irritable bowel syndrome

Irritable Bowel Syndrome

Definition

Irritable bowel syndrome (IBS) is a common intestinal condition characterized by abdominal pain and cramps; changes in bowel movements (diarrhea, constipation, or both); gassiness; bloating; nausea; and other symptoms. There is no cure for IBS. Much about the condition remains unknown or poorly understood; however, dietary changes, drugs, and psychological treatment are often able to eliminate or substantially reduce its symptoms.

Description

IBS is the name people use today for a condition that was once called—among other things—colitis, mucous colitis, spastic colon, nervous colon, spastic bowel, and functional bowel disorder. Some of these names reflected the now outdated belief that IBS is a purely psychological disorder, a product of the patient's imagination. Although modern medicine recognizes that stress can trigger IBS attacks, medical specialists agree that IBS is a genuine physical disorder—or group of disorders—with specific identifiable characteristics.No one knows for sure how many Americans suffer from IBS. Surveys indicate a range of 10-20%, with perhaps as many as 30% of Americans experiencing IBS at some point in their lives. IBS normally makes its first appearance during young adulthood, and in half of all cases symptoms begin before age 35. Women with IBS outnumber men by two to one, for reasons that are not yet understood. IBS is responsible for more time lost from work and school than any medical problem other than the common cold. It accounts for a substantial proportion of the patients seen by specialists in diseases of the digestive system (gastroenterologists). Yet only half-possibly as few as 15%—of IBS sufferers ever consult a doctor.

Causes and symptoms

Symptoms

The symptoms of IBS tend to rise and fall in intensity rather than growing steadily worse over time. They always include abdominal pain, which may be relieved by defecation; diarrhea or constipation; or diarrhea alternating with constipation. Other symptoms—which vary from person to person—include cramps; gassiness; bloating; nausea; a powerful and uncontrollable urge to defecate (urgency); passage of a sticky fluid (mucus) during bowel movements; or the feeling after finishing a bowel movement that the bowels are still not completely empty. The accepted diagnostic criteria—known as the Rome criteria—require at least three months of continuous or recurrent symptoms before IBS can be confirmed. According to Christine B. Dalton and Douglas A. Drossman in the American Family Physician, an estimated 70% of IBS cases can be described as "mild;" 25% as "moderate;" and 5% as "severe." In mild cases the symptoms are slight. As a general rule, they are not present all the time and do not interfere with work and other normal activities. Moderate IBS occasionally disrupts normal activities and may cause some psychological problems. People with severe IBS often find living a normal life impossible and experience crippling psychological problems as a result. For some the physical pain is constant and intense.

Causes

Researchers remain unsure about the cause or causes of IBS. It is called a functional disorder because it is thought to result from changes in the activity of the major part of the large intestine (the colon). After food is digested by the stomach and small intestine, the undigested material passes in liquid form into the colon, which absorbs water and salts. This process may take several days. In a healthy person the colon is quiet during most of that period except after meals, when its muscles contract in a series of wavelike movements called peristalsis. Peristalsis helps absorption by bringing the undigested material into contact with the colon wall. It also pushes undigested material that has been converted into solid or semisolid feces toward the rectum, where it remains until defecation. In IBS, however, the normal rhythm and intensity of peristalsis is disrupted. Sometimes there is too little peristalsis, which can slow the passage of undigested material through the colon and cause constipation. Sometimes there is too much, which has the opposite effect and causes diarrhea. A Johns Hopkins University study found that healthy volunteers experienced 6-8 contractions of the colon each day, compared with up to 25 contractions a day for volunteers suffering from IBS with diarrhea, and an almost complete absence of contractions among constipated IBS volunteers. In addition to differences in the number of contractions, many of the IBS volunteers experienced powerful spasmodic contractions affecting a larger-than-normal area of the colon—"like having a Charlie horse in the gut," according to one of the investigators.DIET. Some kinds of food and drink appear to play a key role in triggering IBS attacks. Food and drink that healthy people can ingest without any trouble may disrupt peristalsis in IBS patients, which probably explains why IBS attacks often occur shortly after meals. Chocolate, milk products, caffeine (in coffee, tea, colas, and other drinks), and large quantities of alcohol are some of the chief culprits. Other kinds of food have also been identified as problems, however, and the pattern of what can and cannot be tolerated is different for each person. Characteristically, IBS symptoms rarely occur at night and disrupt the patient's sleep.STRESS. Stress is an important factor in IBS because of the close nervous system connections between the brain and the intestines. Although researchers do not yet understand all of the links between changes in the nervous system and IBS, they point out the similarities between mild digestive upsets and IBS. Just as healthy people can feel nauseated or have an upset stomach when under stress, people with IBS react the same way, but to a greater degree. Finally, IBS symptoms sometimes intensify during menstruation, which suggests that female reproductive hormones are another trigger.

Diagnosis

Diagnosing IBS is a fairly complex task because the disorder does not produce changes that can be identified during a physical examination or by laboratory tests. When IBS is suspected, the doctor (who can be either a family doctor or a specialist) needs to determine whether the patient's symptoms satisfy the Rome criteria. The doctor must rule out other conditions that resemble IBS, such as Crohn's disease and ulcerative colitis. These disorders are ruled out by questioning the patient about his or her physical and mental health (the medical history), performing a physical examination, and ordering laboratory tests. Normally the patient is asked to provide a stool sample that can be tested for blood and intestinal parasites. In some cases x rays or an internal examination of the colon using a flexible instrument inserted through the anus (a sigmoidoscope or colonoscope) is necessary. The doctor also may ask the patient to try a lactose-free diet for two or three weeks to see whether lactose intolerance is causing the symptoms.

Treatment

Dietary changes, sometimes supplemented by drugs or psychotherapy, are considered the key to successful treatment. The following approach, offered by Dalton and Drossman, is typical of the advice found in the medical literature on IBS. The authors tie their approach to the severity of the patient's symptoms:

Mild symptoms

Dalton and Drossman recommend a low-fat, high-fiber diet. Problem-causing substances such as lactose, caffeine, beans, cabbage, cucumbers, broccoli, fatty foods, alcohol, and medications should be identified and avoided. Bran or 15-25 grams a day of an over-the-counter psyllium laxative (Metamucil or Fiberall) may also help both constipation and diarrhea. The patient can still have milk or milk products if lactose intolerance is not a problem. People with irregular bowel habits—particularly constipated patients—may be helped by establishing set times for meals and bathroom visits.

Moderate symptoms

The advice given by Dalton and Drossman in mild cases applies here as well. They also suggest that patients keep a diary of symptoms for two or three weeks, covering daily activities including meals, and emotional responses to events. The doctor can then review the diary with the patient to identify possible problem areas.Although a high-fiber diet remains the standard treatment for constipated patients, such laxatives as lactulose (Chronulac) or sorbitol may be prescribed. Loperamide (Imodium) and cholestyramine (Questran) are suggested for diarrhea. Abdominal pain after meals can be reduced by taking antispasmodic drugs such as hyoscyamine (Anaspaz, Cystospaz, or Levsin) or dicyclomine (Bemote, Bentyl, or Di-Spaz) before eating.Dalton and Drossman also suggest psychological counseling or behavioral therapy for some patients to reduce anxiety and to learn to cope with the pain and other symptoms of IBS. Relaxation therapy, hypnosis, biofeedback, and cognitive-behavioral therapy are examples of behavioral therapy.

Severe symptoms

When IBS produces constant pain that interferes with everyday life, antidepressant drugs can help by blocking pain transmission from the nervous system. Dalton and Drossman also underscore the importance of an ongoing and supportive doctor-patient relationship.

Alternative treatment

Alternative and mainstream approaches to IBS treatment overlap to a certain extent. Like mainstream doctors, alternative practitioners advise a high-fiber diet to reduce digestive system irritation. They also suggest avoiding alcohol, caffeine, and fatty, gassy, or spicy foods. Recommended stress management techniques include yoga, meditation, hypnosis, biofeedback, and reflexology. Reflexology is a technique of foot massage that is thought to relieve diarrhea, constipation, and other IBS symptoms.Alternative medicine also emphasizes such herbal remedies as ginger (Zingiber officinale), buckthorn (Rhamnus purshiana), and enteric-coated peppermint oil. Enteric coating prevents digestion until the peppermint oil reaches the small intestine, thus avoiding irritation of the upper part of the digestive tract. Chamomile (Matricaria recutita), valerian (Valeriana officinalis), rosemary (Rosemarinus officinalis), lemon balm (Melissa officinalis), and other herbs are recommended for their antispasmodic properties. The list of alternative treatments for IBS is in fact quite long. It includes aromatherapy, homeopathy, hydrotherapy, juice therapy, acupuncture, chiropractic, osteopathy, naturopathic medicine, and Chinese traditional herbal medicine.

Prognosis

IBS is not a life-threatening condition. It does not cause intestinal bleeding or inflammation, nor does it cause other bowel diseases or cancer. Although IBS can last a lifetime, in up to 30% of cases the symptoms eventually disappear. Even if the symptoms cannot be eliminated, with appropriate treatment they can usually be brought under control to the point where IBS becomes merely an occasional inconvenience. Treatment requires a long-term commitment, however; six months or more may be needed before the patient notices substantial improvement.

Resources

Organizations

International Foundation for Functional Gastrointestinal Disorders. P.O. Box 17864, Milwaukee, WI 53217. (888) 964-2001. http://www.iffgd.org.National Digestive Diseases Information Clearinghouse. 2 Information Way, Bethesda, MD 20892-3570. (800) 891-5389. http://www.niddk.nih.gov/health/digest/nddic.htm.

Key terms

Anus — The opening at the lower end of the rectum.Crohn's disease — A disease characterized by inflammation of the intestines. Its early symptoms may resemble those of IBS.Defecation — Passage of feces through the anus.Feces — Undigested food and other waste that is eliminated through the anus. Feces are also called fecal matter or stools.Lactose — A sugar found in milk and milk products. Some people are lactose intolerant, meaning they have trouble digesting lactose. Lactose intolerance can produce symptoms resembling those of IBS.Peristalsis — The periodic waves of muscular contractions that move food through the intestines during the process of digestion.Ulcerative colitis — A disease that inflames and causes breaks (ulcers) in the colon and rectum, which are parts of the large intestine.

irritable

[ir´ĭ-tah-b'l] 1. capable of reacting to a stimulus.2. abnormally sensitive to stimuli.irritable bowel syndrome the most common disorder presented by patients with gastrointestinal complaints, consisting of (1) altered bowel habits with diarrhea, constipation, or alternating diarrhea and constipation; (2) abdominal pain and intolerance to flatus; and (3) absence of detectable organic disease. Many inappropriate terms have been used to describe this disorder, including mucous colitis, nervous colon, spastic colon, and irritable colon. This syndrome should not be confused with colitis" >colitis or other inflammatory diseases of the intestinal tract; in irritable bowel syndrome there is no inflammation, and it is not necessarily limited to the colon.Patient Care. Because of psychological factors that usually contribute to the disorder and its tendency to be chronic in nature, treatment should be holistic and individualized to meet the needs of each patient. In most cases, treatment is needed for an extended period of time. Patients should be assured that there is no relationship between their disorder and malignancy of the bowel. Modes of therapy include psychotherapy, biofeedback training, medications such as antidepressants, antispasmodics, and analgesics, and a diet that is high in bran and fiber.
Nursing care for the patient with irritable bowel syndrome is essentially the same as that for someone with diarrhea or constipation. Patient teaching should include information about gas-forming foods such as legumes and those in the cabbage family. Milk and milk products are restricted in those patients who have shown an intolerance to milk.
Anxiety can often be mitigated by teaching the patient about the nature of the illness and reassurance that it is not related to malignancy of the bowel and can be managed by relatively simple, noninvasive measures. Ineffective coping patterns are not uncommon in these patients. When there is evidence that the patient is either unable to cope or is using harmful coping mechanisms such as smoking, drinking, or drug abuse, health teaching concerning relaxation techniques, wholesome diet, exercise, and recreation is appropriate.

irritable bowel syndrome (IBS),

a condition characterized by gastrointestinal signs and symptoms including constipation, diarrhea, gas, and bloating, all in the absence of organic pathology. Associated with uncoordinated and inefficient contractions of the large intestine.

irritable bowel syndrome

n. Abbr. IBS A chronic disorder characterized by motor abnormalities of the small and large intestines, causing variable symptoms including cramping, abdominal pain, constipation, and diarrhea. Also called irritable colon, spastic colon.

irritable bowel syndrome

Irritable colon GI disease A condition characterized by chronic abdominal pain, bloating, mucus in stools, irregular bowel habits, alternating diarrhea and constipation; IBS may accompany anxiety and panic disorders; Sx tend to wax and wane over yrs; the primary defect appears to be abnormal GI tract contractions–motility, which does not lead to any serious organ problems; it is a diagnosis of exclusion Management Symptomatic–high fiber diet, exercise, relaxation techniques, avoid caffeine, milk products, sweeteners, medications

ir·ri·ta·ble bow·el syn·drome

(IBS) , irritable colon (ir'i-tă-bĕl bow'ĕl sin'drōm, kō'lŏn) A condition characterized by gastrointestinal signs and symptoms including constipation, diarrhea, gas and bloating, all in the absence of organic pathology. Associated with uncoordinated and inefficient contractions of the large intestine.
Synonym(s): spastic colon.

irritable bowel syndrome

A persistent disorder of unknown cause characterized by recurrent abdominal pain, abdominal rumblings (borborygmi), excessive gas production, urgency to empty the bowels and intermittent diarrhoea often alternating with constipation. It most commonly affects women between 20 and 40 especially those of an anxious disposition. After full investigation and reassurance the symptoms will often settle on simple treatment. There is no consensus of opinion and no hard evidence as to the cause of this common disorder. Also known as spastic colon, mucous colitis, colonic spasm or nervous diarrhoea.

Irritable Bowel Syndrome

DRG Category:	391
Mean LOS:	5.1 days
Description:	MEDICAL: Esophagitis, Gastroenteritis, and Miscellaneous Digestive Disorders With Major CC

Irritable bowel syndrome (IBS), sometimes called spastic colon, is the most common digestive disorder in the United States with a prevalence as high as 10% to 20% of the population. It is a poorly understood syndrome of diarrhea, constipation, flatus, and abdominal pain that causes a great deal of stress and embarrassment to its victims. People often suffer with it for years before seeking medical attention.

Although people with IBS have a gastrointestinal (GI) tract that appears normal, colonic smooth muscle function is often abnormal. The autonomic nervous system, which innervates the large bowel, fails to provide the normal contractions interspaced with relaxations that propel stool smoothly forward. Excessive spasm and peristalsis lead to constipation or diarrhea, or both. Generally, patients with IBS have either diarrhea- or constipation-predominant syndrome. Although complications are unusual, they include diverticulitis, colon cancer, and chronic inflammatory bowel disease; IBS, however, does not increase mortality or the risk of inflammatory bowel disease or cancer.

Causes

IBS is a disorder of GI motility. Its exact cause remains unknown, although there is a familial link in about one-third of cases. It is not caused by nerves or poor diet. Both stress and intolerance for some foods, however, can precipitate attacks. Other triggers include some types of abdominal surgery, acute illness that has disrupted bowel function, prolonged use of antibiotics, exposure to toxins, and emotional trauma. Ingestion of caffeine, alcohol, and other gastric stimulants and lactose intolerance seem to play roles for many individuals. The course of the disease is usually specific to the patient, who can identify the individual precipitating factors for exacerbations.

Genetic considerations

IBS appears to run in families, but the exact mechanism is unclear. It is most likely a complex disorder with contributions from several genes and environmental factors. Serotonin transporter gene polymorphism has been associated with IBS.

Gender, ethnic/racial, and life span considerations

Most newly diagnosed patients are young women in their 20s or early 30s. Some recall at the time of diagnosis that as children they experienced abdominal pain or changes in bowel habits. The incidence of newly diagnosed IBS is rare over age 50. Fewer than one-third of the cases of IBS are in men. The disorder is more common in people with white/European ancestry, especially Jews, than in other groups such as Asian Americans and Hispanics/Latinos.

Global health considerations

Western Europe and the United States have similar prevalence statistics. The prevalence of IBS in developed nations is likely higher than in developing nations. These differences are likely because of sociocultural issues, eating patterns, and strategies of healthcare management.

Assessment

History

The Rome II criteria are used to diagnose IBS in patients who have the following symptoms for at least 3 months of the year: (1) Abdominal pain or discomfort that is relieved by defecation, associated with a change in stool frequency, and associated with a change in stool consistency; and (2) supporting symptoms including altered stool frequency, altered stool form, altered stool passage, mucorrhea, abdominal bloating, or subjective distension.

Symptoms that are reported most often are pain in the left lower quadrant, abdominal distention, diarrhea, and constipation, especially alternating bouts of the latter two. The pain may increase after eating and be relieved after a bowel movement. Pain is often cramping in nature and may be accompanied by nausea, belching, flatus, bloating, and sometimes anorexia. As the disease progresses, the patient may suffer fatigue and anxiety related to the many attempts to control the symptoms and lead a normal life. For some individuals with this disorder, the lifestyle is dictated by the need to remain close to a bathroom, which limits both occupation and social life.

Physical examination

With auscultation of the abdomen, normal bowel sounds may be heard, although they may be quiet during constipation. Tympanic sounds may be heard over loops of filled bowel. Although palpation often discloses a relaxed abdomen, it may reveal diffuse tenderness, which becomes worse if the sigmoid colon is palpable. The patient may have pain on rectal examination but does not usually experience rectal bleeding.

Psychosocial

Many patients have consulted physicians who fail to take IBS seriously, telling them to eat a high-fiber diet and relax. Unfortunately, a high-fiber diet, which is good for ordinary constipation, often makes the irritable bowel worse. As the person suffers more frequent bouts of diarrhea and constipation, any attempts to relax become futile. Anxiety over control of symptoms makes the symptoms of IBS worse, creating a vicious circle that becomes hard to break. Depression over the inability to control one’s bodily functions or lead a normal life sometimes becomes a serious problem.

Diagnostic highlights

Test	Normal Result	Abnormality With Condition	Explanation
Flexible sigmoidoscopy or colonoscopy	Visualization of normal sigmoid and colon	Intense spastic contractions; mucosa appears normal (smooth and pink)	Flexible sigmoidoscopy in adults younger than 40; colonoscopy in adults older than 40 years
Barium enema	Normal abdominal structures	Colonic spasms may occur during procedure; may have a normal examination	Identifies colonic spasms and rules out other pathology

Other Tests: Often diagnostic testing will not occur unless the patient has weight loss, iron deficiency anemia, or a family history of gastrointestinal illness. Additional tests are complete blood count, serological tests, serum albumin, stool for guaiac (occult blood), and abdominal x-ray.

Primary nursing diagnosis

Diagnosis

Pain (acute) related to abdominal cramping

Outcomes

Comfort level; Pain control behavior; Pain level; Symptom severity

Interventions

Medication management; Anxiety reduction; Environmental management; Comfort; Pain management

Planning and implementation

Collaborative

As the symptoms worsen during the stress of other physical illnesses or trauma, fluid volume deficit may become a serious problem. It is usually treated by hypotonic intravenous solutions such as half-strength normal saline, sometimes with a potassium supplement. The nurse monitors the patient’s state of hydration and intake and output. If the diarrhea continues to be severe, antidiarrheal and anti-anxiety agents may be prescribed for a short period. Diarrhea, constipation, and abdominal pain are treated by a combination of drugs, diet, and attempts to establish an exercise routine that promotes normal bowel function.

The diet used most often for changes in GI motility is high in fiber and bulk. Bran may be added to increase dietary bulk and control diarrhea. A high-fiber diet may control symptoms and establish regular bowel movements in some; for others, a low-fiber, low-fat diet may be more effective. Some patients have fewer symptoms on a gluten-free diet. Lactose or sorbitol intolerance may require treatment, and hypersensitivity to particular foods may be found by eliminating wheat, citrus foods, and fatty foods.

Pharmacologic highlights

Medication or Drug Class	Dosage	Description	Rationale
Bulk-forming laxatives	Varies with drug	Psyllium hydrophilic mucilloid (Metamucil); calcium polycarbophil (Mitrolan)	Facilitate defecation and enhance comfort
Antidiarrheal agents	Varies with drug	Diphenoxylate hydrochloride with atropine sulfate (Lomotil); loperamide (Imodium)	Decrease cramping and diarrhea; used only during an acute episode because they have a narcotic base and could easily lead to dependency
Antispasmodic agents	Varies with drug	Dicyclomine hydrochloride (Bentyl); propantheline bromide (Pro-Banthine); hyoscyamine (Levsin, Levbid)	Relieve abdominal cramping and spasms

Independent

The patient with IBS needs encouragement to eat meals at regular intervals, to chew the food slowly to help promote normal bowel function, and to drink eight glasses of water daily. Diet should include 30 to 40 g of fiber each day. Most of the fluid intake should be at times other than mealtime. Foods to avoid include alcohol, caffeine, and anything that may irritate the GI tract. For example, if milk or milk products cause cramping or discomfort, they should be avoided.

Incorporating regular exercise in the daily routine may be helpful in controlling GI motility, but strenuous exercise is not desirable. Reassure the patient that stress does not cause the illness, even though it may be a major factor in its severity. Refer patients to a counselor if anxiety and stress management might help manage the condition.

Evidence-Based Practice and Health Policy

Moayyedi, P., Ford, A.C., Talley, N.J., Cremonini, F., Foxx-Orenstein, A.E., Brandt, L.J., & Quigley, E.M. (2010). The efficacy of probiotics in the treatment of irritable bowel syndrome: A systematic review. Gut, 59(3), 325–332.

Investigators conducted a meta-analysis of 19 randomized controlled trials, which included 1,650 patients with IBS, to determine the beneficial effects of probiotics on IBS symptoms.
When compared to the placebo, probiotics significantly reduced pain scores (mean difference, 0.51; 95% CI, 0.09 to 0.91; p = 0.016) and flatulence (mean difference, 0.22; 95% CI, 0.01 to 0.42; p = 0.04).
Overall, the relative risk of IBS improvement increased 29% with probiotics use compared to the placebo (95% CI, 0.57 to 0.88; p < 0.001).

Documentation guidelines

Physical response: Hydration, GI assessment, frequency and consistency of bowel movements, level of discomfort
Emotional response: Level of stress, mood and affect, coping ability
Response to medications
Nutritional status: Tolerance to food, body weight, appetite

Discharge and home healthcare guidelines

Help the patient set a long-term goal to regain control of elimination patterns with manageable short-term goals to reduce stress. Progressive muscle relaxation helps relieve the tension that often stimulates stress-related diarrhea. Explain that as the patient experiences less frequent diarrhea, he or she begins to relax even more. Teach the patient about the disease, the treatment, and how to control the symptoms. Explain that the prognosis for control of the disease depends largely on the establishment of normal bowel habits and a plan for stress management. Explain all medications, including the dosage, action, route, and possible side effects. Explore the patient’s dietary patterns and provide a dietary consultation if it is appropriate.

Patient discussion about irritable bowel syndrome

Q. What percentages of fibromyalgia patients have IBS. My cousin with fibromyalgia aka FMS have also been diagnosed with IBS. Is it a usual happening? What percentages of fibromyalgia patients have IBS?A. Irritable bowel syndrome seems to go hand in hand with FMS, similar to the way in which people with fibromyalgia are also found to have depression. A fairly high percentage of individuals with fibromyalgia aka FMS have also been diagnosed with IBS, or irritable bowel syndrome. So how high is the percentage? It is believed that up to 70 to 80 percent of fibromyalgia patients also suffer from IBS, a form of inflammatory bowel disease. Irritable bowel syndrome seems to go hand in hand with FMS, similar to the way in which people with fibromyalgia are also found to have depression. Statistically, of course, those who have both IBS and FMS are overwhelmingly female, just as patients who are diagnosed with depression, fibromyalgia, or irritable bowel syndrome separately, tend more often to be female versus male.

More discussions about irritable bowel syndrome

irritable bowel syndrome

irritable bowel syndrome

irritable bowel syndrome

irritable bowel syndrome

irritable bowel syndrome

irritable bowel syndrome

irritable bowel syndrome

irritable bowel syndrome

Irritable Bowel Syndrome

Definition

Description

Causes and symptoms

Symptoms

Causes

Diagnosis

Treatment

Mild symptoms

Moderate symptoms

Severe symptoms

Alternative treatment

Prognosis

Resources

Organizations

Key terms

irritable

irritable bowel syndrome (IBS),

irritable bowel syndrome

irritable bowel syndrome

ir·ri·ta·ble bow·el syn·drome

irritable bowel syndrome

Irritable Bowel Syndrome

Causes

Genetic considerations

Gender, ethnic/racial, and life span considerations

Global health considerations

Assessment

History

Physical examination

Psychosocial

Diagnostic highlights

Primary nursing diagnosis

Diagnosis

Outcomes

Interventions

Planning and implementation

Collaborative

Pharmacologic highlights

Independent

Evidence-Based Practice and Health Policy

Documentation guidelines

Discharge and home healthcare guidelines

Patient discussion about irritable bowel syndrome

irritable bowel syndrome

Synonyms for irritable bowel syndrome

noun recurrent abdominal pain and diarrhea (often alternating with periods of constipation)

Synonyms

Related Words