Overlap between irritable bowel syndrome and common gastrointestinal diagnoses: a retrospective cohort study of 29553 outpatients in Germany - BMC Gastroenterology - BMC Gastroenterology

Irritable bowel syndrome (IBS) represents a common gastrointestinal (GI) functional disorder that affects the digestive system and causes symptoms such as stomach cramps, bloating, diarrhea and constipation. IBS can affect patients regardless of their age, sex, socioeconomic status or race, and, due to its chronic nature which significantly impairs quality of life, represents an enormous economic burden as IBS patients are more likely to require time off work an seek medical care [11]. As the diagnosis of IBS is a diagnosis of exclusion and typical IBS symptoms are also frequently observed in other GI disorders, the road to final diagnosis can be challenging and extensive in terms of time. Moreover, a recent study based on health insurance data from Germany suggest that patients with IBS are likely not receiving sufficient diagnostic evaluation in conformity with the relevant guidelines [5]. In the present manuscript, we aimed at determining the prevalence of an overlaps between IBS and other common GI disorders. We used the Disease Analyzer database (IQVIA), which contains diagnoses as well as basic medical and demographic data of over nine million outpatients in Germany, to identify GI diseases that were diagnosed within 12 months before and after diagnosis of IBS was made. In a cohort of 29,553 IBS patients, we show that there is an extensive overlap between the diagnosis of IBS and other GI disorders including intestinal infectious diseases, non-infectious enteritis and colitis, gastritis and duodenitis as well as disease of the esophagus. As such, 26% and 18% of IBS patients were diagnosed with an GI disease 12 month before or after the diagnosis of IBS, respectively.

Diagnosis of IBS is based on the presence of chronic abdominal symptoms as well as the exclusion of other organic diseases that might explain patients´ symptoms [3, 4, 12]. Main symptoms leading to the diagnosis of IBS include abdominal pain and changed bowel habits that are common to different other GI diseases. In many cases, it might therefore be challenging to clearly identify the specific etiology of patients´ complain and in particular the differentiating between IBS and other functional disorders such as functional dyspepsia [13] as well as organic gastrointestinal diagnoses including gastroesophageal reflux disease, erosive esophagitis or inflammatory bowel syndrome requires a high level of clinical experience [14,15,16,17]. In our cohort of IBS patients, we could show that 55% of patients had been diagnosed with a different GI disorder up to 12 months before the diagnosis of IBS was made. Likewise, 41% of patients were diagnoses with another GI disorder 12 months after diagnosis of IBS. Despite the fact that IBS can be diagnosed in the presence of other GI diseases, the German S3 guideline as well as international guidelines demand that there are no characteristic alterations for other clinical pictures which are probably responsible for these symptoms. Thus, our data call into question whether the diagnosis of IBS was made in all cases in accordance with current guidelines. In this line of thinking, our data put into question current data on the high prevalence of IBS in Germany and other Western countries. Nevertheless, it should be remembered that there are forms of IBS that specifically occur after viral or bacterial gastrointestinal infections and are then referred to as post-infectious irritable bowel syndrome (PI-IBS) [18, 19]. Finally, our data on an overlap of IBS and specific GI diseases underscore that IBS must not lead to a delayed diagnosis of other relevant organic disorders such as inflammatory bowel disease, chronic intestinal infectious disease, ulcers or even GI cancer, which require disease-specific therapies. In addition, we would like to point out that GI disorders, which were the focus of the current study, are not the only comorbidities of patients with IBS. A large number of studies have shown that a variety of extraintestinal comorbidities such as psychiatric disorders like anxiety, depression, somatization, chronic fatigue syndrome or sleep disturbance are highly relevant in the context of IBS as well [20,21,22].

Our study is limited by some methodological aspects that we would like to acknowledge. Diagnoses coded in the Disease Analyzer database are recorded based on the ICD-10 classification system that could be associated with a risk of undercoding or misclassification of diagnoses. Regarding IBS in particular, we are unable to provide information on the diagnostic steps performed by the physician to rule out other diagnoses prior to the diagnosis of IBS. Moreover, we acknowledge a lack of available data on lifestyle parameters and socioeconomic aspects including smoking status, alcohol use, physical activity, family status and employment, which are known to have an impact on the diagnosis of IBS [4]. Finally, our study did only include patients from the outpatient sector. Although, in our opinion, IBS is predominantly diagnosed in outpatient practices, the missing data on the hospital sector could lead to a selection bias.

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