Editorial: Recognising the regional variations in profile of irritable bowel syndrome—better late than never! Authors' reply

We thank Dr Ghoshal for his interest in our study, examining differences in IBS between patients in the UK and Malaysia in secondary care, and his acknowledgement of the regional variations in the profile of IBS. IBS does not contribute to mortality, but it has a substantial impact on quality of life, which has been reported to be worse than some severe chronic organic diseases. Although patients with IBS in a primary care study from Malaysia were also shown to have impaired quality of life and higher healthcare utilisation, the differences in the profile and impact of IBS in different regions were uncertain previously.

Ours is the first head-to-head study evaluating the characteristics of patients with IBS between different regions. It revealed more severe gastrointestinal and psychological symptoms, and a greater limitation of activities among patients in the UK compared with Malaysia. Although there was a slight difference in the survey method (paper vs. web-based), potential bias was reduced by participants from both countries completing self-administered questionnaires. In contrast, the prevalence of IBS differed significantly between household in-person interview methods and internet surveys in the Rome Foundation Global Epidemiology study.
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We agree that the likely driver of more severe symptoms and a greater negative impact of IBS among UK vs. Malaysian patients was the higher level of psychological co-morbidity as shown in our study. This was similarly demonstrated by a study from India and Bangladesh. Other possibilities for the differences in IBS severity seen between these two geographical regions could be due to dietary habits, including alcohol intake, which has been reported to be a risk factor for small intestinal bacterial overgrowth (SIBO). Of interest, SIBO is recognised to be associated with IBS and even linked to a more severe form of IBS. UK patients who consumed more alcohol, compared with Malaysian patients as shown in our study, may have had a greater rate of concomitant SIBO / dysbiosis, which may cause more severe IBS.

Although patients who fulfilled the Rome IV criteria for IBS may represent a more severe version of IBS, a meta-analysis of population-based studies reported that the Rome IV criteria were less sensitive than the Rome III criteria to diagnose IBS, with a pooled prevalence of 3.8% vs. 9.2%. However, the change in criteria appears to have a greater impact on patients with IBS from the East than the West, as demonstrated by our current study. Among the patients with Rome III-positive IBS, 71% from the UK met Rome IV criteria, compared with only 49% from Malaysia.

Regional variations in the IBS profile, as demonstrated by this study, suggest that the current classification of disorders of gut–brain interaction, especially IBS, is far from ideal. In contrast, Black et al reported an interesting method of classifying IBS patients based on gastrointestinal symptoms and psychological profiles. This novel method, which takes psychological co-morbidity of patients with IBS into consideration, may potentially be more useful to direct treatment as well as supporting the Rome Foundation's recommended multi-dimensional clinical profile approach.

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