IBS and Diverticular Disease

Welcome back to Audioboards. Today, we’re diving into two common conditions: Irritable Bowel Syndrome, or IBS, and Diverticular Disease, exploring their diagnostic criteria, pathophysiology, and treatment strategies.

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Transcript

Welcome back to Audioboards. Today, we’re diving into two common but often misunderstood gastrointestinal conditions: Irritable Bowel Syndrome, or IBS, and Diverticular Disease.

So what is IBS ?

It is a functional gastrointestinal disorder characterized by chronic abdominal pain and altered bowel habits. The Rome 4 criteria define IBS as recurrent abdominal pain occurring at least one day per week in the last three months, associated with at least two of the following: pain related to defecation, changes in stool frequency, or changes in stool form.

What are some other symptoms that support an IBS diagnosis?

Patients often report abnormal stool frequency, lumpy or hard stools, loose or watery stools, straining, urgency, or a sensation of incomplete evacuation. Bloating and abdominal distention are also common. Many patients experience additional symptoms such as dyspepsia, heartburn, headaches, fatigue, myalgias, anxiety, or depression.

Interesting. So, what do we understand about the pathogenesis of IBS?

IBS has multiple contributing factors. Abnormal motility plays a role—patients may have myoelectrical and motor abnormalities in the colon and small intestine. There’s also visceral hypersensitivity, where bloating and distention arise due to increased sensitivity, gas production, or impaired gas transit.

Right, and there’s evidence of intestinal inflammation. Certain dietary factors, medications like antibiotics, and infections can increase intestinal permeability, leading to inflammation and altered motility. It’s fascinating that post infectious IBS is more common in women and those with psychological stress at the onset of gastroenteritis.

Absolutely. The gut microbiome also plays a role. Changes in microbiota composition can lead to increased postprandial gas, bloating, and distention. Psychological factors, including stress, anxiety, and depression, can influence symptom perception and gut motility.

IBS is classified into four categories: IBS with diarrhea, IBS with constipation, mixed IBS, and unsubtyped IBS. How do these classifications guide diagnosis and treatment?

Patients with IBS and constipation have infrequent bowel movements, hard stools, and straining. IBS with diarrhea is characterized by loose, frequent stools, urgency, or fecal incontinence. Many report firm stools in the morning followed by progressively looser movements. Regardless of type, we must always check for alarm symptoms like nocturnal diarrhea, hematochezia, weight loss, fever, or a family history of cancer, IBD, or celiac disease.

That’s a crucial point. What’s the approach to diagnosis?

We should avoid overtesting. A CBC screens for anemia, and CRP detects inflammation. Fecal calprotectin helps rule out IBD. Testing for celiac disease is essential, as is stool testing for parasites in high-risk patients. Colonoscopy is recommended for those over 45 or with alarming symptoms. If constipation is present, a rectal exam can help assess pelvic floor dysfunction.

Treatment often starts with lifestyle changes. Many patients report dietary intolerances. Common triggers include fatty foods, alcohol, caffeine, spicy foods, and grains. Has there been any success with the low FODMAP diet?

Yes, restricting fermentable short-chain carbohydrates for 2–4 weeks can improve symptoms. Patients then reintroduce foods to identify triggers. The FODMAP diet works by reducing the intake of poorly absorbed sugars, such as fructose, lactose, polyols, and oligosaccharides, which can lead to gas production and bloating. Psyllium fiber and alpha-galactosidase supplements can also help.

And for pharmacologic options?

Peppermint oil, anticholinergics, and loperamide can be used based on symptom type. Eluxadoline, alosetron, osmotic laxatives, and secretagogues like linaclotide can also be beneficial. Antidepressants, particularly tricyclics and SSRIs, may help with both IBS symptoms and comorbid mood disorders.

Great overview! Now, let’s switch gears to diverticular disease.

Colonic diverticulosis is often asymptomatic and found incidentally during colonoscopy. It’s most common in the sigmoid and descending colon. Risk factors include aging, low-fiber diets, obesity, smoking, and certain connective tissue disorders like Ehlers-Danlos and Marfan syndrome.

And when diverticulosis progresses to diverticulitis, what symptoms do we see?

Patients typically have left lower quadrant pain, constipation or loose stools, nausea, vomiting, and sometimes low-grade fever. On exam, tenderness and a palpable mass may be present. Leukocytosis is mild to moderate, but free perforation presents dramatically with peritoneal signs.

CT imaging helps confirm diagnosis and rule out differentials like colonic neoplasia, Crohn’s disease, or ischemic colitis. What’s your management approach for mild cases?

Mild, uncomplicated cases can be managed with a clear liquid diet for 2–3 days and selective antibiotic use. In patients with significant comorbidities or small abscesses, antibiotics like amoxicillin-clavulanate or metronidazole with ciprofloxacin are used.

And for patients with worsening symptoms or complications?

Hospitalization is needed for severe cases, immunocompromised patients, or those with large abscesses. IV fluids, bowel rest, and broad-spectrum IV antibiotics like piperacillin-tazobactam or a second-generation cephalosporin are given. If no improvement occurs within 72 hours, repeat CT and surgical consultation are necessary.

Complications like fistulas, perforation, or obstruction may require elective surgery. What’s the long-term strategy post-recovery?

High-fiber diets are recommended to prevent recurrence. Elective surgical resection may be needed after multiple severe episodes or chronic complications.

Thanks for joining us today!

That’s all for today’s episode. Thanks for listening to AudioBoards. Stay tuned for more educational content in our next episode! The views and opinions expressed on the AudioBoards Podcast do not necessarily reflect those of our employers. This podcast is for educational purposes only and should not be used to diagnose or treat any medical conditions. It is not a substitute for professional medical advice. Always consult a qualified, board-certified healthcare provider for any medical concern.