What is the best approach to manage a 44-year-old male patient with a 2-year history of bloating, acid reflux, lactose intolerance, incomplete evacuation, lower abdominal pain, and increased frequency of bowel movements with mucus, who has not responded to proton pump inhibitors (PPIs), has anxiety, and has undergone esophagogastroduodenoscopy (OGD) showing lax lower esophageal sphincter (LES)/antral gastritis with few antral erosions, and colonoscopy showing hemorrhoids?

Management of IBS with Anxiety and Refractory GERD Symptoms

This patient has IBS with anxiety and functional gastrointestinal symptoms that are being misattributed to GERD—the priority is to stop ineffective PPI therapy, address the underlying IBS with dietary modification (lactose and fructose restriction), and initiate brain-gut behavioral therapy for the anxiety component, as low-dose tricyclic antidepressants should be considered as second-line neuromodulator therapy for both the gastrointestinal pain and anxiety symptoms. 1

Diagnostic Clarification

This patient meets Rome criteria for IBS with the following features: 1

• Recurrent abdominal pain associated with defecation (urge after each meal)
• Change in stool frequency (5-10 times daily, increased from baseline)
• Change in stool form (Bristol 3-6, variable)
• Passage of mucus
• Bloating and incomplete evacuation
• Symptoms >2 years duration

The PPI failure is expected and diagnostically informative—persistence of symptoms on PPI therapy in 25-42% of patients suggests the diagnosis is not primarily GERD, but rather a functional disorder or misdiagnosis. 2 The lax LES and antral erosions found on endoscopy are minor findings that do not explain the predominant symptom pattern of postprandial lower abdominal pain, altered bowel habits, and anxiety. 1

The 5 kg weight loss over 1-2 years is concerning but likely reflects dietary restriction behaviors common in IBS patients with anxiety rather than organic disease, given normal colonoscopy. 1

Immediate Management Steps

1. Discontinue PPI Therapy

• PPIs are ineffective for this symptom complex and may be contributing to bowel symptoms 3
• Prolonged PPI treatment can produce bloating, flatulence, abdominal pain, diarrhea, and small intestinal bacterial overgrowth (SIBO) in up to 26% of patients after 6 months 3
• The antral gastritis/erosions can be managed with lifestyle modifications for reflux if needed, but are not the primary driver of symptoms 1

2. Dietary Intervention (First-Line Treatment)

Lactose restriction is essential given documented lactose intolerance: 1

• Eliminate dairy products containing >280 ml milk equivalent daily
• Note that lactose exclusion alone rarely cures IBS, so additional dietary modifications are needed 1

Fructose restriction should be implemented given symptom pattern: 1, 4

• Avoid sugar-sweetened beverages with high-fructose corn syrup
• Avoid foods with added fructose as sweeteners
• Limit foods containing fructans
• A 2-week dietary restriction trial is the simplest diagnostic and therapeutic approach 1, 4
• Fructose intolerance is present in 60% of IBS patients and improves symptoms in up to 80% when properly implemented 4

Consider low-FODMAP diet under dietitian supervision: 1

• Appropriate for moderate-to-severe gastrointestinal symptoms
• However, given co-occurring anxiety, a "gentle FODMAP diet" or Mediterranean diet may be more appropriate to avoid triggering restrictive eating patterns 1
• Supervised exclusion diets show long-term remission in approximately 50% of IBS patients 1

Critical caveat: Ensure nutritionally balanced diet and monitor for development of restrictive eating pathology, which is common in IBS patients with anxiety. 1, 4

3. Address Anxiety (Essential for Long-Term Outcomes)

Brain-gut behavioral therapy is first-line for IBS with anxiety: 1

• Cognitive behavioral therapy (CBT) is the most effective treatment with best empirical evidence 1
• Gut-directed hypnotherapy is an alternative, particularly effective for younger patients 1
• These therapies address both gastrointestinal symptoms AND psychological comorbidity, unlike standard psychological therapy 1
• Relaxation therapy and mindfulness-based stress reduction can be taught via audio-tapes if formal therapy unavailable 1

Neuromodulator therapy as second-line: 1

• Low-dose tricyclic antidepressants (TCAs) are preferred for gastrointestinal symptoms, particularly pain
• TCAs also help with anxiety and can prolong gut transit time, potentially beneficial for this patient's diarrhea-predominant symptoms 1
• Selective serotonin reuptake inhibitors (SSRIs) are preferred if there is concurrent moderate-to-severe mood disorder, as low-dose TCAs are unlikely to address severe psychological symptoms 1

4. Lifestyle and Self-Management

Structured behavioral modifications: 1

• Keep a 2-week diary of symptoms, stresses, and dietary intake to identify aggravating factors
• Regular exercise and physical activity
• Allow adequate time for regular defecation
• Avoid spicy foods and heavy meals that trigger symptoms (as patient has already identified)
• Breathing techniques and progressive muscle relaxation 1

Follow-Up Strategy

Adjust visit frequency to accommodate mental health needs: 1

• More frequent visits initially (every 4-6 weeks) to build therapeutic relationship and monitor response
• Elongate assessment over multiple visits if necessary, especially given anxiety component 1
• Provide empathy and validation that both gastrointestinal and psychological symptoms are real and taken seriously 1

Threshold for specialist referral: 1

• Specialist gastroenterology dietitian: Given dietary deficits, recent weight loss, and need for structured dietary modification
• Gastropsychologist: Given anxiety symptoms, impaired quality of life, and need for brain-gut behavioral therapy
• Consider SIBO testing (glucose hydrogen breath test) only if symptoms persist despite dietary modifications and anxiety management 1, 3

Common Pitfalls to Avoid

• Do not pursue exhaustive investigation—the focus should be on early IBS diagnosis to facilitate early treatment and integrated management 1
• Do not continue empiric PPI trials—additional trials of different PPIs are low yield in patients who have failed one 12-week trial without objective GERD evidence 1
• Do not implement restrictive diets without dietitian supervision—risk of nutritional deficiency and eating pathology in anxious patients 1, 4
• Do not treat gastrointestinal symptoms in isolation—psychological comorbidity is more important for long-term quality of life than gastrointestinal symptoms alone 1