Gastroenterology

Gastroenterology

Volume 136, Issue 6, May 2009, Pages 1979-1988
Gastroenterology

Postinfectious Irritable Bowel Syndrome

https://doi.org/10.1053/j.gastro.2009.02.074Get rights and content

Approximately 1 in ten patients with irritable bowel syndrome (IBS) believe their IBS began with an infectious illness. Prospective studies have shown that 3% to 36% of enteric infections lead to persistent new IBS symptoms; the precise incidence depends on the infecting organism. Whereas viral gastroenteritis seems to have only short-term effects, bacterial enteritis and protozoan and helminth infections are followed by prolonged postinfective IBS (PI-IBS). Risk factors for developing PI-IBS include, in order of importance, prolonged duration of initial illness, toxicity of infecting bacterial strain, smoking, mucosal markers of inflammation, female gender, depression, hypochondriasis, and adverse life events in the preceding 3 months. Age older than 60 years might protect against PI-IBS, whereas treatment with antibiotics has been associated with increased risk. The mechanisms that cause PI-IBS are unknown but could include residual inflammation or persistent changes in mucosal immunocytes, enterochromaffin and mast cells, enteric nerves, and the gastrointestinal microbiota. Adverse psychological factors contribute to persistent low-grade inflammation. The prognosis for patients with PI-IBS is somewhat better than for those with unselected IBS, but PI-IBS can still take years to resolve. There are no specific treatments for PI-IBS; these should be tailored to the predominant bowel disturbance, which is most frequently diarrhea.

Section snippets

Definition

For the purpose of this review, and in the absence of biomarkers, we will use the relevant Rome criteria for IBS.4 We define PI-IBS as the acute onset of new IBS symptoms in an individual, who has not previously met the Rome criteria for IBS, immediately following an acute illness characterized by 2 or more of the following: fever, vomiting, diarrhea, or a positive bacterial stool culture.5 Although studies should ideally identify patients with PI-IBS based on a combination of symptoms and

Epidemiology

Infective diarrhea is one of the most common illnesses worldwide. Official statistics for infection substantially underrepresent the problem. A large community survey of 9776 individuals in England and Wales showed that the annual incidence of gastrointestinal infection was 19.4 per 100 person-years, of which only 1 in 136 was reported to a national surveillance database.6 Approximately 35% of cases in this survey were caused by viral infections, mostly norovirus and rotavirus; bacterial

Clinical Features of PI-IBS

The majority (63%) of cases of PI-IBS following C jejuni–associated enteritis meet the Rome II criteria for IBS with diarrhea (IBS-D), with predominantly loose stool passed more frequently than normal and with urgency. About 24% of cases have an alternating pattern, and 13% report constipation.2 Bloating and increased frequency of passing mucus per rectum have also been reported.10 Physiological studies show accelerated colonic transit and a decreased threshold for discomfort and pain during

Risk Factors for PI-IBS

As with IBS in general, understanding the risk factors for the syndrome is best considered using a biopsychosocial model that includes influences from both the brain and the gut16 (see Figure 1).

Mechanisms

Acute infectious diarrhea is rarely investigated invasively because the illness often resolves without specific treatment. Therefore, little is known about its pathogenesis.

Differential Diagnosis of PI-IBS: Lactose Intolerance, Bile Acid Malabsorption, and Rare Postinfection Syndromes

Acute acquired hypolactasia following gastroenteritis is well recognized in children, and its effects are usually short lived.85 There is only one study in adults with PI-IBS; it found that lactose intolerance did not occur in any of the 24 adults with PI-IBS 3 to 6 months following infection,86 suggesting that testing for lactose intolerance is unlikely to be useful in management of this condition. The occurrence of bile acid malabsorption following infectious gastroenteritis has been well

Prognosis of PI-IBS

Prolonged follow-up studies of PI-IBS are scarce. One of the earliest studies reported that 5 years after onset, 5 of 11 patients with PI-IBS after S enteritidis infection still had diarrhea more than once each week.98 Other studies found that 8 of 14 patients still had persistent symptoms 5 years after infection.99 According to this study, patients with a history of treatment for anxiety or depression were unlikely to recover, a conclusion similar to that of a much earlier study.100 A recent

Management of PI-IBS

Therapy for PI-IBS should be adjusted to the severity of the patient's symptoms. Once the diagnosis has been formally established, the patient should be reassured that the prognosis is likely to be one of improvement rather than deterioration. Patients for which urgency and diarrhea are main concerns should be given loperamide, titrating the dose to obtain optimum effect. Patients with painful symptoms are often given low doses of amitriptyline. Although there have been no randomized controlled

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    Conflicts of interest The authors disclose the following: Dr Spiller had received research funding from GlaxoSmithKline, Novartis Pharmaceuticals, and Dr Falk Pharma GmbH and has been an advisory board member for Ironwood, Tioga Pharmaceuticals, Albireo, and Sucampo. Dr Garsed discloses no conflicts.

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