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doi:10.3748/wjg.v18.i28.3715

World J Gastroenterol 2012 July 28; 18(28): 3715-3720

ISSN 1007-9327 (print) ISSN 2219-2840 (online)

2012 Baishideng. All rights reserved.

BRIEF ARTICLE

Irritable bowel syndrome: Physicians' awareness and

patients' experience
Linda Bjork Olafsdottir, Hallgrmur Gudjonsson, Heidur Hrund Jonsdottir, Jon Steinar Jonsson,
Einar Bjornsson, Bjarni Thjodleifsson
nosed monthly with IBS by specialists in gastroenterology (SGs) and 2.5 patients by general practitioners (GPs).
All the SGs knew of the criteria to diagnose IBS, as did
46/70 (65.7%) GPs. Seventy-nine percent used the patients history, 38% used a physical examination, and
38% exclusion of other diseases to diagnose IBS. Only
18/80 (22.5%) physicians used specific IBS criteria. Of
the patients interviewed, 59/94 (62.8%) knew they had
experienced IBS. Two out of five patients knew IBS and
had seen a physician because of IBS symptoms. Half of
those received a diagnosis of IBS. A total of 13% were
satisfied with treatment. IBS affected daily activities in
43% of cases.

Linda Bjork Olafsdottir, Hallgrmur Gudjonsson, Einar

Bjornsson, Bjarni Thjodleifsson, Department of Gastroenterology, Landspitali, Faculty of Medicine, University of Iceland,
Hringbraut, 101 Reykjavik, Iceland
Heidur Hrund Jonsdottir, The Social Science Research Institute,
University of Iceland, Saemundargotu 2, 101 Reykjavik, Iceland
Jon Steinar Jonsson, Gardabaer Health Centre, Gardatorgi 7,
210 Gardabae, Iceland
Author contributions: Olafsdottir LB, Thjodleifsson B, Jonsson JS and Gudjosnsson H designed the research; Olafsdottir LB
performed the research; Olafsdottir LB and Jonsdottir HH analyzed the data; and Olafsdottir LB, Bjornsson E, Jonsson JS and
Thjodleifsson B wrote the paper.
Supported by In part by the Medical Research Fund of the National Hospital of Iceland; the Medical Research Fund of Wyeth,
Iceland; Actavis, Iceland; AstraZeneca, Iceland; GlaxoSmithKline, Iceland; and the Icelandic College of Family Physicians
Correspondence to: Linda Bjork Olafsdottir, PhD, MSc
Pharm, MBA, Department of Gastroenterology, Landspitali, Faculty of Medicine, University of Iceland, Hringbraut, 101 Reykjavik, Iceland. linda04@ru.is
Telephone: +354-8966664 Fax: +354-5200801
Received: May 12, 2011 Revised: May 11, 2012
Accepted: June 8, 2012
Published online: July 28, 2012

CONCLUSION: Half of the patients with IBS who consulted a physician received a diagnosis. Awareness and
knowledge of diagnostic criteria for IBS differ between
SGs and GPs.
2012 Baishideng. All rights reserved.

Key words: Irritable bowel syndrome; Questionnaire

study; Diagnostic criteria; Manning criteria; Rome criteria; Physician knowledge
Peer reviewers: Kok Ann Gwee, FAMS, FRCP, PhD, Adjunct

Associate Professor of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Gleneagles Hospital
Annexe Block, 6A Napier Road, Suite No. 05-37, Singapore
258500, Singapore; Damian Casadesus Rodriguez, MD, PhD,
Calixto Garcia University Hospital, J and University, Vedado,
Havana 999075, Cuba

Abstract
AIM: To study if and how physicians use the irritable
bowel syndrome (IBS) diagnostic criteria and to assess
treatment strategies in IBS patients.
METHODS: A questionnaire was sent to 191 physicians regarding IBS criteria, diagnostic methods and
treatment. Furthermore, 94 patients who were diagnosed with IBS underwent telephone interview.

Olafsdottir LB, Gudjonsson H, Jonsdottir HH, Jonsson JS,

Bjornsson E, Thjodleifsson B. Irritable bowel syndrome: Physicians awareness and patients experience. World J Gastroenterol
2012; 18(28): 3715-3720 Available from: URL: http://www.wjgnet.com/1007-9327/full/v18/i28/3715.htm DOI: http://dx.doi.
org/10.3748/wjg.v18.i28.3715

RESULTS: A total of 80/191 (41.9%) physicians responded to the survey. Overall, 13 patients were diag-

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Olafsdottir LB et al . IBS: Physicians' awareness and patients' experience

making a strategy decision and finding the time required,

and their lack of knowledge could interfere with patient
care[21]. No specific treatment options for IBS are available. In clinical practice, the decision to treat is up to the
discretion of the physician[19]. While some physicians
recommend lifestyle modification or trials with over-thecounter products, others recommend antispasmodics and
antidepressants.
In our study, we aimed to analyze IBS from the physicians and patients point of view. The specific aims of
this study were: First, physician study, to assess if and
how physicians [GPs and specialists in gastroenterology
(SGs)]: (1) use the diagnostic criteria to identify IBS; (2)
diagnose patients with IBS, and which symptoms of IBS
they identify; and (3) which treatment they recommend;
and Second, patient study, to assess how patients with
IBS are diagnosed and treated by physicians, as well as
studying the ideas that patients have about IBS. The results of a parallel study based on the same database but
focusing on functional dyspepsia, stability of IBS and
heartburn have been published[22-24].

INTRODUCTION
Irritable bowel syndrome (IBS) is a common functional
gastrointestinal disorder. The prevalence of IBS is estimated to range from 3% to 28% depending on the
country studied[1-4]. The prevalence of IBS in the western
countries is estimated to be 10%-15%[2]. However, ascertaining prevalence is based on various approaches in
studies using different diagnostic criteria.
The criteria that have been used to identify IBS patients are the Manning criteria[5], Rome[6], Rome [7]
and the most recent Rome criteria[8,9]. The Rome criteria are more refined than the Manning criteria and include
the duration of symptoms as part of the definition of
IBS[10]. Studies have also shown that the Manning criteria
are relatively sensitive but lack specificity[11] (Table 1).
It has been questioned whether the Rome criteria are
sensitive enough to diagnose patients in general practice.
The current lack of interest in these criteria, especially
among general practitioners (GPs), is unlikely to change
unless they can be considerably improved[12]. The challenges and uncertainties for diagnosis of IBS have been
listed as follows[13,14]: (1) there is currently no consistent
biological marker of IBS, leaving clinicians to rely on
patient symptoms alone to make the diagnosis; (2) symptoms of IBS are often difficult to quantify objectively; (3)
symptoms can vary among individuals with IBS; and (4)
many organic conditions can masquerade as IBS.
With these uncertainties, many physicians approach
IBS as a diagnosis of exclusion[14]. A recent study concluded that: (1) the best practise diagnostic guidelines
have not been uniformly adopted in IBS, particularly
among primary care providers; (2) most community providers believe IBS is a diagnosis of exclusion (this belief
is associated with increased diagnostic resource use); and
(3) despite the dissemination of guidelines regarding diagnostic testing in IBS, there remains extreme variation in
beliefs among both experts and non-experts[14].
Patients diagnosed with IBS exhibit a higher use of
outpatient visits, inpatient stays, outpatient prescriptions,
and number of hospitalizations than those not diagnosed
with IBS[15-17]. A recent study showed that knowledge
and use of the Rome criteria or their positive predictive
values for IBS did not correlate with reduced use of diagnostic tests[18]. The cost for outpatient visits, drugs and
diagnostic testing has been shown to be 51% higher for
IBS patients than for others[15-17]. IBS patients have been
shown to lose time from work more often than others
and are less productive while at work[19]. This may reflect
the morbidity in this relatively benign disorder, although
up to 70% of IBS patients in the United States do not
consult a health care provider regarding their symptoms[20]. IBS patients are often reluctant to consult a physician, often because they think their symptoms do not
warrant a visit to a physician or are afraid that they have
a serious life-threatening illness[2,19]. United States family practitioners have problems with IBS patients, which
include difficulties in satisfying patients and difficulties in

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MATERIALS AND METHODS

Patient study
Participants and setting: In 1996, an epidemiological
study of gastrointestinal diseases was performed in Iceland[25] among 2000 inhabitants aged 18-75 years. The individuals were randomly selected from the National Registry.
Equal distribution of sex and age was secured in each age
group. In 2006, we attempted to contact all the individuals from 1996, as well as adding 300 new individuals in the
18-27 years age group, who were also randomly selected
from the National Registry of Iceland. A questionnaire
was mailed to individuals at baseline and the study questionnaire and an explanatory letter mailed to all eligible individuals. Reminder letters were mailed at 2 wk, 4 wk and 7
wk, using the Total Method of Dillman[26]. Individuals who
indicated at any point that they did not want to participate
in the study were not contacted further.
Questionnaire: The Bowel Disease Questionnaire (BDQ)[27,28]
was translated from English into Icelandic and modified
for this study. The questionnaire was translated by two gastroenterologists and a pharmacist. A specialist in the Icelandic language at the University of Iceland made linguistic
modifications. The questionnaire was piloted within a small
group of IBS patients diagnosed by a gastroenterologist.
The questionnaire was designed as a self-report instrument
to measure symptoms experienced over the previous year
and to collect the participants past medical history[29].
The Icelandic version of the BDQ questionnaire addressed 47 gastrointestinal symptoms and 32 items that
measured past illness, health care use, and sociodemographic and psychosomatic symptoms, together with a
valid measure of non-gastrointestinal somatic complaints,
the Somatic Symptom Checklist (SSC)[30]. The SSC consisted of 12 non-gastrointestinal and five gastrointestinal

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Olafsdottir LB et al . IBS: Physicians' awareness and patients' experience

Table 1 Manning, Rome, and criteria for irritable
[5-7,9]
bowel syndrome

Table 2 Awareness of the disorder, diagnosis and treatment

in interviewer-diagnosed patients n (%)

Manning
Pain eased after BM
Looser stools at onset of pain
More frequent BM at onset of pain
Abdominal distension
Mucus throughout rectum
Feeling of incomplete emptying
Romecriteria
3 mo or more of continuous or recurrent symptoms
Abdominal pain or discomfort
Relieved with defecation; and/or
Associated with a change in frequency of stool; and/or
Associated with a change in consistency of stool; and
Two or more of the following, at least 25% of occasions or days
Altered stool frequency (> 3 BMs/d or < 3/wk)
Altered stool form (lumpy/hard or loose/watery stool),
Altered stool passage (straining, urgency, tenesmus)
Passage of mucus
Bloating or feeling of abdominal distension
Rome criteria
At least 12 wk (which need not be consecutive)
In the preceding 12 mo, of abdominal discomfort or pain that has two
out of three features
Relieved with defecation; and/or
Onset associated with a change in frequency of stool, and/or
Onset associated with a change in form (appearance) of stool
Rome criteria
Recurrent abdominal pain or discomfort at least 3 d/mo
In the last 3 mo association with two or more of the following:
Improvement with defecation
Onset associated with a change in frequency of stool
Onset associated with a change in form (appearance) of stool

All patients (n = 94)

Diagnosed with IBS
Knowledge of IBS
Seen a physician because of IBS symptoms
Satisfied with treatment for IBS
IBS affects daily activities
Think they will be cured of IBS
Think they will always suffer from IBS
Takes medication for IBS
Uses untraditional medication
Thinks dietary modification is important for
the treatment of IBS
IBS: Irritable bowel syndrome.

order. We assessed the knowledge of validated symptombased criteria for IBS.

Statistical analysis
Tables were constructed for frequency and percentage.
Categorical data were analyzed using the 2 test. The
typeerror protection rate was set at 0.05. The exact P
values are listed in the tables and text. All the research
data were imported into SPSS software.
Ethics
The National Bioethics Committee of Iceland and The
Icelandic Data Protection Authority (Personuvernd) gave
their permission for the research.

BM: Bowel movement.

RESULTS

symptoms or illnesses. Individuals were instructed to

indicate, on a 5-point scale, how often each symptom
appeared and how bothersome it was. There were only a
few changes in the 2006 questionnaire, which addressed
51 gastrointestinal symptoms and 33 items that measured
past illness, health care use, and sociodemographic and
psychosomatic symptoms. The 2006 questionnaire furthermore addressed 17 items to identify heartburn and
symptoms related to heartburn.

Patient study
A total of 94 patients underwent telephone interview
(29.8% male, 70.2% female) with a mean age of 47 years.
All these had IBS according to the Manning criteria and
56.0% according to the Rome criteria (the Rome
criteria being more refined and stricter than the Manning
criteria). When patients were asked if they had experienced IBS (self-assessed), 62.8% reported yes and 21.3%
said they had received an IBS diagnosis from a physician;
60% of these had a Rome--based diagnosis, and 100%
had a Manning-based diagnosis.
Table 2 shows the awareness of IBS. Two out of five
patients had heard of IBS and the same number had
seen a physician because of IBS symptoms, but only half
of those had received a diagnosis of IBS. Only 12/94
(12.8%) IBS patients were satisfied with the treatment
they had been given. IBS did affect daily activities in approximately 43% of the cases (Table 2). One third of the
IBS patients thought they would be cured of IBS but a
similar proportion thought they would always suffer from
IBS (Table 2). IBS patients were found to use more nontraditional medication than prescribed drugs. More than
half of patients believed that dietary modification was
important for treatment of IBS (Table 2).
Three out of five IBS patients were diagnosed by a

Telephone survey: In the questionnaire, patients were

asked to write down their telephone number and give
their permission to participate in a telephone survey.
Subjects who were diagnosed with IBS based on the
Manning criteria and/or the Rome criteria and had
written down their telephone number were called and interviewed.
Physician study
In Iceland (population approximately 300 000), there are
177 physicians working in general practice and 17 SGs
(three physicians who were involved in carrying out this
study were excluded). A questionnaire was sent to these
191 physicians regarding awareness and application of
the three sets of criteria used to diagnose IBS (Table 1),
as well as diagnostic methods and treatment of this dis-

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20 (22.2)
37 (39.4)
37 (39.4)
12 (12.8)
40 (42.6)
29 (30.9)
27 (28.7)
11 (11.7)
15 (16.0)
52 (55.3)

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Olafsdottir LB et al . IBS: Physicians' awareness and patients' experience

120

Table 3 Diagnosis of patients with irritable bowel syndrome (%)

SG
n =9

GP
n = 70

79
38
38
22
7

78
22
44
33
22

80
41
35
19
6

100
80
%

Patients history
Physical examination
Exclusion of other diseases
IBS criteria
Gastrointestinal endoscopy

All patients
n = 801

60
40
20

One physician did not list his profession; IBS: Irritable bowel syndrome;
SG: Specialists in gastroenterology; GP: General practitioners.

gastroenterologist and two out of five by a GP. Most

IBS patients reported abdominal pain (73.7%), bloating
(21.1%), constipation (5.3%) and diarrhea (10.5%) as the
symptom that led to the diagnosis. More than half (57.9%)
of the IBS patients who received management for their
IBS symptoms were satisfied.

Rome I

Manning

Rome

Figure 1 Number of physicians knowing about each set of diagnostic criteria. SG: Specialists in gastroenterology; GP: General practitioners.

Table 4 Most common irritable bowel syndrome symptoms (%)

Abnormal bowel movements

Abdominal pain
Bloating
Gas
Passage of mucus
Incomplete evacuation with defecation

Physician study
An anonymous questionnaire was sent to a total of 191
physicians in Iceland in the fields of primary care, or to
SGs (excluding three physicians involved in carrying out
this study). A total of 80 physicians (41.9%) replied (83%
male, 17% female) and completed the questionnaire. Of
those who answered, 70/175 were GPs and 9/15 were
SGs.
On average, 13 patients were estimated to be diagnosed
with IBS monthly by SGs and 2.5 by GPs. Physicians reported how they diagnosed patients with IBS (Table 3).
Two thirds of all the physicians knew that special diagnostic criteria exist for defining and diagnosing IBS (Figure 1).
When physicians were asked if they knew of the IBS
diagnostic criteria, 71% said yes (64% of GPs, 100% of
SGs). Despite the fact that 64% of GPs claimed they
knew that diagnostic criteria existed, only 10% had heard
of the Manning criteria, 27% of Rome, and 17% of
Rome (Figure 1).
Physicians stated that abnormal bowel movements
such as diarrhea and constipation, abdominal pain and
bloating were the most commonly reported symptoms of
IBS (Table 4).
Physicians reported in most cases that they would give
advice on diet and education about IBS as a treatment
for IBS symptoms. Both GPs and SGs gave their patients
mebeverine in most cases. Psyllium was frequently used
by SGs and chlordiazepoxide, and clidinium was in some
cases used by both GPs and SGs (Table 5).

GPs

SGs

61
86
20
9
5
5

100
67
56
11
0
11

SG: Specialists in gastroenterology; GP: General practitioners.

Table 5 Treatment of irritable bowel syndrome (%)

Medication
Mebeverine
Husk
Chlordiazepoxide and clidinium
Antidepressants
Other medicines
Lifestyle
Food
Relaxation
Exercise
Education about IBS
Do not know/something else

GPs

SGs

89
31
29
7
9

86
43
14
14
14

98
14
16
90
27

86
14
14
86
14

IBS: Irritable bowel syndrome; SG: Specialists in gastroenterology; GP:

General practitioners.

is therefore very important. In recent years, the development of diagnostic criteria for IBS has been ongoing,
leading to the recent introduction of the Rome criteria. There is no doubt that diagnostic criteria constitute a
useful and important tool to help physicians make a positive diagnosis of IBS without resorting simply to excluding other diseases. This study has revealed the proportion
of Icelandic physicians in two fields of medicine who are
aware of the criteria for diagnosing the disease. The study
has addressed not only the question of how informed
physicians are of the criteria for diagnosing IBS, but also
the importance of consensus about the diagnosis of the
disease. This study has also addressed the IBS patients
perspective, how many sought physicians, and how they

DISCUSSION
Most physicians have used the method of exclusion when
diagnosing patients with IBS. Most community providers also believe IBS is a diagnosis of exclusion rather
than using positive criteria to support the diagnosis[14].
This approach-or lack of one-has therefore been time
consuming and costly for the health care system. The
importance of a precise diagnostic tool to diagnose IBS

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GPs
SG

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Olafsdottir LB et al . IBS: Physicians' awareness and patients' experience

experienced the disease.

According to the results of this study, most IBS patients were seen by GPs, and this is most likely also the
case in other countries, underlining the importance of
awareness and knowledge of IBS on the part of the GPs.
Although 64% of all GPs reported that they were aware
of the fact that special criteria to identify IBS existed,
most of them (81%) did not know the criteria and therefore did not rely on them in practice. Most of them seem
to make a positive diagnosis of IBS without the use of
endoscopy. A United States study showed that only 30%
of family practitioners knew that the Manning, Rome
and Rome criteria are used to diagnose IBS, which is
in line with the results of the current study[21]. GPs are
more likely than hospital specialists to perceive functional
gastrointestinal disorders as having a psychological basis,
are far less likely to be familiar with diagnostic criteria,
and are more likely to use other methods to make such
diagnoses[31]. However, physicians are aware of and use
the most common IBS symptoms such as abnormal
bowel movements, abdominal pain and bloating in their
diagnostic approach, and these were the most common
symptoms IBS subjects in the present study.
In the current study, physicians reported in most cases
that they gave advice on diet and education on IBS as a
treatment of IBS symptoms; this finding underlines the
importance of providing reliable and useful information
on IBS to patients, as well as the fact that there are no
specific treatment options for IBS that are useful for all
patients.
It is of interest that among interviewer-diagnosed IBS
patients, only one out of five was diagnosed with IBS,
even though more than half of the IBS patients saw a
physician because of their symptoms. These results were
irrespective of whether the patients fulfilled the Manning
or Rome criteria for IBS. This was also interesting
because the majority of IBS patients reported that IBS
affected daily activities. This emphasises the question
of whether IBS patients reveal to the physicians the low
quality of life caused by IBS. It is also conceivable that
physicians do not recognize IBS as a disorder that leads
to impaired quality of life. The absence of positive diagnosis of IBS might lead to lack of relevant treatment for
specific symptoms of IBS such as abdominal pain. There
is a need for a simple, practical and reliable diagnostic
tool to be used in everyday clinical practice to diagnose
IBS more accurately; a tool that will encourage physicians
to be able to make a reliable diagnosis and to provide effective treatment[32,33].
The limitation of this study was the relatively low response rate in the physician study, which raises the question as to whether the level of awareness and knowledge
of diagnostic criteria might be even lower than the result
obtained. The strengths of the study, however, were that
all physicians in Iceland in the relevant fields of general
practice and gastroenterology were invited to participate,
and the fact that all IBS patients who were contacted by
telephone participated in the survey.

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In conclusion, in this study, only half of the IBS patients who saw a physician received a diagnosis of IBS.
Knowledge of IBS is limited among IBS patients. This
study suggests that few physicians use IBS criteria and
that awareness and knowledge of diagnostic criteria for
IBS differed between SGs and GPs. One out of four
physicians used a diagnosis of exclusion.
More widespread knowledge and use of the diagnostic criteria among physicians can be expected to support
a more accurate diagnosis of IBS.

COMMENTS
COMMENTS
Background

Irritable bowel syndrome (IBS) is a common functional gastrointestinal disorder.

The prevalence of IBS in western countries is estimated to be 10%-15%. The
criteria that have been used to identify IBS patients are the Manning criteria and
Rome, and criteria. It has been questioned whether the Rome criteria
are sensitive enough to diagnose patients in general practice. Many physicians
approach IBS as a diagnosis of exclusion. Patients diagnosed with IBS have
a higher number of outpatient visits, inpatient stays, outpatient prescriptions,
and hospitalizations than those not diagnosed with IBS. IBS patients are often
reluctant to consult a physician, often because they think their symptoms do
not warrant a visit to a physician, or they are afraid that they have a serious lifethreatening illness. United States family practitioners have problems with IBS
patients, which include difficulties in satisfying patients and treatment decision
making, and finding the time required, and their lack of knowledge could interfere with patient care.

Research frontiers

The prevalence of IBS in the general population is high and physicians often
lack the tools to diagnose and treat IBS. It is important for IBS patients as well
as the physicians to understand each other and the IBS symptoms, and to improve knowledge of IBS. The aim of the present study was to analyze IBS from
the physicians and IBS patients points of view. The specific aims of this study
were: First, physician study, to assess if and how physicians [general practitioners (GPs), specialists in gastroenterology (SGs)]: (1) use the diagnostic criteria
to identify IBS; (2) diagnose patients with IBS, and which symptoms of IBS they
identify; and (3) which treatment they recommend; and Second, patient study,
to assess how patients with IBS based on criteria are diagnosed and treated by
physicians and which treatment they receive, as well as studying the ideas that
patients have about IBS.

Innovations and breakthroughs

The prevalence of IBS is high in Iceland. The awareness of IBS is low among
patients with IBS and two out of five of those saw physicians because of IBS
symptoms. Only half of the IBS patients who saw a physician received a diagnosis of IBS. Knowledge of IBS is limited among patients. This study suggests
that few physicians use IBS criteria and that awareness and knowledge of the
diagnostic criteria for IBS differed between SGs and GPs. One out of four physicians used a diagnosis of exclusion.

Applications

IBS patient and physician points of view are important for understanding IBS.
It is important for the physicians to understand IBS patients and to know that
many who seek medical care will not receive a diagnosis. This study creates a
database for further studies and hopefully stimulates studies in other countries.
International awareness and knowledge of IBS diagnosis and treatment can
contribute towards better understanding of IBS.

Peer review

The prevalence of IBS in Western countries is estimated to be 10%-15% and is

associated with extensive health care expenses and diminished quality of life.
Studies that examine IBS from the patients and physicians point of view are
important and there is a need to document secular trends and compare various
countries.

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S- Editor Cheng JX L- Editor Kerr C E- Editor Zhang DN

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July 28, 2012|Volume 18|Issue 28|