Irritable bowel syndrome differential diagnosis: Difference between revisions

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Revision as of 20:10, 5 November 2017

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

Overview

Irritable bowel syndrome must be differentiated from other diseases that cause diarrhea, constipation, and abdominal pain, such as Celiac disease, Inflammatory bowel disease(Crohn's disease and Ulcerative colitis) Thyroid disease (Hyper or Hypothyroidism), strictures due to ischemia, diverticulitis or ischemia, among others.

The differential diagnosis for Irritable bowel syndrome can be listed based on predominant symptoms, such as constipation predominant, diarrhea predominant and pain predominant diseases.

Differentiating Irritable Bowel Syndrome from other Diseases

Diseases with similar symptoms

Celiac disease
Crohn's disease
Zollinger-Ellison syndrome
VIPoma
Diverticulitis
Endometriosis
Gallstones
Gastroesophageal reflux disease (GERD)
Inflammatory bowel disease
Lactose intolerance
Thyroid disease- Hyperthyroidism/Hypothyroidism
Chronic pancreatitis
Small bacterial overgrowth
Intermittent small bowel obstruction

Differential Diagnosis of Irritable Bowel Syndrome on the basis of Constipation:

The differential diagnosis of Irritable bowel Syndrome based on constipation is as follows:^[1]^[2]^[3]^[4]^[5]^[6]^[7]^[8]^[9]^[10]


Differential Diagnosis for Constipation predominant symptoms	Clinical features	Diagnosis

Strictures due to diverticultis,inflammatory bowel disease, ischemia or cancer	Obstipation, constipation	Barium enema, flexible sigmoidoscopy, colonoscopy, CT scan
Hypothyroidism	Fatigue, increased sensitivity to cold, dry skin, constipation, weight gain, puffy face, muscle weakness, hoarseness	Serum Thyroid Stimulating Hormone levels
Medication	Opiates, cholestyramine, Calcium-channel blockers, Anticholinergic medications	Medication history.
Neurologic disease	Concurrent multiple sclerosis, Parkinson disease, autonomic dysfunction(Shy-Drager)	History and neurologic examination
Pelvic floor dysfunction	Straining, self digitation	Rectal examination, defecography, anorectal manometry, balloon expulsion study
Colonic inertia	Infrequent bowel movements	Radiopaque markers, scintigraphy, wireless pH and motility capsule

Differential Diagnosis of Irritable Bowel Syndrome on the basis of Diarrhea:

Diarrhea may be caused by infectious diseases, celiac disease,^[11] parasites,^[12] food allergies^[13] and lactose intolerance.^[14] See the list of causes of diarrhea for other conditions which can cause diarrhea. Celiac disease in particular is most often misdiagnosed as IBS.^[15] The differential diagnosis of Irritable Bowel Syndrome based on diarrhea is as follows:^[16]^[17]^[18]^[19]^[20]^[21]^[22]^[23]^[24]^[25]


Differential Diagnosis for Diarrhea predominant symptoms	Clinical features	Diagnosis

Crohn's disease	Diarrhea, abdominal pain	Colonoscopy, small bowel barium radiograph, CT enterography, magnetic resonance enterography
Ulcerative colitis	Present with abdominal pain, tenesmus, have diarrhea and rectal bleeding	Colonoscopy
Microscopic colitis	Watery diarrhea with nocturnal symptoms	Colonoscopy, flexible sigmoidoscopy and biopsy
Celiac disease	Diarrhea, steatorrhea, anemia	Endoscopy with small bowel biopsy, Tissue transglutaminase antibody
Neuroendocrine tumor	Gastrinoma, Carcinoid and VIP producing tumor	Urine 5HIAA, fasting gastritis(followed by secretin stimulation test), serum VIP
Hyperthyroidism	Increased appetite, insomnia, diarrhea, palpitations, heat intolerance, increased sweating	Serum TSH levels
Lactose intolerance	Flatulence, bloating with lactose consumption	Avoidance trial, lactose breath test
Infectious causes	Abdominal discomfort, diarrhea especially in the setting of recent travel	Stool for ova and parasites, stool Giardia antigen, stool culture, trial of metronidazole
Small bowel bacterial overgrowth	Bloating, diarrhea, abdominal distension	Jejunal aspirate, lactulose breath hydrogen test, antibiotic trial
Clostridium difficile infection(Psuedomembranous colitis)	Recent antibiotic treatment	Stool Polymerase Chain reaction

The diffrentials of chronic watery diarrhea are as follows:

Cause			Osmotic gap		History	Physical exam	Gold standard	Treatment
Cause			< 50 mOsm per kg	> 50 mOsm per kg*	History	Physical exam	Gold standard	Treatment
Watery	Secretory	Crohns	+	-	Abdominal pain followed by diarrhea	Abdominal tenderness when palpated in severe disease Blood seen on rectal exam Fever Tachycardia Hypotension	Colonoscopy with biopsy	Topical mucosamine and corticosteroids are preferred Mesalamineand sulfasalazine are used for remission
		Zollinger-Ellison syndrome	+	-	Abdominal pain and diarrhea Dyspepsia Upper or lower GI bleeding	Abdominal tenderness whenpalpated in severe disease Blood seen on rectal exam, Hematochezia Hematemesis Tachycardia Hypotension	Gastrin levels	Proton pump inhibitors Octreotide
		Hyperthyroidism	+	-	Abdominal pain and diarrhea Dyspepsia Upper or lower GI bleeding	Lump in the neck Proptosis Tremors Increased DTR	TSH with T3 and T4	Carbimazole and methimazole Beta blockers like propylthiouracil Iodine-131
		VIPoma	+	-	Watery diarrhea Dehydration(thirst, dry skin, dry mouth, tiredness, headaches, and dizziness) Lethargy, muscle weakness Nausea, vomiting Crampy abdominal pain Weight loss Flushing	Lump in the neck Proptosis Tremors Increased DTR	Elevated VIPlevels Followed by imaging	Sandostatin or chemotherapy for malignant tumors Surgical removal of the tumor
	Osmotic	Lactose intolerance	-	+	Abdominal pain Bloating Diarrhea Flatulence	Abdominal tenderness	Intestinal biopsy	Avoidance of dietary lactose Substitution to maintain nutrient intake Regulation of calcium intake Use of enzyme lactase
	Osmotic	Celiac disease	-	+	May be asymptomatic Vague abdominal pain Diarrhea Weight loss Malabsorption/ steatorrhea Bloatedness	Abdominal pain and cramping Abdominal distention Tetany Mouth ulcers Dermatitis herpetiformis Signs of the fat-soluble vitamins A, D, E, and K deficiency	IgA tissue transglutaminaseAb	Gluten-free diet
	Functional	Irritable bowel syndrome	-	-	Abdominal pain or discomfort recurring at least 3 days per month in the past 3 months and associated with 2 or more of the following: Improves with defecation Onset associated with change in frequency of stool Onset associated with change in appearance of stool 25% of bowel movements are loose stools History of straining is also common	Abdominal tenderness Hard stool in the rectal vault	Clinical diagnosis ROME III criteria Pharmacologicstudies based criteria	High dietary fiber Osmotic laxatives such as polyethylene glycol, sorbitol, and lactulose Antispasmodicdrugs (e.g. anticholinergics such as hyoscyamine or dicyclomine)

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Differential diagnosis of abdominal pain

The differential diagnosis based on abdominal pain are as follows:

Classification of acute abdomen based on etiology		Presentation	Clinical findings								Diagnosis		Comments
Classification of acute abdomen based on etiology		Presentation	Fever	Rigors and Chills	Abdominal Pain	Jaundice	Hypotension	Guarding	Rebound Tenderness	Bowel sounds	Lab Findings	Imaging	Comments
Common causes of Peritonitis		Spontaneous bacterial peritonitis	+		Diffuse	−	−	−	−	Hypoactive	Ascitic fluid PMN>250 cells/mm³ Culture: Positive for single organism	Ultrasound for evaluation of liver cirrhosis	-
		Perforated gastric and duodenal ulcer	+		Diffuse	−	+	+	+	N	Ascitic fluid LDH > serum LDH Glucose < 50mg/dl Total protein > 1g/dl	Air under diaphragm in upright CXR	Upper GI endoscopy for diagnosis
		Acute suppurative cholangitis	+	+	RUQ	+	+	+	+	±
		Acute cholangitis	+	−	RUQ	+	−	−	−	N	Abnormal LFT	Ultrasound shows biliary dilatation	Biliary drainage (ERCP) + IV antibiotics
		Acute cholecystitis	+		RUQ	+		−	−	Hypoactive	Hyperbilirubinemia Leukocytosis	Ultrasound shows gallstone and evidence of inflammation	Murphy’s sign
		Acute pancreatitis	+		Epigastric	±		−	−	N	Increased amylase / lipase	Ultrasound shows evidence of inflammation	Pain radiation to back
		Acute appendicitis	+		RLQ	−		+	+	Hypoactive	Leukocytosis	Ultrasound shows evidence of inflammation	Nausea & vomiting, decreased appetite
		Acute diverticulitis	+		LLQ	±		+	−	Hypoactive	Leukocytosis	CT scan and ultrasound shows evidence of inflammation
Hollow Viscous Obstruction		Small intestine obstruction	−		Diffuse	−		+	±	Hyperactive then absent	Leukocytosis	Abdominal X ray	Nausea & vomiting associated with constipation, abdominal distention
		Gall stone disease/Cholelithiasis	±	−
		Volvulus	-		Diffuse	-		+	-	Hypoactive	Leukocytosis	CT scan and abdominal X ray	Nausea & vomiting associated with constipation, abdominal distention
		Biliary colic	-		RUQ	+		-	-	N	Increased bilirubin and alkaline phosphatase	Ultrasound	Nausea & vomiting
		Renal colic	-		Flank pain	-		-	-	N	Hematuria	CT scan and ultrasound	Colicky abdominal pain associated with nausea & vomiting
Vascular Disorders	Ischemic causes	Mesenteric ischemia	±		Periumbilical	-		-	-	Hyperactive	Leukocytosis and lactic acidosis	CT scan	Nausea & vomiting, normal physical examination
	Ischemic causes	Acute ischemic colitis	±		Diffuse	-		+	+	Hyperactive then absent	Leukocytosis	CT scan	Nausea & vomiting
	Hemorrhagic causes	Ruptured abdominal aortic aneurysm	-		Diffuse	-		-	-	N	Normal	CT scan	Unstable hemodynamics
	Hemorrhagic causes	Intra-abdominal or retroperitoneal hemorrhage	-		Diffuse	-		-	-	N	Anemia	CT scan	History of trauma
Gynaecological Causes	Fallopian tube	Acute salpingitis	+		LLQ/ RLQ	−		±	±	N	Leukocytosis	Pelvic ultrasound	Vaginal discharge
	Ovarian cyst complications and endometrial disease	Torsion of the cyst	-		RLQ / LLQ	-		±	±	N	Increased ESR and CRP	Ultrasound	Sudden onset severe pain with nausea and vomiting
		Endometriosis	-		RLQ/LLQ	-		+/-	+/-	N	Normal	Laproscopy	Menstrual-associated symptoms, pelvic symptoms
		Cyst rupture	-		RLQ / LLQ	-		+/-	+/-	N	Increased ESR and CRP	Ultrasound	Sudden onset severe pain with nausea and vomiting
	Pregnancy	Ruptured ectopic pregnancy	-		RLQ / LLQ	-		-	-	N	Positive pregnancy test	Ultrasound	History of missed period and vaginal bleeding
Functional	Irritable Bowel Syndrome		-		Diffuse	-	-	-	-	N	Clinical diagnosis ROME III/IV criteria Pharmacologic studies based criteria	-	High dietary fiber Osmotic laxatives Antispasmodicdrugs

The following is a list of diseases that present with acute onset severe lower abdominal pain:


Disease	Findings
Ectopic pregnancy	History of missed menses, positive pregnancy test, ultrasound reveals an empty uterus and may show a mass in the fallopian tubes.^[26]
Appendicitis	Pain localized to the right iliac fossa, vomiting, abdominal ultrasound sensitivity for diagnosis of acute appendicitis is 75% to 90%.^[27]
Ruptured ovarian cyst	Usually spontaneous, can follow history of trauma, mild chronic lower abdominal discomfort may suddenly intensify, ultrasound is diagnostic.^[28]
Ovarian cyst torsion	Presents with acute severe unilateral lower quadrant abdominal pain, nausea and vomiting, tender adnexal mass palpated in 90%, ultrasound is diagnostic.^[29]
Hemorrhagic ovarian cyst	Presents with localized abdominal pain, nausea and vomiting. Hypovolemic shock may be present, abdominal tenderness and guarding are physical exam findings, ultrasound is diagnostic.^[29]
Endometriosis	Presents with cyclic pain that is exacerbated by onset of menses, dyspareunia. laparoscopic exploration is diagnostic.^[29]
Acute cystitis	Presents with features of increased urinary frequency, urgency, dysuria, and suprapubic pain.^[30]^[31]

References

↑ Rasquin A, Di Lorenzo C, Forbes D, Guiraldes E, Hyams JS, Staiano A, Walker LS (2006). "Childhood functional gastrointestinal disorders: child/adolescent". Gastroenterology. 130 (5): 1527–37. doi:10.1053/j.gastro.2005.08.063. PMID 16678566.
↑ Cash BD, Schoenfeld P, Chey WD (2002). "The utility of diagnostic tests in irritable bowel syndrome patients: a systematic review". Am. J. Gastroenterol. 97 (11): 2812–9. doi:10.1111/j.1572-0241.2002.07027.x. PMID 12425553.
↑ Hamm LR, Sorrells SC, Harding JP, Northcutt AR, Heath AT, Kapke GF, Hunt CM, Mangel AW (1999). "Additional investigations fail to alter the diagnosis of irritable bowel syndrome in subjects fulfilling the Rome criteria". Am. J. Gastroenterol. 94 (5): 1279–82. doi:10.1111/j.1572-0241.1999.01077.x. PMID 10235207.
↑ Prott G, Shim L, Hansen R, Kellow J, Malcolm A (2010). "Relationships between pelvic floor symptoms and function in irritable bowel syndrome". Neurogastroenterol. Motil. 22 (7): 764–9. doi:10.1111/j.1365-2982.2010.01503.x. PMID 20456760.
↑ Voderholzer WA, Schatke W, Mühldorfer BE, Klauser AG, Birkner B, Müller-Lissner SA (1997). "Clinical response to dietary fiber treatment of chronic constipation". Am. J. Gastroenterol. 92 (1): 95–8. PMID 8995945.
↑ Spiller R, Camilleri M, Longstreth GF (2010). "Do the symptom-based, Rome criteria of irritable bowel syndrome lead to better diagnosis and treatment outcomes?". Clin. Gastroenterol. Hepatol. 8 (2): 125–9, discussion 129–36. doi:10.1016/j.cgh.2009.12.018. PMID 20152787.
↑ Rao SS, Valestin J, Brown CK, Zimmerman B, Schulze K (2010). "Long-term efficacy of biofeedback therapy for dyssynergic defecation: randomized controlled trial". Am. J. Gastroenterol. 105 (4): 890–6. doi:10.1038/ajg.2010.53. PMC 3910270. PMID 20179692.
↑ Chey WD, Nojkov B, Rubenstein JH, Dobhan RR, Greenson JK, Cash BD (2010). "The yield of colonoscopy in patients with non-constipated irritable bowel syndrome: results from a prospective, controlled US trial". Am. J. Gastroenterol. 105 (4): 859–65. doi:10.1038/ajg.2010.55. PMC 2887227. PMID 20179696.
↑ Begtrup LM, Engsbro AL, Kjeldsen J, Larsen PV, Schaffalitzky de Muckadell O, Bytzer P, Jarbøl DE (2013). "A positive diagnostic strategy is noninferior to a strategy of exclusion for patients with irritable bowel syndrome". Clin. Gastroenterol. Hepatol. 11 (8): 956–62.e1. doi:10.1016/j.cgh.2012.12.038. PMID 23357491.
↑ Mehdi Z, Sakineh E, Mohammad F, Mansour R, Alireza A (2012). "Celiac disease: Serologic prevalence in patients with irritable bowel syndrome". J Res Med Sci. 17 (9): 839–42. PMC 3697208. PMID 23826010.
↑ Spiegel BM, DeRosa VP, Gralnek IM, Wang V, Dulai GS (2004). "Testing for celiac sprue in irritable bowel syndrome with predominant diarrhea: a cost-effectiveness analysis". Gastroenterology. 126 (7): 1721–32. PMID 15188167.
↑ Stark D, van Hal S, Marriott D, Ellis J, Harkness J. (2007). "Irritable bowel syndrome: a review on the role of intestinal protozoa and the importance of their detection and diagnosis". Int J Parasitol. 31 (1): 11–20. PMID 17070814.
↑ Drisko; et al. (2006). "Treating Irritable Bowel Syndrome with a Food Elimination Diet Followed by Food Challenge and Probiotics". Journal of the American College of Nutrition. 25 (6): 514–22. PMID 17229899.
↑ Vernia P, Ricciardi MR, Frandina C, Bilotta T, Frieri G (1995). "Lactose malabsorption and irritable bowel syndrome. Effect of a long-term lactose-free diet". The Italian journal of gastroenterology. 27 (3): 117–21. PMID 7548919.
↑ http://digestive.niddk.nih.gov/ddiseases/pubs/celiac/ - The United States National Institutes of Health Celiac Disease Page
↑ Guagnozzi D, Arias Á, Lucendo AJ (2016). "Systematic review with meta-analysis: diagnostic overlap of microscopic colitis and functional bowel disorders". Aliment. Pharmacol. Ther. 43 (8): 851–862. doi:10.1111/apt.13573. PMID 26913568.
↑ Hilpüsch F, Johnsen PH, Goll R, Valle PC, Sørbye SW, Abelsen B (2017). "Microscopic colitis: a missed diagnosis among patients with moderate to severe irritable bowel syndrome". Scand. J. Gastroenterol. 52 (2): 173–177. doi:10.1080/00365521.2016.1242025. PMID 27796144.
↑ SCOBIE BA, MCGILL DB, PRIESTLEY JT, ROVELSTAD RA (1964). "EXCLUDED GASTRIC ANTRUM SIMULATING THE ZOLLINGER-ELLISON SYNDROME". Gastroenterology. 47: 184–7. PMID 14201408.
↑ Spiegel BM, DeRosa VP, Gralnek IM, Wang V, Dulai GS (2004). "Testing for celiac sprue in irritable bowel syndrome with predominant diarrhea: a cost-effectiveness analysis". Gastroenterology. 126 (7): 1721–32. PMID 15188167.
↑ Irvine AJ, Chey WD, Ford AC (2017). "Screening for Celiac Disease in Irritable Bowel Syndrome: An Updated Systematic Review and Meta-analysis". Am. J. Gastroenterol. 112 (1): 65–76. doi:10.1038/ajg.2016.466. PMID 27753436.
↑ van Rheenen PF, Van de Vijver E, Fidler V (2010). "Faecal calprotectin for screening of patients with suspected inflammatory bowel disease: diagnostic meta-analysis". BMJ. 341: c3369. PMC 2904879. PMID 20634346.
↑ Slattery SA, Niaz O, Aziz Q, Ford AC, Farmer AD (2015). "Systematic review with meta-analysis: the prevalence of bile acid malabsorption in the irritable bowel syndrome with diarrhoea". Aliment. Pharmacol. Ther. 42 (1): 3–11. doi:10.1111/apt.13227. PMID 25913530.
↑ Canavan C, Card T, West J (2014). "The incidence of other gastroenterological disease following diagnosis of irritable bowel syndrome in the UK: a cohort study". PLoS ONE. 9 (9): e106478. doi:10.1371/journal.pone.0106478. PMC 4169512. PMID 25238408.
↑ Ford AC, Chey WD, Talley NJ, Malhotra A, Spiegel BM, Moayyedi P (2009). "Yield of diagnostic tests for celiac disease in individuals with symptoms suggestive of irritable bowel syndrome: systematic review and meta-analysis". Arch. Intern. Med. 169 (7): 651–8. doi:10.1001/archinternmed.2009.22. PMID 19364994.
↑ Ford AC, Spiegel BM, Talley NJ, Moayyedi P (2009). "Small intestinal bacterial overgrowth in irritable bowel syndrome: systematic review and meta-analysis". Clin. Gastroenterol. Hepatol. 7 (12): 1279–86. doi:10.1016/j.cgh.2009.06.031. PMID 19602448.
↑ Morin L, Cargill YM, Glanc P (2016). "Ultrasound Evaluation of First Trimester Complications of Pregnancy". J Obstet Gynaecol Can. 38 (10): 982–988. doi:10.1016/j.jogc.2016.06.001. PMID 27720100.
↑ Balthazar EJ, Birnbaum BA, Yee J, Megibow AJ, Roshkow J, Gray C (1994). "Acute appendicitis: CT and US correlation in 100 patients". Radiology. 190 (1): 31–5. doi:10.1148/radiology.190.1.8259423. PMID 8259423.
↑ Bottomley C, Bourne T (2009). "Diagnosis and management of ovarian cyst accidents". Best Pract Res Clin Obstet Gynaecol. 23 (5): 711–24. doi:10.1016/j.bpobgyn.2009.02.001. PMID 19299205.
↑ ^29.0 ^29.1 ^29.2 Bhavsar AK, Gelner EJ, Shorma T (2016). "Common Questions About the Evaluation of Acute Pelvic Pain". Am Fam Physician. 93 (1): 41–8. PMID 26760839.
↑ {{Cite journal | author = W. E. Stamm | title = Etiology and management of the acute urethral syndrome | journal = Sexually transmitted diseases | volume = 8 | issue = 3 | pages = 235–238 | year = 1981 | month = July-September | pmid = 7292216
↑ {{Cite journal | author = W. E. Stamm, K. F. Wagner, R. Amsel, E. R. Alexander, M. Turck, G. W. Counts & K. K. Holmes | title = Causes of the acute urethral syndrome in women | journal = The New England journal of medicine | volume = 303 | issue = 8 | pages = 409–415 | year = 1980 | month = August | doi = 10.1056/NEJM198008213030801 | pmid = 6993946

Template:WH Template:WS

[pmid16678566-1] Rasquin A, Di Lorenzo C, Forbes D, Guiraldes E, Hyams JS, Staiano A, Walker LS (2006). "Childhood functional gastrointestinal disorders: child/adolescent". Gastroenterology. 130 (5): 1527–37. doi:10.1053/j.gastro.2005.08.063. PMID 16678566.

[pmid12425553-2] Cash BD, Schoenfeld P, Chey WD (2002). "The utility of diagnostic tests in irritable bowel syndrome patients: a systematic review". Am. J. Gastroenterol. 97 (11): 2812–9. doi:10.1111/j.1572-0241.2002.07027.x. PMID 12425553.

[pmid10235207-3] Hamm LR, Sorrells SC, Harding JP, Northcutt AR, Heath AT, Kapke GF, Hunt CM, Mangel AW (1999). "Additional investigations fail to alter the diagnosis of irritable bowel syndrome in subjects fulfilling the Rome criteria". Am. J. Gastroenterol. 94 (5): 1279–82. doi:10.1111/j.1572-0241.1999.01077.x. PMID 10235207.

[pmid20456760-4] Prott G, Shim L, Hansen R, Kellow J, Malcolm A (2010). "Relationships between pelvic floor symptoms and function in irritable bowel syndrome". Neurogastroenterol. Motil. 22 (7): 764–9. doi:10.1111/j.1365-2982.2010.01503.x. PMID 20456760.

[pmid8995945-5] Voderholzer WA, Schatke W, Mühldorfer BE, Klauser AG, Birkner B, Müller-Lissner SA (1997). "Clinical response to dietary fiber treatment of chronic constipation". Am. J. Gastroenterol. 92 (1): 95–8. PMID 8995945.

[pmid20152787-6] Spiller R, Camilleri M, Longstreth GF (2010). "Do the symptom-based, Rome criteria of irritable bowel syndrome lead to better diagnosis and treatment outcomes?". Clin. Gastroenterol. Hepatol. 8 (2): 125–9, discussion 129–36. doi:10.1016/j.cgh.2009.12.018. PMID 20152787.

[pmid20179692-7] Rao SS, Valestin J, Brown CK, Zimmerman B, Schulze K (2010). "Long-term efficacy of biofeedback therapy for dyssynergic defecation: randomized controlled trial". Am. J. Gastroenterol. 105 (4): 890–6. doi:10.1038/ajg.2010.53. PMC 3910270. PMID 20179692.

[pmid20179696-8] Chey WD, Nojkov B, Rubenstein JH, Dobhan RR, Greenson JK, Cash BD (2010). "The yield of colonoscopy in patients with non-constipated irritable bowel syndrome: results from a prospective, controlled US trial". Am. J. Gastroenterol. 105 (4): 859–65. doi:10.1038/ajg.2010.55. PMC 2887227. PMID 20179696.

[pmid23357491-9] Begtrup LM, Engsbro AL, Kjeldsen J, Larsen PV, Schaffalitzky de Muckadell O, Bytzer P, Jarbøl DE (2013). "A positive diagnostic strategy is noninferior to a strategy of exclusion for patients with irritable bowel syndrome". Clin. Gastroenterol. Hepatol. 11 (8): 956–62.e1. doi:10.1016/j.cgh.2012.12.038. PMID 23357491.

[pmid23826010-10] Mehdi Z, Sakineh E, Mohammad F, Mansour R, Alireza A (2012). "Celiac disease: Serologic prevalence in patients with irritable bowel syndrome". J Res Med Sci. 17 (9): 839–42. PMC 3697208. PMID 23826010.

[11] Spiegel BM, DeRosa VP, Gralnek IM, Wang V, Dulai GS (2004). "Testing for celiac sprue in irritable bowel syndrome with predominant diarrhea: a cost-effectiveness analysis". Gastroenterology. 126 (7): 1721–32. PMID 15188167.

[12] Stark D, van Hal S, Marriott D, Ellis J, Harkness J. (2007). "Irritable bowel syndrome: a review on the role of intestinal protozoa and the importance of their detection and diagnosis". Int J Parasitol. 31 (1): 11–20. PMID 17070814.

[13] Drisko; et al. (2006). "Treating Irritable Bowel Syndrome with a Food Elimination Diet Followed by Food Challenge and Probiotics". Journal of the American College of Nutrition. 25 (6): 514–22. PMID 17229899.

[14] Vernia P, Ricciardi MR, Frandina C, Bilotta T, Frieri G (1995). "Lactose malabsorption and irritable bowel syndrome. Effect of a long-term lactose-free diet". The Italian journal of gastroenterology. 27 (3): 117–21. PMID 7548919.

[15] ttp://digestive.niddk.nih.gov/ddiseases/pubs/celiac/ - The United States National Institutes of Health Celiac Disease Page

[pmid26913568-16] Guagnozzi D, Arias Á, Lucendo AJ (2016). "Systematic review with meta-analysis: diagnostic overlap of microscopic colitis and functional bowel disorders". Aliment. Pharmacol. Ther. 43 (8): 851–862. doi:10.1111/apt.13573. PMID 26913568.

[pmid27796144-17] Hilpüsch F, Johnsen PH, Goll R, Valle PC, Sørbye SW, Abelsen B (2017). "Microscopic colitis: a missed diagnosis among patients with moderate to severe irritable bowel syndrome". Scand. J. Gastroenterol. 52 (2): 173–177. doi:10.1080/00365521.2016.1242025. PMID 27796144.

[pmid14201408-18] SCOBIE BA, MCGILL DB, PRIESTLEY JT, ROVELSTAD RA (1964). "EXCLUDED GASTRIC ANTRUM SIMULATING THE ZOLLINGER-ELLISON SYNDROME". Gastroenterology. 47: 184–7. PMID 14201408.

[pmid15188167-19] Spiegel BM, DeRosa VP, Gralnek IM, Wang V, Dulai GS (2004). "Testing for celiac sprue in irritable bowel syndrome with predominant diarrhea: a cost-effectiveness analysis". Gastroenterology. 126 (7): 1721–32. PMID 15188167.

[pmid27753436-20] Irvine AJ, Chey WD, Ford AC (2017). "Screening for Celiac Disease in Irritable Bowel Syndrome: An Updated Systematic Review and Meta-analysis". Am. J. Gastroenterol. 112 (1): 65–76. doi:10.1038/ajg.2016.466. PMID 27753436.

[pmid20634346-21] van Rheenen PF, Van de Vijver E, Fidler V (2010). "Faecal calprotectin for screening of patients with suspected inflammatory bowel disease: diagnostic meta-analysis". BMJ. 341: c3369. PMC 2904879. PMID 20634346.

[pmid25913530-22] Slattery SA, Niaz O, Aziz Q, Ford AC, Farmer AD (2015). "Systematic review with meta-analysis: the prevalence of bile acid malabsorption in the irritable bowel syndrome with diarrhoea". Aliment. Pharmacol. Ther. 42 (1): 3–11. doi:10.1111/apt.13227. PMID 25913530.

[pmid25238408-23] Canavan C, Card T, West J (2014). "The incidence of other gastroenterological disease following diagnosis of irritable bowel syndrome in the UK: a cohort study". PLoS ONE. 9 (9): e106478. doi:10.1371/journal.pone.0106478. PMC 4169512. PMID 25238408.

[pmid19364994-24] Ford AC, Chey WD, Talley NJ, Malhotra A, Spiegel BM, Moayyedi P (2009). "Yield of diagnostic tests for celiac disease in individuals with symptoms suggestive of irritable bowel syndrome: systematic review and meta-analysis". Arch. Intern. Med. 169 (7): 651–8. doi:10.1001/archinternmed.2009.22. PMID 19364994.

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@@ Line 73: / Line 73: @@
 === '''Differential Diagnosis of Irritable Bowel Syndrome on the basis of Diarrhea:''' ===
+Diarrhea may be caused by [[infectious diseases]], [[celiac disease]],<ref>{{cite journal |author=Spiegel BM, DeRosa VP, Gralnek IM, Wang V, Dulai GS |title=Testing for celiac sprue in irritable bowel syndrome with predominant diarrhea: a cost-effectiveness analysis |journal=Gastroenterology |volume=126 |issue=7 |pages=1721-32 |year=2004 |pmid=15188167 |doi=}}</ref> parasites,<ref>{{cite journal |author=Stark D, van Hal S, Marriott D, Ellis J, Harkness J. |title=Irritable bowel syndrome: a review on the role of intestinal protozoa and the importance of their detection and diagnosis. |journal=Int J Parasitol. |volume= 31 |issue=1 |pages=11-20|year=2007 |pmid=17070814 |doi=}}</ref> food allergies<ref>{{cite journal |author=Drisko ''et al'' |title=Treating Irritable Bowel Syndrome with a Food Elimination Diet Followed by Food Challenge and Probiotics |journal=Journal of the American College of Nutrition |volume=25 |issue=6 |pages=514-22 |year=2006 |pmid=17229899 |doi=}}</ref>  and [[lactose intolerance]].<ref>{{cite journal |author=Vernia P, Ricciardi MR, Frandina C, Bilotta T, Frieri G |title=Lactose malabsorption and irritable bowel syndrome. Effect of a long-term lactose-free diet |journal=The Italian journal of gastroenterology |volume=27 |issue=3 |pages=117-21 |year=1995 |pmid=7548919 |doi=}}</ref>  See the [[list of causes of diarrhea]] for other conditions which can cause diarrhea. [[Coeliac disease|Celiac disease]] in particular is most often misdiagnosed as IBS.<ref>http://digestive.niddk.nih.gov/ddiseases/pubs/celiac/ - The United States National Institutes of Health Celiac Disease Page</ref>
 The differential diagnosis of Irritable Bowel Syndrome based on diarrhea is as follows:<ref name="pmid26913568">{{cite journal |vauthors=Guagnozzi D, Arias Á, Lucendo AJ |title=Systematic review with meta-analysis: diagnostic overlap of microscopic colitis and functional bowel disorders |journal=Aliment. Pharmacol. Ther. |volume=43 |issue=8 |pages=851–862 |year=2016 |pmid=26913568 |doi=10.1111/apt.13573 |url=}}</ref><ref name="pmid27796144">{{cite journal |vauthors=Hilpüsch F, Johnsen PH, Goll R, Valle PC, Sørbye SW, Abelsen B |title=Microscopic colitis: a missed diagnosis among patients with moderate to severe irritable bowel syndrome |journal=Scand. J. Gastroenterol. |volume=52 |issue=2 |pages=173–177 |year=2017 |pmid=27796144 |doi=10.1080/00365521.2016.1242025 |url=}}</ref><ref name="pmid14201408">{{cite journal| author=SCOBIE BA, MCGILL DB, PRIESTLEY JT, ROVELSTAD RA| title=EXCLUDED GASTRIC ANTRUM SIMULATING THE ZOLLINGER-ELLISON SYNDROME. | journal=Gastroenterology | year= 1964 | volume= 47 | issue=  | pages= 184-7 | pmid=14201408 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14201408  }} </ref><ref name="pmid15188167">{{cite journal |vauthors=Spiegel BM, DeRosa VP, Gralnek IM, Wang V, Dulai GS |title=Testing for celiac sprue in irritable bowel syndrome with predominant diarrhea: a cost-effectiveness analysis |journal=Gastroenterology |volume=126 |issue=7 |pages=1721–32 |year=2004 |pmid=15188167 |doi= |url=}}</ref><ref name="pmid27753436">{{cite journal |vauthors=Irvine AJ, Chey WD, Ford AC |title=Screening for Celiac Disease in Irritable Bowel Syndrome: An Updated Systematic Review and Meta-analysis |journal=Am. J. Gastroenterol. |volume=112 |issue=1 |pages=65–76 |year=2017 |pmid=27753436 |doi=10.1038/ajg.2016.466 |url=}}</ref><ref name="pmid20634346">{{cite journal |vauthors=van Rheenen PF, Van de Vijver E, Fidler V |title=Faecal calprotectin for screening of patients with suspected inflammatory bowel disease: diagnostic meta-analysis |journal=BMJ |volume=341 |issue= |pages=c3369 |year=2010 |pmid=20634346 |pmc=2904879 |doi= |url=}}</ref><ref name="pmid25913530">{{cite journal |vauthors=Slattery SA, Niaz O, Aziz Q, Ford AC, Farmer AD |title=Systematic review with meta-analysis: the prevalence of bile acid malabsorption in the irritable bowel syndrome with diarrhoea |journal=Aliment. Pharmacol. Ther. |volume=42 |issue=1 |pages=3–11 |year=2015 |pmid=25913530 |doi=10.1111/apt.13227 |url=}}</ref><ref name="pmid25238408">{{cite journal |vauthors=Canavan C, Card T, West J |title=The incidence of other gastroenterological disease following diagnosis of irritable bowel syndrome in the UK: a cohort study |journal=PLoS ONE |volume=9 |issue=9 |pages=e106478 |year=2014 |pmid=25238408 |pmc=4169512 |doi=10.1371/journal.pone.0106478 |url=}}</ref><ref name="pmid19364994">{{cite journal |vauthors=Ford AC, Chey WD, Talley NJ, Malhotra A, Spiegel BM, Moayyedi P |title=Yield of diagnostic tests for celiac disease in individuals with symptoms suggestive of irritable bowel syndrome: systematic review and meta-analysis |journal=Arch. Intern. Med. |volume=169 |issue=7 |pages=651–8 |year=2009 |pmid=19364994 |doi=10.1001/archinternmed.2009.22 |url=}}</ref><ref name="pmid19602448">{{cite journal |vauthors=Ford AC, Spiegel BM, Talley NJ, Moayyedi P |title=Small intestinal bacterial overgrowth in irritable bowel syndrome: systematic review and meta-analysis |journal=Clin. Gastroenterol. Hepatol. |volume=7 |issue=12 |pages=1279–86 |year=2009 |pmid=19602448 |doi=10.1016/j.cgh.2009.06.031 |url=}}</ref>