Fass R, Longstreth G F, Pimentel M, Fullerton S, Russak S M, Chiou C F, Reyes E, Crane P, Eisen G, McCarberg B, Ofman J
Department of Medicine, Southern Arizona Veterans Affairs Medical Center, Tucson, USA.
Arch Intern Med. 2001 Sep 24;161(17):2081-8. doi: 10.1001/archinte.161.17.2081.
Irritable bowel syndrome (IBS) presents a significant diagnostic and management challenge for primary care practitioners. Improving the accuracy and timeliness of diagnosis may result in improved quality and efficiency of care.
To systematically appraise the existing diagnostic criteria and combine the evidence with expert opinion to derive evidence- and consensus-based guidelines for a diagnostic approach to patients with suspected IBS.
We performed a systematic literature review (January 1966-April 2000) of computerized bibliographic databases. Articles meeting explicit inclusion criteria for diagnostic studies in IBS were subjected to critical appraisal, which formed the basis of guideline statements presented to an expert panel. To develop a diagnostic algorithm, an expert panel of specialists and primary care physicians was used to fill in gaps in the literature. Consensus was developed using a modified Delphi technique.
The systematic literature review identified only 13 published studies regarding the effectiveness of competing diagnostic approaches for IBS, the accuracy of diagnostic tests, and the internal validity of current diagnostic symptom criteria. Few studies met accepted methodological criteria. While symptom criteria have been validated, the utility of endoscopic and other diagnostic interventions remains unknown. An analysis of the literature, combined with consensus from experienced clinicians, resulted in the development of a diagnostic algorithm relevant to primary care that emphasizes a symptom-based diagnostic approach, refers patients with alarm symptoms to subspecialists, and reserves radiographic, endoscopic, and other tests for referral cases. The resulting algorithm highlights the reliance on symptom criteria and comprises a primary module, 3 submodules based on the predominant symptom pattern (constipation, diarrhea, and pain) and severity level, and a subspecialist referral module.
The dearth of available evidence highlights the need for more rigorous scientific validation to identify the most accurate methods of diagnosing IBS. Until such time, the diagnostic algorithm presented herein could inform decision making for a range of providers caring for primary care patients with abdominal discomfort or pain and altered bowel function suggestive of IBS.
肠易激综合征（IBS）给初级保健医生带来了重大的诊断和管理挑战。提高诊断的准确性和及时性可能会改善护理质量和效率。
系统评估现有的诊断标准，并将证据与专家意见相结合，以得出基于证据和共识的疑似IBS患者诊断方法指南。
我们对计算机化书目数据库进行了系统的文献综述（1966年1月至2000年4月）。符合IBS诊断研究明确纳入标准的文章经过严格评估，这构成了提交给专家小组的指南声明的基础。为了开发一种诊断算法，使用了由专家和初级保健医生组成的专家小组来填补文献中的空白。采用改良的德尔菲技术达成共识。
系统的文献综述仅发现13项已发表的研究，涉及IBS竞争性诊断方法的有效性、诊断测试的准确性以及当前诊断症状标准的内部有效性。很少有研究符合公认的方法学标准。虽然症状标准已经得到验证，但内镜检查和其他诊断干预措施实用性仍不明确。对文献的分析，结合经验丰富的临床医生的共识，得出了一种与初级保健相关的诊断算法，该算法强调基于症状的诊断方法，将有警示症状的患者转诊给专科医生，并为转诊病例保留影像学、内镜检查和其他检查。由此产生的算法突出了对症状标准的依赖，包括一个主要模块、基于主要症状模式（便秘、腹泻和疼痛）和严重程度的3个子模块，以及一个专科转诊模块。
现有证据的匮乏凸显了进行更严格科学验证以确定IBS最准确诊断方法的必要性。在此之前，本文提出的诊断算法可为一系列照顾有腹部不适或疼痛以及肠道功能改变提示IBS的初级保健患者的医疗服务提供者提供决策依据。
