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{{Irritable bowel syndrome}}
{{Irritable bowel syndrome}}
{{CMG}}; {{AE}}  
{{CMG}}; {{AE}} {{Cherry}}


==Overview==
==Overview==
Patients with IBS usually appear normal. Physical examination of patients with IBS may elicit tenderness in the abdomen. A digital rectal examination must be performed in all patients to rule out rectal growths, blood in stool and evaluate for dyssynergic defecation (where paradoxical contraction of the rectal sphincter occurs on bearing down and abnormal perineal descent).  Physical findings such as fever, abdominal mass, hepatosplenomegaly, lymph node enlargement, weight loss, peritoneal signs and ascites are absent and help rule out organic causes.    
Patients with [[Irritable bowel syndrome|irritable bowel syndrome]] usually appear normal on [[Physical examination|physical exam]]. [[Physical examination]] of patients with [[Irritable bowel syndrome|IBS]] may elicit [[Tenderness (medicine)|abdominal tenderness]] in some patients. A [[Rectal examination|digital rectal examination]] must be performed in all patients to rule out [[rectal]] growths, blood in [[Human feces|stool]] and evaluate for dyssynergic [[defecation]] (where paradoxical contraction of the rectal [[sphincter]] occurs on straining, leading to [[constipation]]).  Physical findings such as [[fever]], [[abdominal mass]], [[hepatosplenomegaly]], [[lymph node]] enlargement, [[weight loss]], [[Peritoneum|peritoneal]] signs and [[ascites]] are absent in [[Irritable bowel syndrome|IBS]] and help rule out organic causes.      
==Physical Examination==
===Appearance of the patient===
*Patients with [[Irritable bowel syndrome|irritable bowel syndrome]] usually appear normal/mildly distressed. Physical exam is normal in most patients.<ref name="pmid27492916">{{cite journal |vauthors=Bharucha AE, Chakraborty S, Sletten CD |title=Common Functional Gastroenterological Disorders Associated With Abdominal Pain |journal=Mayo Clin. Proc. |volume=91 |issue=8 |pages=1118–32 |year=2016 |pmid=27492916 |pmc=4985027 |doi=10.1016/j.mayocp.2016.06.003 |url=}}</ref><ref name="pmid21872090">{{cite journal |vauthors=Malone MA |title=Irritable bowel syndrome |journal=Prim. Care |volume=38 |issue=3 |pages=433–47; viii |year=2011 |pmid=21872090 |doi=10.1016/j.pop.2011.05.003 |url=}}</ref><ref name="pmid19151451">{{cite journal |vauthors=Abdullah M |title=Irritable bowel syndrome: current review on pathophysiology and diagnotic aspects |journal=Acta Med Indones |volume=40 |issue=4 |pages=218–25 |year=2008 |pmid=19151451 |doi= |url=}}</ref><ref name="pmid17606954">{{cite journal |vauthors=Wilson JF |title=In the clinic. Irritable bowel syndrome |journal=Ann. Intern. Med. |volume=147 |issue=1 |pages=ITC7–1–ITC7–16 |year=2007 |pmid=17606954 |doi=10.7326/0003-4819-147-1-200707030-01007 |url=}}</ref><ref name="pmid16455728">{{cite journal |vauthors=Agrawal A, Whorwell PJ |title=Irritable bowel syndrome: diagnosis and management |journal=BMJ |volume=332 |issue=7536 |pages=280–3 |year=2006 |pmid=16455728 |pmc=1360402 |doi=10.1136/bmj.332.7536.280 |url=}}</ref>


=== VItals Signs ===
===Vital signs===


·      [[Blood pressure]]
*Afebrile
 
*Regular [[pulse]]
·      Orthostatics
*Normal [[blood pressure]]  
 
*Normal [[respiratory rate]]
=== Skin ===
*IBS-diarrhea patients with [[dehydration]]/[[hypovolemia]] as a complication develop:<ref name="pmid10086438">{{cite journal |vauthors=McGee S, Abernethy WB, Simel DL |title=The rational clinical examination. Is this patient hypovolemic? |journal=JAMA |volume=281 |issue=11 |pages=1022–9 |year=1999 |pmid=10086438 |doi= |url=}}</ref>
·      Skin examination
**[[tachycardia]]
 
**low [[blood pressure]]
·      Signs of [[dehydration]]
**[[Orthostatic hypotension|postural hypotension]]
 
'''Physical examination''' — 
 
 volume depletion.
 
'''Skin and mucous membranes''' — If the skin on the thigh, calf, or forearm is pinched in normal subjects, it will immediately return to its normally flat state when the pinch is released
 
Although reduced skin turgor is an important clinical finding, normal turgor does not exclude the presence of hypovolemia.
 
This is particularly true with mild volume deficits, in young patients whose skin is very elastic, and in obese patients, since fat deposits under the skin prevent the changes in subcutaneous turgor from being appreciated.
 
The skin is also usually dry in hypovolemic patients, and a dry axilla is particularly suggestive of the diagnosis
 
The tongue and oral mucosa may also be dry since salivary secretions are decreased in this setting.
 
'''Arterial blood pressure''' — The arterial blood pressure changes from near normal with mild hypovolemia to low in the upright position and then, with progressive volume depletion, to persistently low regardless of posture. Postural hypotension leading to dizziness may be the patient's major complaint and is strongly suggestive of hypovolemia
 
'''Abdominal pain'''
 
=== Abdomen ===
·      Back, genital and rectal examinations
 
·      Complete abdominal examination
 
=== Acute Abdomen ===
In cases of ischemic acute abdomen, bowel sounds will be absent.
 
'''PHYSICAL EXAMINATION''' — Begin the physical examination by assessing the vital signs. Though fever increases the suspicion for infection,
 
Elderly patients with an intraabdominal infection are four times more likely than younger patients to present with hypothermia [2].
 
An oral temperature may be affected by respiratory rate, which is often elevated in those with pain [34].
 
 If there is concern about an inaccurate reading, check a rectal temperature.
 
An elevated respiratory rate may itself be a compensatory reaction and should alert the clinician to the possibility of underlying metabolic acidosis.  
 
Next, inspect The patient who is restless, curled up, and agitated may suggest renal colic, while a patient lying perfectly still in bed with knees bent raises concern for peritonitis. Inspection may reveal signs of previous surgeries (eg, midline incision scar), abdominal pulsations, or signs of systemic disease (eg, pallor in shock, spider angiomata in cirrhosis), which can be especially important in those who are unable to provide a history.
 
On auscultation, listen for bowel sounds for two minutes.
 
Bowel sounds are normally heard as two to twelve medium-pitched gurgles per minute.
 
 The absence of bowel sounds over two minutes suggests peritonitis.
 
 Hyperactive medium-pitched bowel sounds are associated with blood or inflammation within the gastrointestinal (GI) tract.
 
 Periodic rushes of high-pitched "tinkling" bowel sounds or the complete absence of bowel sounds, in the presence of abdominal distention, suggests bowel obstruction [35].
 
A bruit may be heard in the presence of an abdominal aortic aneurysm (AAA).
 
Palpation of the abdomen enables the clinician to identify the location and degree of tenderness and to detect signs of peritoneal irritation, such as involuntary guarding and rigidity.
 
 One approach is to initially perform light palpation in the area away from the site of pain. Palpation can then be extended in either a clockwise or counterclockwise rotation towards the area of maximal pain.
 
 Once the area of maximal tenderness is localized, maneuvers to elicit somatic signs can be performed. If a specific area of tenderness is not identified with light palpation, deeper palpation can be performed to identify other abnormalities such as hepatomegaly, splenomegaly, aortic dilatation, or signs of a retrocecal appendix.  
 
Although insensitive, the psoas, obturator, and Rovsing signs have good specificity for acute
 
In a patient with equivocal signs and symptoms, serial examinations can improve diagnostic accuracy [47].  
 
===Appearance of the Patient===
*Patients with IBS usually appear normal/mildly distressed.
 
===Vital Signs===
 
*patients are usually afebrile.
*patients have regular pulse, tachycardia may be present in case of dehydration
*Blood pressure is normal in most patients, decreased in case of dehydration
*Respiratory rate normal


===Skin===
===Skin===
* skin turgor is normal in most patients
* Skin turgor is normal in most patients
* skin turgor is reduced in IBS-diarrhea patients with dehydration as a complication
* [[Irritable bowel syndrome|IBS]]-[[diarrhea]] patients with [[dehydration]]/[[hypovolemia]] as a complication develop:<ref name="pmid10086438">{{cite journal |vauthors=McGee S, Abernethy WB, Simel DL |title=The rational clinical examination. Is this patient hypovolemic? |journal=JAMA |volume=281 |issue=11 |pages=1022–9 |year=1999 |pmid=10086438 |doi= |url=}}</ref>
 
** decreased skin turgor
===HEENT===
** dryness of tongue and oral [[Mucous membrane|mucosa]]  due to decreased [[Salivary gland|salivary]] secretions
WNL
 
===Neck===
WNL


===Lungs===
===Lungs===
* Normal chest expansion
* Normal chest expansion
*Normal vesicular breath sounds in B/L lung fields
*Normal [[Vesicular breathing|vesicular]] breath sounds in B/L lung fields
*Normal [[tactile fremitus]]
*Normal [[tactile fremitus]]


===Heart===
===Heart===
*[[Heart sounds#First heart tone S1, the "lub"(components M1 and T1)|S1]] /[[Heart sounds#Second heart tone S2 the "dub"(components A2 and P2)|S2]] normal
*[[Heart sounds#First heart tone S1, the "lub"(components M1 and T1)|S1]] /[[Heart sounds#Second heart tone S2 the "dub"(components A2 and P2)|S2]] normal
*No additional sounds


===Abdomen===
===Abdomen===
Findings on abdominal examination are as follows:<ref name="pmid19521341">{{cite journal |vauthors=Brandt LJ, Chey WD, Foxx-Orenstein AE, Schiller LR, Schoenfeld PS, Spiegel BM, Talley NJ, Quigley EM |title=An evidence-based position statement on the management of irritable bowel syndrome |journal=Am. J. Gastroenterol. |volume=104 Suppl 1 |issue= |pages=S1–35 |year=2009 |pmid=19521341 |doi=10.1038/ajg.2008.122 |url=}}</ref><ref name="pmid10588169">{{cite journal |vauthors=Schmulson MW, Chang L |title=Diagnostic approach to the patient with irritable bowel syndrome |journal=Am. J. Med. |volume=107 |issue=5A |pages=20S–26S |year=1999 |pmid=10588169 |doi= |url=}}</ref><ref name="pmid4023607">{{cite journal |vauthors=Svendsen JH, Munck LK, Andersen JR |title=Irritable bowel syndrome--prognosis and diagnostic safety. A 5-year follow-up study |journal=Scand. J. Gastroenterol. |volume=20 |issue=4 |pages=415–8 |year=1985 |pmid=4023607 |doi= |url=}}</ref>
* Examination results are usually normal  
* Examination results are usually normal  
* [[Abdominal distention]] may be present
* [[Abdominal distention]] may be present
*[[Abdominal tenderness]] may be elicited in different quadrants  
*[[Abdominal tenderness]] may be elicited in different quadrants  
*Absence of abdominal masses, organomegaly
*Absence of abdominal masses, [[Splenomegaly|hepatospleenomegaly]]
*Normal bowel sounds
*Normal [[Intestine|bowel]] sounds
*To rule out organic causes, rectal exam must be done in patients to evaluate for:
 
=== Rectal exam ===
*IBS patients usually have a normal [[rectal]] exam.To rule out organic causes of [[constipation]] and [[diarrhea]], rectal exam must be done in patients to evaluate for: <ref name="pmid16803612">{{cite journal |vauthors=Whitehead WE, Palsson OS, Feld AD, Levy RL, VON Korff M, Turner MJ, Drossman DA |title=Utility of red flag symptom exclusions in the diagnosis of irritable bowel syndrome |journal=Aliment. Pharmacol. Ther. |volume=24 |issue=1 |pages=137–46 |year=2006 |pmid=16803612 |doi=10.1111/j.1365-2036.2006.02956.x |url=}}</ref><ref name="pmid6724251">{{cite journal |vauthors=Kruis W, Thieme C, Weinzierl M, Schüssler P, Holl J, Paulus W |title=A diagnostic score for the irritable bowel syndrome. Its value in the exclusion of organic disease |journal=Gastroenterology |volume=87 |issue=1 |pages=1–7 |year=1984 |pmid=6724251 |doi= |url=}}</ref><ref name="pmid18397419">{{cite journal |vauthors=Talley NJ |title=How to do and interpret a rectal examination in gastroenterology |journal=Am. J. Gastroenterol. |volume=103 |issue=4 |pages=820–2 |year=2008 |pmid=18397419 |doi=10.1111/j.1572-0241.2008.01832.x |url=}}</ref><ref name="pmid20656061">{{cite journal |vauthors=Tantiphlachiva K, Rao P, Attaluri A, Rao SS |title=Digital rectal examination is a useful tool for identifying patients with dyssynergia |journal=Clin. Gastroenterol. Hepatol. |volume=8 |issue=11 |pages=955–60 |year=2010 |pmid=20656061 |doi=10.1016/j.cgh.2010.06.031 |url=}}</ref><ref name="pmid26032152">{{cite journal |vauthors=Soh JS, Lee HJ, Jung KW, Yoon IJ, Koo HS, Seo SY, Lee S, Bae JH, Lee HS, Park SH, Yang DH, Kim KJ, Ye BD, Byeon JS, Yang SK, Kim JH, Myung SJ |title=The diagnostic value of a digital rectal examination compared with high-resolution anorectal manometry in patients with chronic constipation and fecal incontinence |journal=Am. J. Gastroenterol. |volume=110 |issue=8 |pages=1197–204 |year=2015 |pmid=26032152 |doi=10.1038/ajg.2015.153 |url=}}</ref>
** presence of [[stool]] and its consistency
** presence of [[stool]] and its consistency
**Rectal tenderness
**[[Rectal]] tenderness
**Strictures
**Strictures
** Masses
** Masses
**rectal prolapse  
**rectal [[prolapse]]
** [[Fistula|Fistulas]]  
** [[Fistula|Fistulas]]  
** [[Hemorrhoid|Hemorrhoids]]  
** [[Hemorrhoid|Hemorrhoids]]  
** [[Abscess|Abscesses]]  
** [[Abscess|Abscesses]]  
** [[Fissure|Fissures]]
** [[Fissure|Fissures]]
**impaired sphincter function due to a neurologic disorder  
**impaired [[sphincter]] function due to a [[Neurology|neurologic]] disorder  
**responses of the puborectalis and external anal sphincter muscles while straining to rule out dyssynergic defecation.
**responses of the [[puborectalis]] and [[External anal sphincter|external anal sphincter muscles]] while straining to rule out dyssynergic [[defecation]]
 
===Genitourinary===
*WNL
 
===Neuromuscular===
*Patient is usually oriented to persons, place, and time
 
===Extremities===
*


==References==
==References==

Latest revision as of 14:48, 4 December 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sudarshana Datta, MD [2]

Overview

Patients with irritable bowel syndrome usually appear normal on physical exam. Physical examination of patients with IBS may elicit abdominal tenderness in some patients. A digital rectal examination must be performed in all patients to rule out rectal growths, blood in stool and evaluate for dyssynergic defecation (where paradoxical contraction of the rectal sphincter occurs on straining, leading to constipation). Physical findings such as fever, abdominal mass, hepatosplenomegaly, lymph node enlargement, weight loss, peritoneal signs and ascites are absent in IBS and help rule out organic causes.   

Physical Examination

Appearance of the patient

Vital signs

Skin

Lungs

Heart

  • S1 /S2 normal
  • No additional sounds

Abdomen

Findings on abdominal examination are as follows:[7][8][9]

Rectal exam

References

  1. ↑ Bharucha AE, Chakraborty S, Sletten CD (2016). "Common Functional Gastroenterological Disorders Associated With Abdominal Pain". Mayo Clin. Proc. 91 (8): 1118–32. doi:10.1016/j.mayocp.2016.06.003. PMC 4985027. PMID 27492916.
  2. ↑ Malone MA (2011). "Irritable bowel syndrome". Prim. Care. 38 (3): 433–47, viii. doi:10.1016/j.pop.2011.05.003. PMID 21872090.
  3. ↑ Abdullah M (2008). "Irritable bowel syndrome: current review on pathophysiology and diagnotic aspects". Acta Med Indones. 40 (4): 218–25. PMID 19151451.
  4. ↑ Wilson JF (2007). "In the clinic. Irritable bowel syndrome". Ann. Intern. Med. 147 (1): ITC7–1–ITC7–16. doi:10.7326/0003-4819-147-1-200707030-01007. PMID 17606954.
  5. ↑ Agrawal A, Whorwell PJ (2006). "Irritable bowel syndrome: diagnosis and management". BMJ. 332 (7536): 280–3. doi:10.1136/bmj.332.7536.280. PMC 1360402. PMID 16455728.
  6. ↑ 6.0 6.1 McGee S, Abernethy WB, Simel DL (1999). "The rational clinical examination. Is this patient hypovolemic?". JAMA. 281 (11): 1022–9. PMID 10086438.
  7. ↑ Brandt LJ, Chey WD, Foxx-Orenstein AE, Schiller LR, Schoenfeld PS, Spiegel BM, Talley NJ, Quigley EM (2009). "An evidence-based position statement on the management of irritable bowel syndrome". Am. J. Gastroenterol. 104 Suppl 1: S1–35. doi:10.1038/ajg.2008.122. PMID 19521341.
  8. ↑ Schmulson MW, Chang L (1999). "Diagnostic approach to the patient with irritable bowel syndrome". Am. J. Med. 107 (5A): 20S–26S. PMID 10588169.
  9. ↑ Svendsen JH, Munck LK, Andersen JR (1985). "Irritable bowel syndrome--prognosis and diagnostic safety. A 5-year follow-up study". Scand. J. Gastroenterol. 20 (4): 415–8. PMID 4023607.
  10. ↑ Whitehead WE, Palsson OS, Feld AD, Levy RL, VON Korff M, Turner MJ, Drossman DA (2006). "Utility of red flag symptom exclusions in the diagnosis of irritable bowel syndrome". Aliment. Pharmacol. Ther. 24 (1): 137–46. doi:10.1111/j.1365-2036.2006.02956.x. PMID 16803612.
  11. ↑ Kruis W, Thieme C, Weinzierl M, Schüssler P, Holl J, Paulus W (1984). "A diagnostic score for the irritable bowel syndrome. Its value in the exclusion of organic disease". Gastroenterology. 87 (1): 1–7. PMID 6724251.
  12. ↑ Talley NJ (2008). "How to do and interpret a rectal examination in gastroenterology". Am. J. Gastroenterol. 103 (4): 820–2. doi:10.1111/j.1572-0241.2008.01832.x. PMID 18397419.
  13. ↑ Tantiphlachiva K, Rao P, Attaluri A, Rao SS (2010). "Digital rectal examination is a useful tool for identifying patients with dyssynergia". Clin. Gastroenterol. Hepatol. 8 (11): 955–60. doi:10.1016/j.cgh.2010.06.031. PMID 20656061.
  14. ↑ Soh JS, Lee HJ, Jung KW, Yoon IJ, Koo HS, Seo SY, Lee S, Bae JH, Lee HS, Park SH, Yang DH, Kim KJ, Ye BD, Byeon JS, Yang SK, Kim JH, Myung SJ (2015). "The diagnostic value of a digital rectal examination compared with high-resolution anorectal manometry in patients with chronic constipation and fecal incontinence". Am. J. Gastroenterol. 110 (8): 1197–204. doi:10.1038/ajg.2015.153. PMID 26032152.

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