IBS Fact : Evidence-based management of irritable bowel syndrome

Upper GI endoscopy in irritable bowel syndrome (IBS)

As the name implies, this method uses a so-called endoscope which is a thin tube with a camera and a light source mounted on its top. The endoscope is inserted through the mouth to explore the upper gastrointestinal tract, i.e. the oesophagus, stomach and the first section of the small bowel. The technique is similar to colonoscopy with the exception that the endoscope is now inserted via the mouth and not the anus. 

The camera of the endoscope allows the physician to directly view the lining of the explored sections and to observe inflamed areas, ulcers, swellings or constrictions. Small tissue samples (biopsies) can also be collected for additional microscopic or laboratory examinations. In people with IBS-like symptoms, in particular diarrhoea, an upper GI endoscopy is mainly conducted to rule out or confirm coeliac disease. The examination consists of a sample biopsy from the small bowel and is carried out once the likelihood of coeliac disease has been confirmed by a blood test. Coeliac disease is confirmed if microscopic abnormalities are observed in the collected tissue samples. If no abnormalities are observed, the diagnosis of IBS is maintained and/or additional examinations are preformed to rule out other conditions. Statistically, coeliac disease turns out to be the underlying condition in 4% of patients with suspected IBS who suffer from diarrhoea or alternating diarrhoea and constipation. Preparation for the endoscopy involves refraining from eating or drinking for 6-8 hours prior to the appointment in order to ensure the upper gastrointestinal tract is empty. This is important to allow optimal visibility, but also to lower the risk of vomiting, which may be dangerous in sedated patients. Patients should also refrain from drinking alcohol on the day before the procedure. Detailed instructions are given to patients prior to the examination. Patients should inform their examining physician about any medications or supplements they are taking and any medical problems or special conditions they may have (e.g. pacemaker) well before the examination. Some medicines may need to be discontinued or adjusted before the procedure or afterward. Shortly before to the procedure, the patient is usually given drugs to relieve any pain, inhibit the gagging reflex, and to induce a mild sedation, which still allows the patient to cooperate during the procedure.

Because of the sedation, anyone who undergoes upper gastrointestinal endoscopy should be accompanied home by a friend or relative after the procedure. Once anesthetized, the patient is asked to swallow, while the endoscope is gently passed down the oesophagus into the stomach, and eventually into the first part of the small intestine. In patients with suspected coeliac disease, small tissue samples of the lining of the small intestine are then collected. These will be examined later under a microscope to determine whether tissue damage typical of coeliac disease can be observed. The procedure takes from 15 to 30 minutes, after which the patient is taken to the recovery area. Because of the sedation, there is no pain with the procedure, and patients seldom remember much about it. Following the procedure, some minor side effects such as bloating, nausea may persist for a short time and sore throat for up to two days. Serious side effects are very rare and may include chest pain, breathing difficulties, increasing swallowing or throat pain, vomiting, abdominal pain tar-coloured stool and fever. Medical care should be sought immediately should these symptoms occur. Overall, however, the procedure is very save and complications are unlikely. The results of the endoscopic examination are available right away, but your physician may want to share these with you at a later date when the sedation has subsided. A pathologist will examine the biopsy samples and will send a report to your physician to discuss them with you. If the endoscopic examination and collected tissue samples reveal an inflammation or tissue damage of the small bowel, coeliac disease may be diagnosed. This will require appropriate treatment consisting mainly of avoiding any dietary gluten. In contrast, since IBS does not cause any visible damage to the intestinal wall, an absence of inflammation along with persistent GI complaints may be considered a confirmation of true IBS.

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