Functional bowel disorders and irritable bowel syndrome in Europe

Functional gastrointestinal disorders, and in particular irritable bowel syndrome, represent the bulk of outpatient practice in gastroenterology. They also generate a significant number of consultations in primary care facilities. Irritable bowel syndrome is a well-recognized symptom complex in clinical practice, where patients have unexplained abdominal pain closely linked to a disturbance of bowel habit.1 Not only is irritable bowel syndrome highly prevalent, but it also induces considerable suffering and is a major burden on society. In recent years, our ability to positively identify irritable bowel syndrome and to understand the scope of the problem has increased. Functional bowel disorders are defined as a variable combination of chronic and recurrent gastrointestinal symptoms that are not explained by structural or biochemical abnormalities. Distinct syndromes have been defined by typical clusters of symptoms and regarded over past decades as separate clinical entities.2 In parallel, scientific interest and understanding of these disorders has progressively grown because of their recognition as diagnostic entities and as a result of new investigative techniques in gastrointestinal physiology, epidemiology and clinical assessment. A list of the syndromes that are recognized as functional gastrointestinal disorders is provided in Table 1. These syndromes have common characteristics: functional bowel disorders are in essence chronic, or relapse frequently; psychosocial factors are recognized as important components of pathophysiology; psychiatric comorbidity is often present; and medical treatments are poorly and transiently effective. Irritable bowel syndrome is the most frequent condition recognized in patients consulting both in general practice and gastroenterology. Irritable bowel syndrome is defined as the association of chronic abdominal pain with bowel disturbances; constipation, diarrhoea or the alternation of both.3 The condition develops most frequently in young adults, and women represent 80% of patients, but it may also be diagnosed in children or in elderly patients (Figure 1). Although not life-threatening, irritable bowel syndrome may severely impair quality of life and usually persists over several years. Its evolution is unpredictable and characterized by acute episodes interspersed with quiet periods, or by a continuity of long symptomatic periods. The clinical picture depends on the severity of the condition in each patient, which frequently determines the level of consultation (Table 2). Prevalence of irritable bowel syndrome in male and female adult populations, according to age groups. Irritable bowel syndrome is diagnosed from the patient's history, along with the absence of symptoms or signs of an organic disease, also considered as 'alarm features' that will lead the physician to perform or request additional investigations. A physical examination is important in order to look for other diseases and to provide authority for the physician to reassure the patient. There is currently no specific test available for irritable bowel syndrome. A sigmoidoscopy or a colonoscopy is recommended to rule out inflammation or cancer.4 Pathophysiological abnormalities described in irritable bowel syndrome include intestinal and colonic motor disorders, hypersensitivity of the gut and psychosocial factors. In addition, physical and sexual abuses are reported by up to 40% of irritable bowel syndrome patients and worsen the prognosis.5 Most patients require pharmaceutical treatment, although response is variable.6 Antispasmodics are frequently prescribed but their efficacy has not been fully proven.7 Mild laxatives and antidiarrhoeal agents often relieve bowel disturbances. Anti-depressants are frequently effective at lower doses than those used for treatment of depression.8 In moderate and severe patients with continuous complaints, psychotherapy may be effective in restoring coping strategies and in managing psycho-affective disorders linked to irritable bowel syndrome.9 The prevalence of irritable bowel syndrome ranges between 3 and 22% of the adult population in European countries (Table 3). In all studies coming from European countries and the USA, the prevalence of irritable bowel syndrome is higher in women than men, and occurs predominantly in adulthood. The disorder accounts for 20–50% of referrals to gastroenterology clinics.10-12 Some studies suggest that women tend to consult a physician more frequently than men.13 While point prevalences are estimated at 10–20%, lifetime prevalences are much higher. The sheer numbers indicate that irritable bowel syndrome is an important disorder from a well-being and health-economics perspective. The incidence of irritable bowel syndrome appears to be substantially lower than its prevalence, although fewer data are available.14 Some studies have evaluated the incidence of irritable bowel syndrome to be 9% of the adult population. Moreover, this rate should probably be lowered, as new onset of irritable bowel syndrome symptoms is rare in patients free of digestive complaints and in elderly patients. On the other hand, irritable bowel syndrome frequently overlaps with non-ulcer dyspepsia.15 Symptoms of irritable bowel syndrome can interchange with upper gut symptoms of dyspepsia and reflux. The factors that account for the onset and disappearance patterns are largely unknown. The health economics relating to any given set of symptoms is, to a large extent, a function of the healthcare system concerned. Some studies have evaluated the cost of irritable bowel syndrome in terms of healthcare consumption (physician visits, investigations, psychotherapy) and pharmaceuticals. As irritable bowel syndrome may considerably impair quality of life, work absenteeism should also be considered as a significant indirect cost in irritable bowel syndrome patients. Overall, irritable bowel syndrome or chronic functional syndromes represent about 50% of all reasons for consultation with a gastroenterologist.10-12 However, only 10–50% of adults with symptoms typical of irritable bowel syndrome ever present for medical evaluation. The reasons why only a minority present for care remains inadequately understood. Pain severity is a known contributing factor but appears to explain only a minority of consultation behaviour.13 Psychological distress has been shown to be higher in patients consulting for irritable bowel syndrome compared with non-consulters with similar symptoms, suggesting that psychological distress drives healthcare seeking.16 A few studies have evaluated the healthcare costs generated by patients diagnosed with irritable bowel syndrome. In a large survey of 1301 patients over 9 months performed in France, it turned out that the average yearly cost per patient of managing irritable bowel syndrome was €823, of which 69% was attributable to medical expenses, 15% to various other treatment options and 16% to indirect costs.17 Patients were frequently prescribed three or more concomitant medications. More recently, studies performed in the UK concluded that the yearly overall cost of managing irritable bowel syndrome was €206.90 to €266.60 per patient.18, 19 Expenditures included medications, use of healthcare resources and loss of working days, which was in average 5 days every 6 months. This figure varies considerably in the literature. An American study estimated a yearly cost of €802.20 per patient, not including the cost of medication.20 Finally, a German study has been recently published, which evaluated all medical costs and indirect costs in a sample of 200 irritable bowel syndrome patients recruited from 50 doctors working in private practice.21 This study highlighted the important burden of irritable bowel syndrome in terms of indirect costs due to days off work. In addition, psychotherapy appeared to be under-used by patients seen by family doctors or internists with no special interest in irritable bowel syndrome. Psychotherapy may be particularly beneficial in moderate and severe patients consulting in referral centres (Table 4). From the various studies quoted here, it can be concluded that patients visit their doctors about four times per year in the UK or USA but that German or French irritable bowel syndrome patients visited their doctors nearly three times as often. However, the total number of days off work attributed to irritable bowel syndrome was similar in all countries. In addition to these expenses, it is worth noting that a certain amount of money is additionally spent by patients for paramedical consultations and remedies or for accessing care resources referred to as 'alternative' medicines, which are impossible to accurately quantify. While some data on healthcare utilization from different countries throughout Europe fall reasonably close to each other, there are considerable differences in costs (Table 5). The costs reported from Canada and the UK are nearly three times lower than those of France, Germany and the USA. It is likely that the different cost data shown in Table 5 represent the different situations in healthcare systems. Irritable bowel syndrome and other functional digestive disorders are frequently chronic and disabling, but not life-threatening conditions. Better understanding of their multifactorial pathophysiology and the recognition of these diagnoses as pertinent clinical entities has led to improved management of these patients, both from a diagnostic and therapeutic point of view. When we assume that the prevalence of irritable bowel syndrome is about 10% of the adult population in Western Europe, we can estimate, on the basis of an average cost of €1000 per patient-year, the total cost of irritable bowel syndrome to be approximately €28.38 billion in EU countries. The financial burden of irritable bowel syndrome is thus considerable.

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