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 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 2  |  Issue : 3  |  Page : 238-244

Pattern of irritable bowel syndrome and its impact on quality of life: A tertiary hospital based study from Kolkata on newly diagnosed patients of irritable bowel syndrome attending general medical outpatient department


1 Department of General Medicine, Nilratan Sircar Medical College, Sealdah, India
2 Department of Intensive Care Medicine, AMRI Hospital, Saltlake, Kolkata, West Bengal, India

Date of Web Publication12-Jun-2015

Correspondence Address:
Dr. Uma Sinharoy
IA-298/3, Sector III, Salt Lake City, Bidhannagar, Kolkata - 700 097, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2348-3334.158699

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  Abstract 

Background and Aims: Irritable bowel syndrome (IBS) is a highly prevalent functional gastrointestinal disorder long considered a diagnosis of exclusion. It is associated with decreased quality of life and significant economic burden to both the individual patient and society. To the best of our knowledge, this was the first study from this part of India assessing the relative impact on quality of life with respect to subtype of IBS. Subjects and Methods: The study was conducted between December 2011 and December 2013 among 1000 IBS patients attending general medical outpatient department of a tertiary care hospital in Kolkata (West Bengal, India). The Rome III criterion was used for diagnosis of IBS. IBS was further classified as diarrhea predominant (IBS-D), constipation-predominant (IBS-C) and mixed variety (IBS-M). This was a prospective, observational, cross-sectional study to assess the demographic and socioeconomic parameters, and impact of IBS on the quality of life of the patients by using short form-36 (SF-36) questionnaire. Results: The study found that IBS-D (67.6%) was the most common type, followed by IBS-M (30.4%) and IBS-C (2%). The majority of patients were males (59.2%). Overall none of the demographic and socioeconomic parameters analyzed in the study was found to have any significant bearing on the subtype of IBS affecting them. Eight scales of the SF-36 questionnaire were individually analyzed and correlated with the different subtypes of IBS. IBS-D group had the worst scores while IBS-M had the best score of quality of life. The difference between IBS-D and IBS-M was found to be statistically significant (P < 0.001) on every aspect. Conclusions: The study highlights that IBS is a bio-psychosocial disorder with poor quality of life. Most of the patients of IBS reporting to physicians have IBS-D. The socioeconomic and demographic factors do not appear to be significant determinants in this condition. IBS-D causes worst impact on quality of living among all subtypes.

Keywords: Constipation, diarrhea, irritable bowel syndrome, quality of life, Rome III criteria


How to cite this article:
Sinharoy U, Sinharoy K, Mukhopadhyay P, La Longkumer A, Sinharoy I. Pattern of irritable bowel syndrome and its impact on quality of life: A tertiary hospital based study from Kolkata on newly diagnosed patients of irritable bowel syndrome attending general medical outpatient department. CHRISMED J Health Res 2015;2:238-44

How to cite this URL:
Sinharoy U, Sinharoy K, Mukhopadhyay P, La Longkumer A, Sinharoy I. Pattern of irritable bowel syndrome and its impact on quality of life: A tertiary hospital based study from Kolkata on newly diagnosed patients of irritable bowel syndrome attending general medical outpatient department. CHRISMED J Health Res [serial online] 2015 [cited 2020 Aug 7];2:238-44. Available from: http://www.cjhr.org/text.asp?2015/2/3/238/158699


  Introduction Top


Irritable bowel syndrome (IBS) is a functional bowel disorder characterized by abdominal pain or discomfort and altered bowel habits in the absence of detectable structural abnormalities. It has chronic symptoms that vary over time and overlap with those of non-IBS disorders. It is associated with decreased quality of life and significant economic burden to both the individual patient and society.

Irritable bowel syndrome is a clinical diagnosis and physicians generally rely on symptom-based criteria to stamp a case as IBS. However, its estimated prevalence in the community varies significantly depending on the diagnostic criteria used. Several clinical criteria have evolved since the advent of Manning Criteria in 1978, Kruis Criteria in 1984 and the latest Rome Criteria with its three revised forms including Rome I (1992), Rome II (2000), and Rome III (2006). The 2006 Rome III updated criteria is most refined with promising clinical utility.

Functional abdominal symptoms are highly prevalent in the general population, many do not seek healthcare, but the intensity of symptoms may be one factor promoting the seeking of medical assistance. [1] Individuals with IBS have higher healthcare use and costs than their non-IBS counterparts. IBS is a difficult condition to investigate in population-based research, because there is no single diagnostic test to confirm disease presence and the symptoms of IBS may also be associated with other conditions including infections. [2],[3],[4],[5]

The symptoms of IBS are heterogeneous, wax and wane over time and frequently overlap or coexist with symptoms found in other disorders such as chronic constipation, functional dyspepsia, gastro-esophageal reflux disease (GERD), inflammatory bowel disease, celiac disease, and lactose intolerance. [6],[7],[8],[9] IBS can coexist with other functional disorders, most notably fibromyalgia, chronic fatigue syndrome, headache, backache, chronic pelvic pain, and psychological conditions such as anxiety, symptom related fears, and somatization leading to heavy economic burden and poor quality of life. [10],[11],[12]

Studies have shown that there is good evidence for a decrease in health-related quality of life in patients with moderate to severe IBS and that the quality of life in IBS is impaired to a degree comparable with other disorders such as depression and GERD. With this background, the present study evaluates the pattern of IBS and its impact on quality of life in newly diagnosed patients of IBS attending a tertiary care hospital. The short form-36 questionnaire (SF-36) which is an established way of measuring quality of life outcomes has been used for the same.

Aims and objectives

  • To assess the patient profile including socioeconomic parameters and clinical subtypes of IBS. Diagnosis was based on Rome III diagnostic criteria for IBS
  • To evaluate the impact of IBS on quality of life of individual patients.



  Subjects and Methods Top


This study was a prospective, observational, cross-sectional hospital-based single center study conducted from December 2011 to December 2013 among 1000 patients labeled as having IBS after satisfying inclusion and exclusion criteria. Patients with chronic lower gastrointestinal symptoms without any previously known organic illness attributable for such symptoms attending the outpatient department (OPD) of General Medicine were included in the study. Patients who were prior investigated but with negative results for organic causes were included in this study. Patients in presence of alarm features/red flag signs predictive of organic diagnosis such as documented weight loss, nocturnal symptoms, rectal bleeding, anemia, fever, and family history of colon carcinoma were also eventually excluded from this study unless there was evidence to the contrary.

Inclusion criteria

Any patient who presented to the OPD of general medicine with complaints of lower abdominal symptoms including lower abdominal distension, abdominal discomfort or pain on defecation, feeling of incomplete defecation, abdominal discomfort or pain relieved by defecation, and one or more of the symptoms (diarrhea, constipation, alternating diarrhea, and constipation) without any history or investigation result suggestive of any organic or structural gastrointestinal disease was included in the study.

Exclusion criteria

Patients presenting with complaints of lower abdominal symptoms in whom other organic causes are evident and previously diagnosed patients with Crohn's disease, ulcerative colitis, celiac disease, diverticulitis, lactose intolerance, and peptic ulcer were virtually excluded from the study.


  Study techniques Top


Each patient presenting to the OPD of General Medicine after being selected as study population was enquired about detailed history addressing the multiple symptoms, age of onset, and quality of life and thorough clinical examination was done in all cases. Laboratory facilities as available at the hospital were utilized as per case requirement. Every patient was given a proforma on the first visit. Each item of this proforma (though written in English) was explained and verbally translated in local language. A predesigned questionnaire was used for collecting data through face-to-face interview for eligible patients, which included both male and female gender, all visiting the OPD for general medical problems.

The questionnaire was divided into three parts. The first part was Rome III criteria for diagnosis and subtype of IBS. The second part was to investigate patient characteristics and socio-economic demographic and clinical parameters data. The third part was to measure the impact of IBS on quality of life by following SF-36 questionnaire. The SF-36 is a multipurpose, short term health survey with 36 questions. It yields an eight scale profile of functional health and well-being scores, as well as psychometrically based physical and mental health summary measures and a preference-based health utility index.

Rome III diagnostic criteria (Criteria fulfilled for the past 3 months with symptom onset at least 6 months before diagnosis) for IBS and sub-classifications:

Recurrent abdominal pain or discomfort ("Discomfort" means an uncomfortable sensation not described as pain) at least 3 days a month in the past 3 months, associated with two or more of the following:

  • Improvement with defecation
  • Onset associated with a change in frequency of stool
  • Onset associated with a change in form (appearance) of stool.


The Rome III sub-classification is based solely on stool consistency. [6] Patients with hard stools more than 25% of the time and loose stools <25% of the time are defined as "IBS with constipation" (IBS-C) while "IBS with diarrhea" (IBS-D) patients have loose stools more than 25% of the time and hard stools <25% of the time. About one-third to one-half of IBS patients are "IBS-mixed" (IBS-M), who describe both hard and soft stools more than 25% of the time, with a small (4%) unclassified (IBS-U), with neither loose nor hard stools more than 25% of the time. [13] Those whose bowel habit changes from one subtype to another during follow-up over months and years are termed "alternators". The terms "constipation" and "diarrhea" can reflect a wide variety of different symptom experiences to different patients, and so whenever a patient uses these terms, an exploration of their meaning is required. [14] Any combination of infrequent defecation, passage of hard stools, excessive straining, feelings of incomplete rectal evacuation, or rectal discomfort may be referred to as constipation, whereas increased stool frequency, urgency, or the passage of liquid or watery stools, or even more frequent small hard stools, may be referred to as diarrhea by the patient.

In this study, diagnosis of IBS is done according to the Rome III criteria and patients were further classified as IBS-D, IBS-C, and IBS-M as per the stool consistency described by the patients.

Ethical approval: The research work was ethically approved by the institution based ethical committee.


  Analysis of data Top


The data were collected as per the protocol and summation was done using Microsoft Excel software. The statistical analysis was conducted with the statistical package for the social science system (SPSS) version 17.0. Continuous variables were presented as mean ± standard division, and categorical variables were presented as frequency and percentage. Normally distributed continuous variables were compared using ANOVA. If the F value was significant and variance was homogeneous, Tukey multiple comparison test was used to assess the differences between the individual groups; otherwise, Tamhane's T2 test was used. Nominal categorical data between the groups were compared using Chi-squared test or Fisher's exact test as appropriate. P <0.05 was considered to be statistically significant.


  Results Top


A total of 1000 patients of IBS were included in this study from December 2011 to December 2013.

It was found that diarrhea-predominant subtype (IBS-D) was the most common type (67.6%), followed by mixed type (IBS-M 30.4%) with constipation-predominant IBS-C being the least common type (only 2%) of IBS in this study [Figure 1]. The total demographic and socioeconomic picture of the study population has been depicted in [Table 1]. The age of the patients ranged between 18 and 63 years in this study. Majority of the patients suffering from IBS were young and middle-aged adults with both young and old age group having lower incidence of IBS. It was further found that age had no bearing on the subtype of IBS that the patient suffered from. A total of 592 (59.2%) male and 408 (40.8%) female patients were included in this study. The majority of patients in all the subtypes were males. There was no statistically significant difference in any of the subtypes of IBS with respect to sex-wise distribution of the patients. The occupational and educational status of a patient also did not have any statistically significant correlation with the subtype of IBS affecting them. The data also reflect the educational and occupational status of the patients in general coming to the hospital for treatment. Of the patients included in this study, 90.6% (906) were married and 9.4% (94) were unmarried.
Table 1: Demographic profile of IBS patients


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Figure 1: Pie chart showing the frequency of subtypes of irritable bowel syndrome in the study

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Impact on quality of life due to suffering from IBS was assessed by the SF-36 questionnaire. SF-36 analyzes eight scales to score physical functioning, social functioning, general health, emotional wellbeing, energy or fatigue scores, pain scores, and role limitation due to physical health and emotional problems [Table 2] and [Table 3]. The lowest mean physical score was found to be in diarrhea-predominant subtype of IBS (83.42), followed by constipation-predominant type (85) and the highest mean score was found in mixed type of IBS (86.97). On analysis, it was found that there was statistically significant difference (P < 0.001) in the physical functioning score between diarrhea-predominant and mixed subtype of IBS. It implies that patients of mixed subtype of IBS had significantly better physical functioning as compared to those with diarrhea-predominant subtype. The role limitation due to physical health and emotional health assessment on SF-36 showed that there was maximum role limitation in patients of diarrhea-predominant IBS, followed by constipation -predominant type and the mixed type IBS patients were least affected. The difference between diarrhea predominant and mixed subtypes of IBS was statistically significant (P < 0.001). This implies that mixed type of IBS caused significantly less role limitation due to physical and emotional problems as compared to diarrhea-predominant type of IBS.
Table 2: Scores of physical functioning, emotional wellbeing and role limitation due to physical health and emotional health among different subtypes of IBS


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Table 3: Scores of energy or fatigue, social functioning, general health and pain scores among different subtypes of IBS


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It was found that patients with diarrhea-predominant type of IBS had lowest general health score and emotional well-being score while patients with mixed type of IBS having the best score. The difference of scores between the diarrhea-predominant and mixed type of IBS affected patients in this study was also statistically significant (P < 0.001). Patients with diarrhea-predominant type of IBS had lowest Energy/Fatigue score and pain scores and patients with mixed type of IBS having the highest. Lowest Social functioning score was among IBS-D population and IBS-M had the highest Social functioning score. The patients with diarrhea-predominant type of IBS were found to have lowest General health score and patients with mixed type of IBS had the highest score. The overall quality of life scoring including physical and psychosocial elements was significantly lower in IBS-D subtype than in mixed type of IBS patients in this study.

The study results can be summarized by saying that the demographic and socioeconomic factors did not have significant bearing on the subtype of IBS one suffered from. It was also found that diarrhea-predominant type of IBS, also the commonest type had the worst impact on the overall quality of life. This impact was found to be worse than that produced by mixed type of IBS on quality of life by a statistically significant margin (P < 0.001). The difference between other comparison groups was not found to be statistically significant.


  Discussion Top


This study was conducted in a tertiary care hospital of Kolkata among recently diagnosed 1000 patients of IBS. In this study, IBS was studied with respect to its subtypes, demographic and socioeconomic parameters and the impact of IBS on patient's quality of life. SF-36 questionnaire was used in the study. This was in line with recommendations of Nellesen et al., who conducted a systematic review on IBS and chronic constipation. They found 14 studies utilized SF-36 questionnaire and within-study domain scores were significantly lower in IBS patients compared with non-IBS controls. They concluded that the results were not typically reported by IBS subtype. They recommended that future research should refine burden of illness estimates to subtypes. [15]

In this study, diarrhea-predominant subtype was found to be the commonest (67.6%) and constipation-predominant the least common (2.0%) type of IBS. This was not in line with findings of Tillisch et al. [13] who reported that mixed type of IBS is the commonest form with up to a half of the patients affected by it. In another study by Ghoshal et al. [16] it was found that out of 2785 patients, 57% had mixed symptoms, 39% had constipation-predominant IBS, and 4% had diarrhea predominant symptoms. This variation may be attributed to different study population in this study. Furthermore, it may reflect the referral pattern in the study setting since most of the patients with constipation are referred to surgical department for treatment.

It was found in this study that majority of the patients suffering from IBS were young and middle-aged adults with both young and old age group having lower incidence of IBS. This is in line with established belief in IBS. [13] It was further found that age had no significant bearing on the subtype of IBS that the patient suffered from. This is similar to the finding by Jahangiri et al. [17] who found that the difference in IBS prevalence within different age groups was not statistically significant.

In this study, the majority of patients in all the subtypes were males. This is in contrast to the findings of many studies in the west who report female preponderance in case of IBS. [18],[19] However, in studies in Indian settings there has been male preponderance, which is in line with our finding. [10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23] Lovell et al. [18] also found in their systematic review of IBS that South Asian studies did not report significantly higher prevalence of IBS in females. This finding may also reflect greater level of healthcare seeking by males in the study population. There was no statistically significant difference in any of the subtypes of IBS with respect to sex-wise distribution of the patients. This finding is in contrast to some studies which reported gender-wise difference in the patterns of IBS. [18],[24] Although some studies like that by Gonzales Gamarra et al. [25] found no association between IBS and sex of the patient, which is in line with our finding.

After statistical analysis, it was found that the occupational and educational status of the patients had no statistically significant correlation with the subtype of IBS affecting them in this study. Lovell and Ford [19] also found in their meta-analysis that there was no effect of socioeconomic status on the pattern of IBS, but only four studies reported these data. Also Gonzales Gamarra et al. [25] found no association between IBS and occupation of the patient, which is in line with our finding.

It was also found that diarrhea-predominant type of IBS, also the commonest type had the worst impact on overall quality of life. This impact was found to be worse than that produced by mixed type of IBS on quality of life by a statistically significant margin. The difference between other comparison groups was not found to be statistically significant. Similar to many other studies, this study also reports that IBS negatively affects the quality of life. [3],[26],[27],[28],[29],[30] However, there are very few past studies assessing the relative impact on quality of life with respect to subtype of IBS. Hence, our finding needs further investigation and validation by conducting more similar studies. If our findings are validated by other studies, then different approaches to tackle quality of life issues in various subtypes of IBS may be needed as each affects quality of life with different intensity. Hence, a more aggressive approach may be needed for patients with diarrhea-predominant IBS, in line with our findings.

The limitation of this study was that it depends upon patients of IBS themselves reporting to the hospital for treatment. This causes substantial number of patients to go unassessed, as IBS is a disease with high prevalence. [7],[31],[32] Also, the study population in this study is affected by other factors like probable lesser reporting of female patients to hospital and also the fact that many patients with constipation-predominant IBS are confused with chronic constipation and treated in surgical department. Hence, limiting the number of constipation-predominant IBS patients in the study. Another limitation in this study was the lack of follow-up and hence missing out on alternators and lacking the ability to measure the impact of IBS on quality of life over a period of time.

It should however be said that more efforts like this study are needed for further understanding of IBS which is an extremely common clinical problem tackled by physicians.


  Acknowledgment Top


We are grateful to all faculty members and postgraduate students of the department of General Medicine of our Medical College for their wholehearted cooperation.

 
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Abstract
Introduction
Subjects and Methods
Study techniques
Analysis of data
Results
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Acknowledgment
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