Is the label of post-infectious irritable bowel syndrome (PI-IBS) removed after complete recovery?

Post-Infectious IBS Label After Complete Recovery

The diagnostic label of post-infectious irritable bowel syndrome (PI-IBS) is removed after complete symptom resolution, as PI-IBS is defined by the presence of ongoing symptoms that meet Rome IV criteria following an episode of infectious gastroenteritis. 1

Definition and Diagnostic Criteria

PI-IBS is characterized by:

• Recurrent abdominal pain (at least 1 day/week in the last 3 months) with symptom onset at least 6 months before diagnosis, associated with ≥2 of the following:
  • Pain related to defecation
  • Associated with change in stool frequency
  • Associated with change in stool form 1
• Symptoms developing immediately following resolution of acute infectious gastroenteritis 1
• No prior IBS diagnosis before the infectious episode 1

Natural History and Recovery

• Less than half (approximately 43%) of PI-IBS patients recover completely within 6 years of follow-up 2
• Recovery is defined as resolution of symptoms to the point where Rome IV criteria are no longer met 1
• Once symptoms have completely resolved, the patient no longer meets diagnostic criteria for PI-IBS and the label should be removed 1
• PI-IBS has a better prognosis than non-infectious IBS, with symptoms gradually decreasing over time in many patients 3, 4

Factors Affecting Recovery

• Female sex is a strong risk factor for developing and maintaining PI-IBS (relative risk 2.2) 2
• Psychological factors may impair recovery:
  • Only 1 in 8 patients with history of anxiety or depression recover within 6 years, compared to 9 in 19 without such history 2
  • PI-IBS patients generally have less psychiatric illness compared to non-PI-IBS patients 5
• Diarrhea-predominant symptoms are more common in PI-IBS (70%) compared to non-PI-IBS (42%) 5

Pathophysiological Considerations

• PI-IBS involves several pathophysiological mechanisms that may persist even after apparent clinical recovery:
  • Persistent low-grade inflammation 6
  • Increased intestinal permeability 3, 6
  • Altered gut microbiota 1, 6
  • Increased enterochromaffin cells compared to non-PI-IBS patients 5
  • Visceral hypersensitivity 3, 6

Management During Recovery Process

• Treatment should follow general IBS management principles based on predominant symptoms 1
• For IBS-D (most common in PI-IBS): loperamide, ondansetron, ramosetron, or eluxadoline 1, 7
• For IBS-M: SSRIs, rifaximin, psychological therapy, or antispasmodics 1, 7
• For IBS-C (least common in PI-IBS): water-soluble fibers, osmotic laxatives, linaclotide, or lubiprostone 1, 7
• Reassurance should be provided that symptoms are likely to improve or resolve over time, especially with suspected viral-associated PI-IBS 1

Clinical Implications

• When symptoms completely resolve, the patient no longer meets diagnostic criteria for PI-IBS and the label should be removed 1
• Monitoring for symptom recurrence is prudent, as the underlying pathophysiological changes may persist beyond symptom resolution 6
• Patient education about the link between the prior intestinal infection and IBS symptoms is an important first step in management 1

Common Pitfalls

• Failing to distinguish between symptom improvement and complete resolution when determining if PI-IBS label should be removed 1
• Not recognizing that some patients may experience irregular bowel movements prior to the acute illness (but without the pain characteristic of IBS) and can still be defined as developing PI-IBS 1
• Overlooking the need for follow-up after apparent recovery, as symptoms may fluctuate or recur 2, 4