |vauthors=Menees SB, Powell C, Kurlander J, Goel A, Chey WD |title=A meta-analysis of the utility of C-reactive protein, erythrocyte sedimentation rate, fecal calprotectin, and fecal lactoferrin to exclude inflammatory bowel disease in adults with IBS |journal=Am. J. Gastroenterol. |volume=110 |issue=3 |pages=444–54 |year=2015 |pmid=25732419 |doi=10.1038/ajg.2015.6 |url=}}</ref><ref name="pmid28954618">{{cite journal |vauthors=Linedale EC, Andrews JM |title=Diagnosis and management of irritable bowel syndrome: a guide for the generalist |journal=Med. J. Aust. |volume=207 |issue=7 |pages=309–315 |year=2017 |pmid=28954618 |doi= |url=}}</ref><ref name="pmid27667579">{{cite journal |vauthors=Spiller R, Major G |title=IBS and IBD - separate entities or on a spectrum? |journal=Nat Rev Gastroenterol Hepatol |volume=13 |issue=10 |pages=613–21 |year=2016 |pmid=27667579 |doi=10.1038/nrgastro.2016.141 |url=}}</ref><ref name="pmid27658156">{{cite journal |vauthors=Manceau H, Chicha-Cattoir V, Puy H, Peoc'h K |title=Fecal calprotectin in inflammatory bowel diseases: update and perspectives |journal=Clin. Chem. Lab. Med. |volume=55 |issue=4 |pages=474–483 |year=2017 |pmid=27658156 |doi=10.1515/cclm-2016-0522 |url=}}</ref>
*** Inflammatory markers (ESR, C-reactive protein, plasma viscosity) are likely to be raised  
*** [[Inflammatory]] markers ([[Erythrocyte sedimentation rate|ESR]], [[C-reactive protein (CRP)|C-reactive protein]], [[plasma]] viscosity) are likely to be raised  
*** LFTs: decreased serum albumin  
*** LFTs: decreased [[serum albumin]]
*** Complete blood count shows IDA due to blood loss  
*** [[Complete blood count]] shows [[iron deficiency anemia]] due to [[blood]] loss  
*** Fecal calprotectin  
*** Fecal calprotectin  
*** antibodies to a bacterial toxin produced by:
*** [[Antibodies]] to a [[bacterial]] [[toxin]] produced by:<ref name="pmid28451914">{{cite journal |vauthors=Rezaie A, Park SC, Morales W, Marsh E, Lembo A, Kim JH, Weitsman S, Chua KS, Barlow GM, Pimentel M |title=Assessment of Anti-vinculin and Anti-cytolethal Distending Toxin B Antibodies in Subtypes of Irritable Bowel Syndrome |journal=Dig. Dis. Sci. |volume=62 |issue=6 |pages=1480–1485 |year=2017 |pmid=28451914 |doi=10.1007/s10620-017-4585-z |url=}}</ref><ref name="pmid25970536">{{cite journal |vauthors=Pimentel M, Morales W, Rezaie A, Marsh E, Lembo A, Mirocha J, Leffler DA, Marsh Z, Weitsman S, Chua KS, Barlow GM, Bortey E, Forbes W, Yu A, Chang C |title=Development and validation of a biomarker for diarrhea-predominant irritable bowel syndrome in human subjects |journal=PLoS ONE |volume=10 |issue=5 |pages=e0126438 |year=2015 |pmid=25970536 |pmc=4430499 |doi=10.1371/journal.pone.0126438 |url=}}</ref><ref name="pmid27681080">{{cite journal |vauthors=Schmulson M, Balbuena R, Corona de Law C |title=Clinical experience with the use of anti-CdtB and anti-vinculin antibodies in patients with diarrhea in Mexico |journal=Rev Gastroenterol Mex |volume=81 |issue=4 |pages=236–239 |year=2016 |pmid=27681080 |doi=10.1016/j.rgmx.2016.07.001 |url=}}</ref><ref name="pmid25970536">{{cite journal |vauthors=Pimentel M, Morales W, Rezaie A, Marsh E, Lembo A, Mirocha J, Leffler DA, Marsh Z, Weitsman S, Chua KS, Barlow GM, Bortey E, Forbes W, Yu A, Chang C |title=Development and validation of a biomarker for diarrhea-predominant irritable bowel syndrome in human subjects |journal=PLoS ONE |volume=10 |issue=5 |pages=e0126438 |year=2015 |pmid=25970536 |pmc=4430499 |doi=10.1371/journal.pone.0126438 |url=}}</ref>
**** ''Campylobacter jejuni''   
**** ''[[Campylobacter jejuni]]''   
**** vinculin
**** [[Vinculin]]
** Giardiasis: prevalent in developing countries  
** In [[Irritable bowel syndrome|IBS]]- [[diarrhea]] patients with recent [[antibiotic]] use, [[Human feces|stool]] samples should be taken to exclude ''[[Clostridium difficile]]'' infection:<ref name="pmid27682513">{{cite journal |vauthors=Barlow GM, Rezaie A, Lin E, Pimentel M |title=A definitive blood test for post-infectious irritable bowel syndrome? |journal=Expert Rev Gastroenterol Hepatol |volume=10 |issue=11 |pages=1197–1199 |year=2016 |pmid=27682513 |doi=10.1080/17474124.2016.1242411 |url=}}</ref>
*** stool sample for microscopy  
*** [[Enzyme immunoassay]] 
*** culture with specific request to look for ova, cyst and parasites
*** [[Polymerase chain reaction]]
** Lactase deficiency:  
** [[Giardiasis]]: [[Prevalence|Prevalent]] in developing countries  
*** Hydrogen breath test  
*** [[Stool]] sample for [[microscopy]]
*** Evaluation after a 3-week lactose-free diet.
*** Culture with specific request to look for [[Ovum|ova]], [[cyst]] and [[parasites]]
** Bile salt malabsorption:
** [[Lactase]] deficiency: <ref name="pmid11293439">{{cite journal |vauthors=Parker TJ, Woolner JT, Prevost AT, Tuffnell Q, Shorthouse M, Hunter JO |title=Irritable bowel syndrome: is the search for lactose intolerance justified? |journal=Eur J Gastroenterol Hepatol |volume=13 |issue=3 |pages=219–25 |year=2001 |pmid=11293439 |doi= |url=}}</ref><ref name="pmid12425553">{{cite journal |vauthors=Cash BD, Schoenfeld P, Chey WD |title=The utility of diagnostic tests in irritable bowel syndrome patients: a systematic review |journal=Am. J. Gastroenterol. |volume=97 |issue=11 |pages=2812–9 |year=2002 |pmid=12425553 |doi=10.1111/j.1572-0241.2002.07027.x |url=}}</ref>
*** Biochemical testing of blood (e.g., testing for serum 7α-hydroxy-4-cholesten-3-one [C4, a bile acid precursor])   
*** [[Hydrogen Breath Test|Hydrogen breath test]]
*** Therapeutic trial of cholestyramine (bile acid sequestrant)  
*** Evaluation after a 3-week [[lactose]]-free diet.
**Colon Cancer:
** [[Bile salt]] [[malabsorption]]:
***Complete blood-count
*** Biochemical testing of [[blood]] (e.g., testing for [[serum]] 7α-hydroxy-4-cholesten-3-one [C4, a [[bile acid]] precursor])   
***Erythrocyte sedimentation rate  
*** Therapeutic trial of [[cholestyramine]] ([[bile acid sequestrant]])  
***C reactive protein
**[[Colorectal cancer|Colon Cancer]]:
***Thyroid function test
***[[Complete blood count]]
***Liver function
***[[Erythrocyte sedimentation rate]]
***Stool examination
***[[C-reactive protein|C reactive protein]]
***Stool culture
***[[Thyroid function tests|Thyroid function test]]
***[[Liver function tests|Liver function]]
***[[Stool examination]]
***[[Stool culture]]
**In pain predominant [[Irritable bowel syndrome|IBS]] patients, [[Bile duct|biliary]] and [[Pancreas|pancreatic]] disease are excluded by:
***[[Amylase|Serum amylase]]
***[[Liver function tests]]
* Other organic causes are suspected if lab investigations show the following:
* Other organic causes are suspected if lab investigations show the following:
** Complete blood count: evidence of anemia
** [[Complete blood count]]: evidence of [[anemia]]
** ESR raised
** [[Erythrocyte sedimentation rate|ESR]] raised
** Stool Volume >200–300 mL/day
** [[Human feces|Stool]] volume >200–300 mL/day
** Stool content: Blood and leukocytes
** [[Human feces|Stool]] content: [[Blood]] and [[White blood cells|leukocytes]]
''''' '''''
 


==== ''''' ''Role of biomarkers''' ====
* A [[biomarker]] may help in objective evaluation as a measure of normal biological processes such as transit through the [[Colon (anatomy)|colon]], [[serotonin]] and [[bile acid]] metabolism. This may be highly [[Prevalence|prevalent]] in certain [[Irritable bowel syndrome|IBS]] subtypes.Antibodies to cytolethal distending toxin B (CdtB) and [[vinculin]] are some novel biomarkers that help in distinguishing irritable bowel syndrome with [[diarrhea]] (IBS-D) from other causes of [[diarrhea]].<ref name="pmid11240971">{{cite journal |vauthors= |title=Biomarkers and surrogate endpoints: preferred definitions and conceptual framework |journal=Clin. Pharmacol. Ther. |volume=69 |issue=3 |pages=89–95 |year=2001 |pmid=11240971 |doi=10.1067/mcp.2001.113989 |url=}}</ref><ref name="pmid19923339">{{cite journal |vauthors=Barbara G, Stanghellini V |title=Biomarkers in IBS: when will they replace symptoms for diagnosis and management? |journal=Gut |volume=58 |issue=12 |pages=1571–5 |year=2009 |pmid=19923339 |doi=10.1136/gut.2008.169672 |url=}}</ref><ref name="pmid26264216">{{cite journal |vauthors=Camilleri M |title=Review article: biomarkers and personalised therapy in functional lower gastrointestinal disorders |journal=Aliment. Pharmacol. Ther. |volume=42 |issue=7 |pages=818–28 |year=2015 |pmid=26264216 |pmc=4558225 |doi=10.1111/apt.13351 |url=}}</ref><ref name="pmid26076071">{{cite journal |vauthors=Sood R, Gracie DJ, Law GR, Ford AC |title=Systematic review with meta-analysis: the accuracy of diagnosing irritable bowel syndrome with symptoms, biomarkers and/or psychological markers |journal=Aliment. Pharmacol. Ther. |volume=42 |issue=5 |pages=491–503 |year=2015 |pmid=26076071 |doi=10.1111/apt.13283 |url=}}</ref><ref name="pmid25970536">{{cite journal |vauthors=Pimentel M, Morales W, Rezaie A, Marsh E, Lembo A, Mirocha J, Leffler DA, Marsh Z, Weitsman S, Chua KS, Barlow GM, Bortey E, Forbes W, Yu A, Chang C |title=Development and validation of a biomarker for diarrhea-predominant irritable bowel syndrome in human subjects |journal=PLoS ONE |volume=10 |issue=5 |pages=e0126438 |year=2015 |pmid=25970536 |pmc=4430499 |doi=10.1371/journal.pone.0126438 |url=}}</ref><ref name="pmid25244349">{{cite journal |vauthors=Camilleri M, Shin A, Busciglio I, Carlson P, Acosta A, Bharucha AE, Burton D, Lamsam J, Lueke A, Donato LJ, Zinsmeister AR |title=Validating biomarkers of treatable mechanisms in irritable bowel syndrome |journal=Neurogastroenterol. Motil. |volume=26 |issue=12 |pages=1677–85 |year=2014 |pmid=25244349 |pmc=4245393 |doi=10.1111/nmo.12421 |url=}}</ref><ref name="pmid25970536">{{cite journal |vauthors=Pimentel M, Morales W, Rezaie A, Marsh E, Lembo A, Mirocha J, Leffler DA, Marsh Z, Weitsman S, Chua KS, Barlow GM, Bortey E, Forbes W, Yu A, Chang C |title=Development and validation of a biomarker for diarrhea-predominant irritable bowel syndrome in human subjects |journal=PLoS ONE |volume=10 |issue=5 |pages=e0126438 |year=2015 |pmid=25970536 |pmc=4430499 |doi=10.1371/journal.pone.0126438 |url=}}</ref><ref name="pmid28128666">{{cite journal |vauthors=Camilleri M, Halawi H, Oduyebo I |title=Biomarkers as a diagnostic tool for irritable bowel syndrome: where are we? |journal=Expert Rev Gastroenterol Hepatol |volume=11 |issue=4 |pages=303–316 |year=2017 |pmid=28128666 |doi=10.1080/17474124.2017.1288096 |url=}}</ref><ref name="pmid28451914">{{cite journal |vauthors=Rezaie A, Park SC, Morales W, Marsh E, Lembo A, Kim JH, Weitsman S, Chua KS, Barlow GM, Pimentel M |title=Assessment of Anti-vinculin and Anti-cytolethal Distending Toxin B Antibodies in Subtypes of Irritable Bowel Syndrome |journal=Dig. Dis. Sci. |volume=62 |issue=6 |pages=1480–1485 |year=2017 |pmid=28451914 |doi=10.1007/s10620-017-4585-z |url=}}</ref>


==References==
==References==
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Latest revision as of 16:18, 4 December 2017

Irritable bowel syndrome Microchapters

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sudarshana Datta, MD [2]

Overview

The diagnosis of irritable bowel syndrome (IBS) is based on clinical symptoms and elimination of other organic gastrointestinal diseases. This is due to lack of definitive radiologic or laboratory diagnostic tests in IBS. If the history and physical examination are suggestive of IBS in the absence of alarm features, complete blood count, occult blood test, complete metabolic panel and ESR are usually normal. Additional tests may be costly and harmful in young patients with typical IBS symptoms, in the absence of alarm features. To determine the aggressiveness of the diagnostic evaluation, the American Gastroenterological Association has defined certain factors that must be considered such as degree of psychosocial impairment, age and sex of the patient, family history of colorectal cancer etc. In patients that require aggressive diagnostic evaluation, additional diseases such as Celiac disease, IBD, Clostridium difficile infection, giardiasis, lactase deficiency, bile salt malabsorption and colon cancer should be ruled out.

Laboratory Findings

 Role of biomarkers

References

  1. ↑ Longstreth GF, Thompson WG, Chey WD, Houghton LA, Mearin F, Spiller RC (2006). "Functional bowel disorders". Gastroenterology. 130 (5): 1480–91. doi:10.1053/j.gastro.2005.11.061. PMID 16678561.
  2. ↑ Drossman DA, Camilleri M, Mayer EA, Whitehead WE (2002). "AGA technical review on irritable bowel syndrome". Gastroenterology. 123 (6): 2108–31. doi:10.1053/gast.2002.37095. PMID 12454866.
  3. ↑ Spiller R, Aziz Q, Creed F, Emmanuel A, Houghton L, Hungin P, Jones R, Kumar D, Rubin G, Trudgill N, Whorwell P (2007). "Guidelines on the irritable bowel syndrome: mechanisms and practical management". Gut. 56 (12): 1770–98. doi:10.1136/gut.2007.119446. PMC 2095723. PMID 17488783.
  4. ↑ Brandt LJ, Bjorkman D, Fennerty MB, Locke GR, Olden K, Peterson W, Quigley E, Schoenfeld P, Schuster M, Talley N (2002). "Systematic review on the management of irritable bowel syndrome in North America". Am. J. Gastroenterol. 97 (11 Suppl): S7–26. PMID 12425586.
  5. ↑ Yawn BP, Lydick E, Locke GR, Wollan PC, Bertram SL, Kurland MJ (2001). "Do published guidelines for evaluation of irritable bowel syndrome reflect practice?". BMC gastroenterology. 1: 11. PMID 11701092.
  6. ↑ Ford AC, Lacy BE, Talley NJ (2017). "Irritable Bowel Syndrome". N. Engl. J. Med. 376 (26): 2566–2578. doi:10.1056/NEJMra1607547. PMID 28657875.
  7. ↑ Weaver KR, Melkus GD, Henderson WA (2017). "Irritable Bowel Syndrome". Am J Nurs. 117 (6): 48–55. doi:10.1097/01.NAJ.0000520253.57459.01. PMID 28541989.
  8. ↑ De Ponti F (2004). "Pharmacology of serotonin: what a clinician should know". Gut. 53 (10): 1520–35. doi:10.1136/gut.2003.035568. PMC 1774227. PMID 15361507.
  9. ↑ 9.0 9.1 9.2 Menees SB, Powell C, Kurlander J, Goel A, Chey WD (2015). "A meta-analysis of the utility of C-reactive protein, erythrocyte sedimentation rate, fecal calprotectin, and fecal lactoferrin to exclude inflammatory bowel disease in adults with IBS". Am. J. Gastroenterol. 110 (3): 444–54. doi:10.1038/ajg.2015.6. PMID 25732419.
  10. ↑ Thompson WG, Heaton KW, Smyth GT, Smyth C (2000). "Irritable bowel syndrome in general practice: prevalence, characteristics, and referral". Gut. 46 (1): 78–82. PMC 1727778. PMID 10601059.
  11. ↑ 11.0 11.1 Brandt LJ, Chey WD, Foxx-Orenstein AE, Schiller LR, Schoenfeld PS, Spiegel BM, Talley NJ, Quigley EM (2009). "An evidence-based position statement on the management of irritable bowel syndrome". Am. J. Gastroenterol. 104 Suppl 1: S1–35. doi:10.1038/ajg.2008.122. PMID 19521341.
  12. ↑ Vargues R (1967). "[The determination of complement]". Transfusion (Paris) (in French). 10 (3): 277–92. PMID 4169512.
  13. ↑ Begtrup LM, Engsbro AL, Kjeldsen J, Larsen PV, Schaffalitzky de Muckadell O, Bytzer P, Jarbøl DE (2013). "A positive diagnostic strategy is noninferior to a strategy of exclusion for patients with irritable bowel syndrome". Clin. Gastroenterol. Hepatol. 11 (8): 956–62.e1. doi:10.1016/j.cgh.2012.12.038. PMID 23357491.
  14. ↑ Lacy BE, Moreau JC (2016). "Diarrhea-predominant irritable bowel syndrome: Diagnosis, etiology, and new treatment considerations". J Am Assoc Nurse Pract. 28 (7): 393–404. doi:10.1002/2327-6924.12387. PMID 27436200.
  15. ↑ Fass R, Longstreth GF, Pimentel M, Fullerton S, Russak SM, Chiou CF, Reyes E, Crane P, Eisen G, McCarberg B, Ofman J (2001). "Evidence- and consensus-based practice guidelines for the diagnosis of irritable bowel syndrome". Arch. Intern. Med. 161 (17): 2081–8. PMID 11570936.
  16. ↑ Chey WD, Nojkov B, Rubenstein JH, Dobhan RR, Greenson JK, Cash BD (2010). "The yield of colonoscopy in patients with non-constipated irritable bowel syndrome: results from a prospective, controlled US trial". Am. J. Gastroenterol. 105 (4): 859–65. doi:10.1038/ajg.2010.55. PMC 2887227. PMID 20179696.
  17. ↑ Schmulson MW, Chang L (1999). "Diagnostic approach to the patient with irritable bowel syndrome". Am. J. Med. 107 (5A): 20S–26S. PMID 10588169.
  18. ↑ Svendsen JH, Munck LK, Andersen JR (1985). "Irritable bowel syndrome--prognosis and diagnostic safety. A 5-year follow-up study". Scand. J. Gastroenterol. 20 (4): 415–8. PMID 4023607.
  19. ↑ Sultan S, Malhotra A (2017). "Irritable Bowel Syndrome". Ann. Intern. Med. 166 (11): ITC81–ITC96. doi:10.7326/AITC201706060. PMID 28586906.
  20. ↑ 20.0 20.1 Cash BD, Rubenstein JH, Young PE, Gentry A, Nojkov B, Lee D, Andrews AH, Dobhan R, Chey WD (2011). "The prevalence of celiac disease among patients with nonconstipated irritable bowel syndrome is similar to controls". Gastroenterology. 141 (4): 1187–93. doi:10.1053/j.gastro.2011.06.084. PMC 3186819. PMID 21762658.
  21. ↑ Guagnozzi D, Arias Á, Lucendo AJ (2016). "Systematic review with meta-analysis: diagnostic overlap of microscopic colitis and functional bowel disorders". Aliment. Pharmacol. Ther. 43 (8): 851–862. doi:10.1111/apt.13573. PMID 26913568.
  22. ↑ Hilpüsch F, Johnsen PH, Goll R, Valle PC, Sørbye SW, Abelsen B (2017). "Microscopic colitis: a missed diagnosis among patients with moderate to severe irritable bowel syndrome". Scand. J. Gastroenterol. 52 (2): 173–177. doi:10.1080/00365521.2016.1242025. PMID 27796144.
  23. ↑ 23.0 23.1 Cash BD, Schoenfeld P, Chey WD (2002). "The utility of diagnostic tests in irritable bowel syndrome patients: a systematic review". Am. J. Gastroenterol. 97 (11): 2812–9. doi:10.1111/j.1572-0241.2002.07027.x. PMID 12425553.
  24. ↑ Kruis W, Thieme C, Weinzierl M, Schüssler P, Holl J, Paulus W (1984). "A diagnostic score for the irritable bowel syndrome. Its value in the exclusion of organic disease". Gastroenterology. 87 (1): 1–7. PMID 6724251.
  25. ↑ Sanders DS, Carter MJ, Hurlstone DP, Pearce A, Ward AM, McAlindon ME, Lobo AJ (2001). "Association of adult coeliac disease with irritable bowel syndrome: a case-control study in patients fulfilling ROME II criteria referred to secondary care". Lancet. 358 (9292): 1504–8. doi:10.1016/S0140-6736(01)06581-3. PMID 11705563.
  26. ↑ 26.0 26.1 Ford AC, Chey WD, Talley NJ, Malhotra A, Spiegel BM, Moayyedi P (2009). "Yield of diagnostic tests for celiac disease in individuals with symptoms suggestive of irritable bowel syndrome: systematic review and meta-analysis". Arch. Intern. Med. 169 (7): 651–8. doi:10.1001/archinternmed.2009.22. PMID 19364994.
  27. ↑ Mehdi Z, Sakineh E, Mohammad F, Mansour R, Alireza A (2012). "Celiac disease: Serologic prevalence in patients with irritable bowel syndrome". J Res Med Sci. 17 (9): 839–42. PMC 3697208. PMID 23826010.
  28. ↑ Rubio-Tapia A, Hill ID, Kelly CP, Calderwood AH, Murray JA (2013). "ACG clinical guidelines: diagnosis and management of celiac disease". Am. J. Gastroenterol. 108 (5): 656–76, quiz 677. doi:10.1038/ajg.2013.79. PMC 3706994. PMID 23609613.
  29. ↑ Irvine AJ, Chey WD, Ford AC (2017). "Screening for Celiac Disease in Irritable Bowel Syndrome: An Updated Systematic Review and Meta-analysis". Am. J. Gastroenterol. 112 (1): 65–76. doi:10.1038/ajg.2016.466. PMID 27753436.
  30. ↑ van Rheenen PF, Van de Vijver E, Fidler V (2010). "Faecal calprotectin for screening of patients with suspected inflammatory bowel disease: diagnostic meta-analysis". BMJ. 341: c3369. PMC 2904879. PMID 20634346.
  31. ↑ Waugh N, Cummins E, Royle P, Kandala NB, Shyangdan D, Arasaradnam R, Clar C, Johnston R (2013). "Faecal calprotectin testing for differentiating amongst inflammatory and non-inflammatory bowel diseases: systematic review and economic evaluation". Health Technol Assess. 17 (55): xv–xix, 1–211. doi:10.3310/hta17550. PMC 4781415. PMID 24286461.
  32. ↑ Linedale EC, Andrews JM (2017). "Diagnosis and management of irritable bowel syndrome: a guide for the generalist". Med. J. Aust. 207 (7): 309–315. PMID 28954618.
  33. ↑ Spiller R, Major G (2016). "IBS and IBD - separate entities or on a spectrum?". Nat Rev Gastroenterol Hepatol. 13 (10): 613–21. doi:10.1038/nrgastro.2016.141. PMID 27667579.
  34. ↑ Manceau H, Chicha-Cattoir V, Puy H, Peoc'h K (2017). "Fecal calprotectin in inflammatory bowel diseases: update and perspectives". Clin. Chem. Lab. Med. 55 (4): 474–483. doi:10.1515/cclm-2016-0522. PMID 27658156.
  35. ↑ 35.0 35.1 Rezaie A, Park SC, Morales W, Marsh E, Lembo A, Kim JH, Weitsman S, Chua KS, Barlow GM, Pimentel M (2017). "Assessment of Anti-vinculin and Anti-cytolethal Distending Toxin B Antibodies in Subtypes of Irritable Bowel Syndrome". Dig. Dis. Sci. 62 (6): 1480–1485. doi:10.1007/s10620-017-4585-z. PMID 28451914.
  36. ↑ 36.0 36.1 36.2 36.3 Pimentel M, Morales W, Rezaie A, Marsh E, Lembo A, Mirocha J, Leffler DA, Marsh Z, Weitsman S, Chua KS, Barlow GM, Bortey E, Forbes W, Yu A, Chang C (2015). "Development and validation of a biomarker for diarrhea-predominant irritable bowel syndrome in human subjects". PLoS ONE. 10 (5): e0126438. doi:10.1371/journal.pone.0126438. PMC 4430499. PMID 25970536.
  37. ↑ Schmulson M, Balbuena R, Corona de Law C (2016). "Clinical experience with the use of anti-CdtB and anti-vinculin antibodies in patients with diarrhea in Mexico". Rev Gastroenterol Mex. 81 (4): 236–239. doi:10.1016/j.rgmx.2016.07.001. PMID 27681080.
  38. ↑ Barlow GM, Rezaie A, Lin E, Pimentel M (2016). "A definitive blood test for post-infectious irritable bowel syndrome?". Expert Rev Gastroenterol Hepatol. 10 (11): 1197–1199. doi:10.1080/17474124.2016.1242411. PMID 27682513.
  39. ↑ Parker TJ, Woolner JT, Prevost AT, Tuffnell Q, Shorthouse M, Hunter JO (2001). "Irritable bowel syndrome: is the search for lactose intolerance justified?". Eur J Gastroenterol Hepatol. 13 (3): 219–25. PMID 11293439.
  40. ↑ "Biomarkers and surrogate endpoints: preferred definitions and conceptual framework". Clin. Pharmacol. Ther. 69 (3): 89–95. 2001. doi:10.1067/mcp.2001.113989. PMID 11240971.
  41. ↑ Barbara G, Stanghellini V (2009). "Biomarkers in IBS: when will they replace symptoms for diagnosis and management?". Gut. 58 (12): 1571–5. doi:10.1136/gut.2008.169672. PMID 19923339.
  42. ↑ Camilleri M (2015). "Review article: biomarkers and personalised therapy in functional lower gastrointestinal disorders". Aliment. Pharmacol. Ther. 42 (7): 818–28. doi:10.1111/apt.13351. PMC 4558225. PMID 26264216.
  43. ↑ Sood R, Gracie DJ, Law GR, Ford AC (2015). "Systematic review with meta-analysis: the accuracy of diagnosing irritable bowel syndrome with symptoms, biomarkers and/or psychological markers". Aliment. Pharmacol. Ther. 42 (5): 491–503. doi:10.1111/apt.13283. PMID 26076071.
  44. ↑ Camilleri M, Shin A, Busciglio I, Carlson P, Acosta A, Bharucha AE, Burton D, Lamsam J, Lueke A, Donato LJ, Zinsmeister AR (2014). "Validating biomarkers of treatable mechanisms in irritable bowel syndrome". Neurogastroenterol. Motil. 26 (12): 1677–85. doi:10.1111/nmo.12421. PMC 4245393. PMID 25244349.
  45. ↑ Camilleri M, Halawi H, Oduyebo I (2017). "Biomarkers as a diagnostic tool for irritable bowel syndrome: where are we?". Expert Rev Gastroenterol Hepatol. 11 (4): 303–316. doi:10.1080/17474124.2017.1288096. PMID 28128666.

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