Postinfectious Irritable Bowel Syndrome
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
References (111)
- et al.
Relative importance of enterochromaffin cell hyperplasia, anxiety, and depression in postinfectious IBS
Gastroenterology
(2003) - et al.
Functional bowel disorders
Gastroenterology
(2006) - et al.
Distinctive clinical, psychological, and histological features of postinfective irritable bowel syndrome
Am J Gastroenterol
(2003) - et al.
Incidence and epidemiology of irritable bowel syndrome after a large waterborne outbreak of bacterial dysentery
Gastroenterology
(2006) - et al.
Postinfectious irritable bowel syndrome after a food-borne outbreak of acute gastroenteritis attributed to a viral pathogen
Clin Gastroenterol Hepatol
(2007) - et al.
Psychometric scores and persistence of irritable bowel after infectious diarrhoea
Lancet
(1996) - et al.
Irritable bowel syndrome in twins: heredity and social learning both contribute to etiology
Gastroenterology
(2001) - et al.
Psychosocial risk markers for new onset irritable bowel syndrome—results of a large prospective population-based study
Pain
(2008) - et al.
Is irritable bowel syndrome more common in patients presenting with bacterial gastroenteritis?A community-based, case-control study
Am J Gastroenterol
(2003) - et al.
Dyspepsia and irritable bowel syndrome after a Salmonella gastroenteritis outbreak: one-year follow-up cohort study
Gastroenterology
(2005)
Incidence and epidemiology of irritable bowel syndrome after a large waterborne outbreak of bacterial dysentery
Gastroenterology
Irritable bowel syndrome—post salmonella infection
J Infect
Persisting symptoms and duodenal inflammation related to Giardia duodenalis infection
J Infect
Abnormalities of 5-hydroxytryptamine metabolism in irritable bowel syndrome
Clin Gastroenterol Hepatol
Molecular defects in mucosal serotonin content and decreased serotonin reuptake transporter in ulcerative colitis and irritable bowel syndrome
Gastroenterology
Visceral hyperalgesia and intestinal dysmotility in a mouse model of postinfective gut dysfunction
Gastroenterology
Activated mast cells in proximity to colonic nerves correlate with abdominal pain in irritable bowel syndrome
Gastroenterology
Mast cell-dependent excitation of visceral-nociceptive sensory neurons in irritable bowel syndrome
Gastroenterology
Rectal distention testing in patients with irritable bowel syndrome: sensitivity, specificity, and predictive values of pain sensory thresholds
Gastroenterology
Chronic stress induces mast cell-dependent bacterial adherence and initiates mucosal inflammation in rat intestine
Gastroenterology
Increased levels of substance P in the myenteric plexus of Trichinella-infected rats
Gastroenterology
Vanilloid receptor 1 immunoreactivity in inflamed human bowel
Lancet
Activation of the mucosal immune system in irritable bowel syndrome
Gastroenterology
Hypothalamic-pituitary-gut axis dysregulation in irritable bowel syndrome: plasma cytokines as a potential biomarker?
Gastroenterology
Immune activation in patients with irritable bowel syndrome
Gastroenterology
Psychological stress activates interleukin-1beta gene expression in human mononuclear cells
Brain Behav Immun
Bacterial succession in the colon during childhood and adolescence: molecular studies in a southern Indian village
Am J Clin Nutr
Host-mediated inflammation disrupts the intestinal microbiota and promotes the overgrowth of Enterobacteriaceae
Cell Host Microbe
Eradication of small intestinal bacterial overgrowth reduces symptoms of irritable bowel syndrome
Am J Gastroenterol
Antibiotics increase functional abdominal symptoms
Am J Gastroenterol
Impact of Clostridium difficile on inflammatory bowel disease
Clin Gastroenterol Hepatol
Association of adult coeliac disease with irritable bowel syndrome: a case-control study in patients fulfilling ROME II criteria referred to secondary care
Lancet
Post Salmonella irritable bowel syndrome—5 year review
J Infect
Clinical economics review: irritable bowel syndrome
Aliment Pharmacol Ther
Characteristics of patients with irritable bowel syndrome recruited from three sources: implications for clinical trials
Aliment Pharmacol Ther
Study of infectious intestinal disease in England: rates in the community, presenting to general practice, and reported to national surveillanceThe Infectious Intestinal Disease Study Executive
Br Med J
Relationship of Campylobacter toxigenicity in vitro to the development of postinfectious irritable bowel syndrome
J Infect Dis
Prevalence of gastrointestinal symptoms six months after bacterial gastroenteritis and risk factors for development of the irritable bowel syndrome: postal survey of patients
Br Med J
Structural and functional changes of the duodenum in human norovirus infection
Gut
Sequential changes in small intestinal structure and function during rotavirus infection in neonatal rats
Gut
The role of psychological and biological factors in postinfective gut dysfunction
Gut
Changes in anorectal function in persistent bowel disturbance following salmonella gastroenteritis
Eur J Gastroenterol Hepatol
Editorial: gastrointestinal illness and the biopsychosocial model
J Clin Gastroenterol
Resistance to human cytomegalovirus infection may be influenced by genetic polymorphisms of the tumour necrosis factor-alpha and interleukin-1 receptor antagonist genes
Scand J Infect Dis
Variation in the TNF-alpha promoter region associated with susceptibility to cerebral malaria
Nature
Role of tumor necrosis factor-alpha and interleukin-10 gene polymorphisms in irritable bowel syndrome
Am J Gastroenterol
Interleukin 10 genotypes in irritable bowel syndrome: evidence for an inflammatory component?
Gut
Increased somatic complaints and health-care utilization in children: effects of parent IBS status and parent response to gastrointestinal symptoms
Am J Gastroenterol
The cognitive behavioural model of irritable bowel syndrome: a prospective investigation of patients with gastroenteritis
Gut
Cited by (592)
Efficacy and safety of probiotics in irritable bowel syndrome: A systematic review and meta-analysis
2024, Clinical Nutrition ESPENHericium erinaceus ethanol extract and ergosterol exert anti-inflammatory activities by neutralizing lipopolysaccharide-induced pro-inflammatory cytokine production in human monocytes
2022, Biochemical and Biophysical Research CommunicationsRisk Factors of Developing Postinfectious Irritable Bowel Syndrome in Shigellosis Patients, 5 Years After Hospitalization During the Outbreak
2024, Open Forum Infectious DiseasesFUNCTIONAL FOODS IN HEALTH AND DISEASES
2024, Applications of Functional Foods in Disease Prevention
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.