It is interesting to note that every paper about irritable bowel syndrome (IBS), no matter if it is an original, a review, or an editorial, begins with an explanation of the definition and the relevance of the syndrome. This does not happen with other diseases (yes, diseases), such as inflammatory bowel diseases (IBD) or neoplastic lesions. It seems that we have to explain or apologize for our decision to write about this topic.
It is clear that the interest in gastrointestinal functional disorders (GIFD) is not very extensive. Gastroenterologists, mainly (and unfortunately) young gastroenterologists, prefer to dedicate their time to other tasks, such as inflammatory disorders and, massively, to endoscopy. It seems that they just don’t like seeing patients with functional disorders. This makes me think that a kind of “pathophobia” exists. This pathophobia means that some doctors, including gastroenterologists, decide by themselves that visiting patients with GIFD is not interesting enough or that the disorders are not sufficiently severe to deserve their dedication. It is not infrequent to hear: “I am not interested in functional disorders”, “I prefer not to visit IBS patients”, or “This is not a disease”. How is it possible to not pay attention to a disorder with a prevalence close to 10%? (1). How can one remain impassive in front of one of the most frequent causes of medical consultation? Is this licit? Is it adequate? Is it medicine? I have met many doctors not interested in IBS, but not one patient suffering from IBS that lacked interest. How mysterious!
The reality is that IBS is frequent and relevant in every country, including Spain, and, independent of how different societies, cultures, or diets are among different nations, the prevalence is quite similar (1, 2). There is a very popular sentence that Spanish people use when something that is not easy to explain occurs in our country: “España es diferente” (Spain is different). We use it for good and for bad things, for small things, and for our (frequent) economical/political catastrophes; this slogan has been used even in touristic promotions.
Is Spain different regarding IBS? The aim of this mini-editorial is to briefly analyze whether there are differences concerning several aspects related to IBS, including patients’ symptoms and behaviors, doctors’ perception of the syndrome, and the research dedication.
The overall prevalence of IBS ranges from around 6 to 14% depending on the used diagnostic criteria and the population evaluated (1, 2, 3). Regarding Spain, it is a common assumption that following a healthy Mediterranean diet and enjoying life should prevent us from having IBS; the truth is that our diet is rich in fats and sugar, and that our way of living is also stressful. Unfortunately, we are not immune to GIFD and the prevalence is about 6–8% (2, 3, 4). IBS subtypes in Spain, as in many other countries, roughly follow the one-third rule: one-third of IBS patients have constipation (IBS-C), one-third diarrhea (IBS-D), and the other third a mix of constipation and diarrhea (IBS-M); of course, only once the IBS unclassified subtype has been excluded (5, 6). Nevertheless, it seems that in Spain and other Mediterranean countries, IBS-C is more frequent that IBS-D (4), whereas in Northern European countries and the United States the opposite occurs (5).
By definition, the main symptoms of IBS are similar all over the world: “recurrent abdominal pain associated with defecation or a change in bowel habits (constipation, diarrhea, or a mix of constipation and diarrhea)” (7). Nevertheless, here and there, as pointed out in the new Rome IV definition, abdominal bloating/distention are extremely frequent and bothering manifestations in these patients. In fact, bloating is probably the most challenging symptom of IBS.
How often do patients suffering from IBS look for medical attention in Spain? Most of the subjects (around 75%) who meet the IBS diagnostic criteria have been evaluated in our National Health System (8). This differs from figures in other countries like the United States where only about 30% of IBS patients have visited a physician for this reason (9). It seems that the main cause for this disparity relates to the different functioning of health-care systems. Spain has universal and completely open access for patients. Therefore, while it is frequently said that IBS patients attended by physicians are only the tip of the iceberg, in Spain the bottom of iceberg is smaller.
A more difficult question, compared to the previous one, is how often do IBS patients receive medical attention? They go to the doctor, but in many cases the interest of general physicians and gastroenterologists in these cases is reduced. After many different tests, a diagnosis of “there is nothing wrong”, and a therapeutic approach based on “there is not much to do”, they begin an endless trip from doctor to doctor until patients become so tired that they engage in a new circle of alternative, complementary, or paramedicines.
In 2007 we performed a survey evaluating many different aspects of IBS, including the knowledge and interest of professionals. In that survey, 218 Spanish gastroenterologists participated: 32% responded that they had much interest in IBS; 59% had some interest; and for 9% the interest was small. However, one of the most interesting questions (and answers) was the one about the criteria they most frequently applied in clinical practice (remember that this was in 2007): Manning 42%, Rome I 52%, Rome II 80%, Rome III 62%, and Rome IV 8%*. Great, in 2007 we had an 8% of futurologists in Spain! Let me doubt the results obtained from this type of opinion studies, including the ones that I have done. People give an answer based on what they should do, but not what they actually do.
Nevertheless, not everything is so painful when talking about GIFD in Spain. We have been very active in research and education. Juan Malagelada, mentor of many Spanish researchers in this field, can be considered a founding father. Many other well-known investigators also deserve to be mentioned: Fernando Azpiroz; Javier Santos; Anna Accarino; Jordi Serra; and Enrique Rey, among others. It is impossible to recount the history of GIFD, and specifically of IBS, without mentioning these names. In addition, a Spanish gastroenterologist has had the honor and the privilege of chairing the Rome IV Committee for Functional Bowel Disorders (10). Moreover, one of the five sections in which the Spanish Gastroenterology Association (AEG: Asociación Española de Gastroenterología) is divided is devoted to Neurogastroenterology, including motor and functional disorders. In addition, and coordinated with the previous one, there is the Spanish Group of Motility (Grupo Español de Motilidad) founded 25 years ago and currently presided by Constanza Ciriza.
Does it mind that GIFD, IBS, or Neurogastroenterology in Spain are having a golden era nowadays? The answer is no. We are a resistance group surrounded by many other gastroenterologists interested in other fields. At the end of all my talks and seminars, I always ask the audience who is interested in/devoted to endoscopy and almost all hands are raised; who is interested in IBD and about two-thirds of the attendees respond affirmatively; who likes GIFD and, then, at the back of the room there are one or two hands up, frequently young physicans.
I do believe, and I have personally confirmed it, that the situation is not much different in other countries. IBS is painful not only for patients but also for many physicians. Clearly, there is an imbalance between the perception of sufferers and professionals regarding IBS (Figure 1). How to correct this imbalance between the need for patients’ care and doctors’ disinterest is a matter of knowledge, dedication, empathy, and time (I hope).