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Irritable bowel syndrome, chronic pelvic inflammatory disease and endometriosis

Kumar, Devinder

European Journal of Gastroenterology & Hepatology: December 2004 - Volume 16 - Issue 12 - p 1251-1252
Leading Articles

Irritable bowel syndrome (IBS) is common. The symptom criteria for the diagnosis of IBS remain non specific. Similarly, pelvic inflammatory disease and endometriosis present with symptoms that may be similiar to those of IBS. The site of pain, intermenstrual bleeding and exacerbation of symptoms by food may be able to help differentiate the two groups. However, there is still considerable overlap in the symptomatology of the two conditions and to this end both specialties should work together to investigate and manage these patients.

Department of General Surgery, St George's Hospital, Tooting, London.

Correspondence to D. Kumar, Department of General Surgery, St George's Hospital, 3rd Floor, St James Wing, Blackshaw Road, London SW17 0QT, UK. Tel: +44 (0)208 725 1301; fax: +44 (0)208 725 3611; e-mail:

Recieved 14 February 2004

Approximately one-quarter of the population of Great Britain is said to suffer from irritable bowel syndrome [1]. The diagnosis, pathophysiology and management of irritable bowel syndrome have been the subject of study for gastroenterologists for several decades. As far back as 1923, Hutchison [2] described the ‘chronic abdomen'. He wrote: ‘… the symptoms of the chronic abdomen are many, various, and ever renewed. Some of them refer directly to the abdominal organs, others are of a more remote and general character; but whatever they are, they are always described with great prolixity and in minute detail. Amongst those most commonly complained of are abdominal aches and pains of various sorts and in various places, but especially in the right iliac fossa. Instead of actual pain the patient may speak of a ‘‘raw feeling inside’', or ‘‘an indescribable feeling in the stomach’’ or of a ‘‘dragging’'. Constipation of greater or less degree almost always figures prominently in the symptoms, and flatulence is also frequent …'. Much of what he described remains unchanged even today. The only agreement about the irritable bowel syndrome is the idea that it occurs in the absence of demonstrable organic disease. More recently, the emphasis has been on making a positive diagnosis of the irritable bowel syndrome based on its symptoms. Although attempts have been made to define the irritable bowel syndrome using specific symptom criteria, the specificity of such symptoms in making a diagnosis is often low.

Equally, gastrointestinal symptoms including diarrhoea and constipation and abdominal pain are well-established events associated with the menstrual cycle [3]. The physiological basis for bowel symptoms during menstruation has not been well established. There is some suggestion that the bowel symptoms may be mediated by prostaglandins during the initial phase of menstruation [4]. Whether these prostaglandins result in a contraction of the gastrointestinal smooth muscle to produce the symptoms remains unclear. Patients with irritable bowel syndrome also show an exaggerated response to prostaglandins released during menstruation.

Gynaecological conditions of pelvic inflammatory disease and endometriosis often present with symptoms that may be similar to those of gastrointestinal disorders. This may result in a delayed diagnosis of such conditions, and often these women are treated for other assumed disorders before the definitive diagnosis of endometriosis or pelvic inflammatory disease is made. In this issue, Lea et al. have compared the symptomatology of irritable bowel syndrome, chronic pelvic inflammatory disease and endometriosis in 50 women with irritable bowel syndrome and 51 patients with gynaecological disorders. They used a questionnaire to study the symptoms and found that patients with irritable bowel syndrome suffered significantly more upper abdominal pain, disturbance of bowel habit and abdominal distension than patients with gynaecological disorders. The gynaecological patients were found to have intermenstrual bleeding, premenstrual exacerbation of pain and forniceal tenderness. In irritable bowel syndrome, the symptoms were exacerbated by food and stress. Gynaecological patients, on the other hand, had a definite diagnosis of either pelvic inflammatory disease or endometriosis made on laparoscopy. Patients with coexistent symptomatology were excluded. It is interesting to note that pelvic pain and dysmenorrhoea, which are regarded as classic symptoms of endometriosis, did not feature significantly in this analysis. Dyspareunia, however, was similar in the two groups. This study highlights once again the symptoms that define the irritable bowel syndrome by showing a significant difference between the two groups. The symptoms of endometriosis comprise lower abdominal or pelvic pain, dysmenorrhoea and dyspareunia. The sensitivity of symptoms in making a diagnosis of endometriosis or pelvic inflammatory disease is very low. Gynaecologists recommend that such diagnoses should be made only on laparoscopy.

The possibility of overlap between symptoms of functional, gastrointestinal disorders and gynaecological disorders has been considered for a long time. True distinction between the two groups of disorders based on symptom analysis still eludes gastroenterologists and gynaecologists alike. The situation is compounded further by the fact that during normal physiological events, such as menstruation, gastrointestinal symptoms become worse. If one considers endometriosis as an exaggerated response to normal physiology, then the picture becomes even more confused. Also, it has to be remembered that the two disorders can coexist and therefore should be investigated as such. The message, however, from the present article is worthwhile, in that specialists from both disciplines should collaborate and work together, particularly in circumstances where there is evidence of overlapping symptomatology, so that either diagnosis is not delayed or missed.

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1. Thompson WG. Irritable bowel syndrome: prevalence, prognosis and consequences. Can Med Assoc J 1986; 134:111–113.
2. Hutchison R. The chronic abdomen. Br Med J 1923; 1:667–669.
3. Hinds JP, Stoney B, Wald A. Does gender or the menstrual cycle affect colonic transit? Am J Gastroenterol 1989; 84:123–126.
4. Turnbull GK, Thompson DG, Day S, Martin J, Walker E, Lennard-Jones JE. Relationship between symptoms, menstrual cycle and orocaecal transit in normal and constipated women. Gut 1989; 30:30–34.

irritable bowel syndrome; endometriosis; pelvic inflammatory disease

© 2004 Lippincott Williams & Wilkins, Inc.