Special Reports and ReviewsSystematic review of the comorbidity of irritable bowel syndrome with other disorders: What are the causes and implications?☆,☆☆
Section snippets
Methodologic considerations
We searched the world medical literature indexed in Medline from 1966 to the present for the following terms: irritable bowel syndrome, IBS, functional bowel, and colonic disorders–functional, in conjunction with the terms comorbidity, comorbid disorder, psychiatric illness, psychiatric disorder, mental disorder, somatoform disorder, anxiety, anxiety disorder, depression, depressive disorder, panic, panic disorder, somatization, fibromyalgia, chronic fatigue syndrome, headache,
Do the comorbid disorders share pathophysiologic mechanisms with irritable bowel syndrome?
The 4 nongastrointestinal conditions just described that are strongly associated with IBS share some clinical features: They are all substantially more common in women, may be triggered or exacerbated by stress, and are associated with fatigue, sleep difficulties, anxiety, and depression. Furthermore, these 4 disorders all have a high degree of overlap with each other.30, 52 It would seem likely that disorders with so many similarities and excess overlap would share a common etiology; however,
Overlap with other functional gastrointestinal disorders
The comorbidity of IBS with other functional gastrointestinal disorders is even more striking than its overlap with nongastrointestinal somatic conditions; compare Table 3 with Table 1.Study Methods Subjects Findings IBS Criteria and Comments Kennedy et al. 199851 Community survey 3169 respondents including 546 with IBS, 442 with BHR, and 539 with GERD 46.5% of IBS pts had GERD, and 47% of GERD pts had IBS (reported OR for the association: 2.72).
Is IBS a distinct entity or part of a global disorder?
This important question has been addressed by 3 types of studies: measurement of somatization, factor analysis, and multivariate statistical analysis.
Diagnostic ambiguity
All of the disorders that are comorbid with IBS are characterized by vague, sometimes overlapping symptoms,154 and Mayer et al.15 suggested that there is a physiologic basis for this vagueness: visceral afferents converge with somatic afferents on the same dorsal horn cells in the spinal cord, and the spinal segments to which visceral afferents project are overlapping. Wessely et al.155 further suggested that classification of these somatic symptoms into discrete diagnoses may be an artifact of
Study limitations
The studies reviewed here have a number of limitations, including the following:
Few of them are based on representative samples; most come from subspecialty clinics, which are affected by patient self-selection for treatment and other forms of ascertainment bias.
The case definitions for IBS and the other disorders of interest vary greatly across studies, and also have changed over time.
Many of the studies involve very small samples.
The criteria for diagnosis vary from patient self-report on
Comorbid disorders
Future work should assess large samples from either the general population or general medical patients, such as primary care patients; measure in the same samples all the commonly known comorbid conditions; and use well-defined clinical criteria for each of the disorders assessed.
Dual-etiology hypothesis
This hypothesis has implications for the kinds of experiments investigators might want to conduct on the pathophysiology and treatment of IBS. It suggests that it may be more productive to look for subgroups of
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Address requests for reprints to: William E. Whitehead, Ph.D., Division of Digestive Diseases, CB#7080, University of North Carolina, Chapel Hill, North Carolina 27599. e-mail: [email protected].
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Supported by NIDDKD (RO1 DK31369).