When file outweighs the patient, watch out

September 1, 2007

This month, I decided to forgo my feeble attempts at humor and instead report on the clinical and radiographic findings of a rather prevalent clinical syndrome, which I believe I am the first to formally describe. For lack of a better name (or any sense of modesty), I have labeled it Tipler's Irritable Body Syndrome, or TIBS.

This month, I decided to forgo my feeble attempts at humor and instead report on the clinical and radiographic findings of a rather prevalent clinical syndrome, which I believe I am the first to formally describe. For lack of a better name (or any sense of modesty), I have labeled it Tipler's Irritable Body Syndrome, or TIBS.

I have done no large population survey, but my gut tells me TIBS is very common and on the upswing. Of course, this may reflect the Lyme phenomenon: Once a new disease is recognized, the rate of diagnosis skyrockets. This is different from the Lime phenomenon, where once you have a Mexican beer with a citrus squeeze, you can't go without.

As with many clinical syndromes, the diagnosis is based on the finding of various major and minor criteria-the more criteria the patient meets, the more likely TIBS is the correct diagnosis. Both clinical and imaging findings occur in both groups of criteria. Major criteria score two points each, and minor score one. A total over 20 clinches the diagnosis.

Major criteria, clinical, include previous diagnosis of fibromyalgia, reactive hypoglycemia, chronic tension headaches, irritable bowel syndrome, dysmenorrhea or erectile dysfunction, panic attacks, reactive depression, chronic fatigue syndrome, or recurrent syncope. Patient is on a first-name basis with emergency room staff and takes an antidepressant for any diagnosis other than depression.

Physical examination finds more than three tattoos, more than three surgical scars (at least one for hiatal hernia, gastric stapling, hysterectomy, or breast augmentation), obesity, or no visible pathology. Chief complaint is pain everywhere, inability to concentrate, postprandial pain without weight loss, "migraines" every day, migratory numbness, or blackout spells without injury.

Major criteria, imaging, include a film jacket weighing more than 20 pounds or list of exams on PACs of more than two pages, three or more negative CT scans of same body region, or three or more negative pelvic ultrasounds. Patient has had a discogram or more than one gallbladder ejection study or requires a family member in the room when having a diagnostic exam.

Minor criteria, clinical, are previous diagnosis of insomnia, eating disorder, carpal tunnel syndrome, chronic low back pain, pelvic pain syndrome, or chronic epididymitis. Patient is approaching his or her 30th, 40th, or 50th birthday.

Physical examination finds body piercings after age 30, one to three tattoos, very low weight, tanning booth tan, or more than two elective surgery scars. Chief complaint is don't feel right, food tastes different, eyes get blurry, or some body part hurts-primarily at work.

Minor criteria, imaging, include a film jacket weighing 10 to 20 pounds or a full page on PACS, two negative CT scans of one area, MRI of entire spine, and wrist arthrogram.

TIBS patients can be divided into two broad groups: insured and uninsured. The uninsured present unusual diagnostic challenges and are best referred to tertiary centers. Insured TIBS patients are walking IRAs.

Once the diagnosis of TIBS is made, how are these patients managed? Benign neglect is the overall goal. These patients have nonmedical issues, but they are looking for medical solutions. For some, the sick role may be more fun than their normal life. Many face aging, but don't want to. Others may have trouble dealing with the myriad of problems called life.

Try to avoid invasive procedures. Remember, first do no harm. These patients are going to get tests somewhere, so try to offer them a benign test that will satisfy their need to have something done.

Dealing with TIBS patients faces one major pitfall. They can actually get sick. While their ratio of complaints and presentations to serious diagnoses is different from yours or mine, incidence of actual illness is not necessarily zero. As my favorite resident used to say, "Even turkeys get sick occasionally."

A label like Irritable Body Syndrome will make these patients ecstatic. No wonder they feel bad, no wonder they miss work, no wonder they need to be babied. It isn't their fault. They have TIBS.

Dr. Tipler is a private-practice radiologist in Staunton, VA. He can be reached by fax at 540/332-4491 or by e-mail at btipler@medicaltees.com.