Outcome of Alarm Symptoms and Colonoscopy in Functional Bowel Disorders and Functional Abdominal Pain Syndrome.

INTRODUCTION : Functional gastrointestinal disorders such as the Functional bowel disorders and functional abdominal pain are the most common disorders encountered by the gastroenterologist and constitute a considerable economic burden to the health care system. However, the accuracy of a diagnosis based purely on the presenting gastrointestinal symptoms continues to worry practicing physicians. Traditionally, a diagnosis of a functional bowel disorder is based on the classical symptom patterns in the absence of an organic explanation by appropriate testing. Thus functional bowel disorders are diagnosed when unexplained abdominal pain and bowel symptoms coexist while the role of other potential diagnostic criteria remains unclear. There is a limit to the repertoire of gastrointestinal symptoms and hence it is understandable that symptoms alone may not be accurate enough to identify functional from organic disease. However, in the absence of a reproducible and accepted biological marker, symptoms currently remain the primary means of identifying patients in clinical practice and recruiting patients for research studies. Several diagnostic approaches that are based on the patient’s symptoms, such as the Manning criteria, the Kruis scoring system or the Rome criteria, have been proposed to assist the diagnostic process. However, the available literature suggests that symptom based diagnostic algorithms, although often used for clinical and research studies, have poor sensitivity. Although diagnostic algorithms such as the Manning criteria or the Rome criteria can discriminate IBS from health or upper gastrointestinal tract conditions, studies do not provide convincing evidence that the criteria can discriminate IBS from organic disease of the colon. Thus, in clinical practice functional gastrointestinal disorders are still often identified by exclusion. In daily clinical practice, history taking includes a search for leading symptoms, as suggested by diagnostic algorithms for functional bowel disorders, as well as an intensive clinical search for evidence of organic disease (alarm symptoms or features), such as older age at symptom onset, weight loss, gastrointestinal bleeding, etc. Current guidelines recommend a full diagnostic workup in patients who present with such alarm features. Vanner and colleagues suggested that evaluating alarm symptoms in combination with the Rome I criteria improved the predictive value for diagnosing IBS. However, the value of these symptoms in discriminating organic disease from functional disorders remains uncertain, especially as alarm features are common, even in younger people in the general population. AIM OF THE STUDY : 1. To assess the value of alarm features in differentiating organic disease from functional bowel disorders and functional abdominal pain syndrome. 2. To assess the outcome of colonoscopy in diseases of the lower gastrointestinal Tract. CONCLUSIONS : 1. The incidence of organic and functional disorders in patients presenting with lower gastrointestinal complaints are 34.9% and 65.1% respectively. 2. The commonest organic disorder to be diagnosed was perianal disease (40%) and the commonest functional disorder was functional constipation (29.6%). 3. No significant differences in the mean age or age group distribution were discernible between the two groups of disorders. 4. There were no significant differences in the gender ratio or educational status of patients in the two groups. 5. The clinical symptoms that were helpful in distinguishing an organic illness from a functional disorder were the presence of nocturnal symptoms, blood in stools, mass descending per rectum and weight loss. None of the symptoms evaluated favored the diagnosis of a functional LGI disorder by inclusion. 6. The presence of anemia, mass abdomen and abnormalities on per rectal examination suggested an organic disease. 7. The laboratory investigations that differentiated an organic from functional disease include a low hemoglobin, elevated ESR, stool occult blood positivity, low serum proteins and albumin, abnormalities on ultrasonography and colonoscopy with terminal ileoscopy. 8. The clinical differentiation between functional and organic LGI disease had a sensitivity of 69%, specificity of 62%, positive predictive value of 77%, negative predictive value of 51%, efficacy of 66% with fair agreement on Kappa statistics. 9. It may be appropriate that the Rome criteria for functional bowel disorders and functional abdominal pain syndrome be expanded to include key alarm features, basic investigations and colonoscopy