Opinion statement
Defining which patients with irritable bowel syndrome (IBS) are “refractory” is a highly subjective undertaking. Duration of symptoms, severity of symptoms, type of symptoms, and a host of other medical, epidemiologic, and psychosocial variables all play a role in this determination. It is safe to say that a long duration of disease per se does not constitute a refractory patient. A number of studies have given us some suggestion of what constitutes refractoriness in IBS. Patients who have a predominant pain complaint as opposed to those who are mainly concerned about their bowel habit (either diarrhea or constipation) are more likely to be disabled by their IBS. However, at a clinical level, patients who are considered refractory are usually seen as individuals who fail to improve on a variety of drug therapies or who have high healthcare utilization despite aggressive treatment of their IBS. Finally, patients who are unhappy about their care and/or are assertive in their request to “be cured” can also be seen as refractory because of unrealistic expectations they set for both themselves and the physician. The key to effectively dealing with patients with “refractory” IBS is to understand that their behaviors most often have correlates and underlying issues that need to be dealt with in order to effectively address the patient’s concerns. Unfortunately, most patients who fall into this category are quickly identified as “difficult,” “unpleasant,” or even “crazy” and are not infrequently dismissed by their treating physician. This leads to an ever-enlarging circle of healthcare utilization, with patients seeking out physicians and other practitioners looking for the elusive cure. A key component of this process is an increasing frustration and cynicism regarding the healthcare system and physicians in particular, which does no good for anyone involved. It is clearly critical for the physician dealing with a patient with IBS and a history of poor response to treatment to understand these correlates. Failure to do so creates a continuation of the cycle of treatment failure and frustration that so often characterizes these patients’ care.
Similar content being viewed by others
References and Recommended Reading
Drossman DA, McKee D, Sandler R, et al.: Psychosocial factors in the irritable bowel syndrome. A multivariate study of patients and nonpatients with irritable bowel syndrome. Gastroenterology 1988, 95:701–708.
Drossman DA, Talley NJ, Leserman J, et al.: Sexual and physical abuse and gastrointestinal illness: review and recommendations. Ann Intern Med 1995, 123:782–794.
Whitehead WE, Bosmajian L, Zonderman AB, et al.: Symptoms of psychologic distress associated with irritable bowel syndrome: comparison of community and medical clinic samples. Gastroenterology 1988, 95:709–714.
Leserman J, Li Z, Drossman DA, et al.: Impact of sexual and physical abuse dimensions on health status: development of an abuse severity measure. Psychosom Med 1997, 59:152–160.
Sperber A, Alzmon Y, Neumann L, et al.: Fibromyalgia in the irritable bowel syndrome: studies of prevalence and clinical implications. Am J Gastroenterol 1999, 94:3541–3546.
Jackson JL, O’Malley PG, Tomkins G, et al.: Treatment of functional gastrointestinal disorders with antidepressant medications: a meta-analysis. Am J Med 2000, 108:65–72. An excellent review and meta-analysis supporting the use of antidepressants for irritable bowel syndrome symptomatology.
Creed FH, Fernandes L, Guthrie EA, et al.: The costeffectiveness of psychotherapy and paroxetine for severe irritable bowel syndrome. Gastroenterology 2003, 124:303–317. An excellent contemporary study demonstrating the effectiveness of multimodal treatment of refractory irritable bowel syndrome.
Olden KW, Drossman DA: Psychological and psychiatric aspects of gastrointestinal disease. Med Clin North Am 2000, 84:1313–1327.
Author information
Authors and Affiliations
Rights and permissions
About this article
Cite this article
Olden, K.W. Approach to the patient with severe, refractory irritable bowel syndrome. Curr Treat Options Gastro 6, 311–317 (2003). https://doi.org/10.1007/s11938-003-0023-8
Issue Date:
DOI: https://doi.org/10.1007/s11938-003-0023-8