healthcare Article Assessment of Public’s Awareness Regarding Irritable Bowel Syndrome in Aseer Region, Saudi Arabia Mohammed A. Bawahab 1 , Muneer Jan Bhat 1, * , Fahad Nasser Mohammed Asiri 1 , Khalid Ali Mohammed Alshahrani 1 , Abdulaziz Mohammed Alshehri 1 , Bassam Ahmed Almutairi 1 , Muath Mohammed Alhumaidi 1 and Rayan M. Eskandar 2 1 2 * Surgery Department, Faculty of Medicine, King Khalid University, Abha P.O. Box 641, Saudi Arabia Ibn Sina Medical College, Jeddah P.O. Box 641, Saudi Arabia Correspondence: mbhat@kku.edu.sa; Tel.: +966-592235041 Abstract: Irritable bowel syndrome (IBS) is a gastrointestinal disorder characterized by altered bowel habits, abdominal pain, or discomfort. It is a highly prevalent disorder that affects patients’ quality of life. A workup is usually required to diagnose IBS, as its differential diagnosis includes some serious conditions such as carcinoma of the colon. The present study aimed to assess the awareness and beliefs of the general population regarding IBS. This study was conducted in the Aseer Region, in the southwestern part of Saudi Arabia. It followed a cross-sectional research design that was conducted during the period from January to March 2021 using a structured self-administered questionnaire to assess the demographic variables in addition to questions to assess participants’ awareness and beliefs related to IBS. Following a convenience sample, the study included 779 participants, with 43.3% being male, mostly in the age group 21–30 years (36.7%), and 68.7% being university graduates. Most participants (70.5%) were aware of IBS, and had the correct knowledge about its etiology, symptoms, risk factors, prognosis, and management. It is recommended to conduct various awareness-raising programs regarding IBS to improve the public’s knowledge and to decrease functional disabilities and their impact on life. Keywords: irritable bowel syndrome; knowledge; risk factors; general public; Saudi Arabia Citation: Bawahab, M.A.; Bhat, M.J.; Asiri, F.N.M.; Alshahrani, K.A.M.; Alshehri, A.M.; Almutairi, B.A.; Alhumaidi, M.M.; Eskandar, R.M. Assessment of Public’s Awareness Regarding Irritable Bowel Syndrome in Aseer Region, Saudi Arabia. Healthcare 2023, 11, 1084. https:// doi.org/10.3390/healthcare11081084 Received: 1 March 2023 Revised: 29 March 2023 Accepted: 6 April 2023 Published: 11 April 2023 Copyright: © 2023 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/). 1. Introduction Functional gastrointestinal disorders (FGID), such as functional dyspepsia (FD) and irritable bowel syndrome (IBS), are featured by chronic or recurrent abdominal symptoms of pain. In the case of irritable bowel syndrome (IBS), it is connected with either relief or exacerbation by defecation, or changes in bowel habits [1]. In addition, changes in bowel habits are related to both relief and exacerbation. Mood disorders, intestinal microbiota, chronic infections, altered intestinal permeability, and low-grade mucosal inflammation, including eosinophilia, systemic immune activation, altered bile salt metabolism, abnormalities in the serotonin metabolism, and genetic factors have all been proposed as potential causes of FGID [1]. Irritable bowel syndrome, often known as IBS, is a condition that affects the digestive tract and is characterized by stomach pain and chronic discomfort, as well as changes in the appearance of stools, mucus discharge, and bowel abnormalities [2,3]. IBS is not caused by any medical illness. It is a chronic and debilitating functional disorder of the gastrointestinal tract that affects 9–23% of the population across the world, causing a considerable impact on the quality of life, and resulting in functional disabilities [3]. According to the findings of a study that was carried out in the Al Jouf district of Saudi Arabia, the prevalence of IBS ranges between 8.9% and 9.2%. The incidence of irritable bowel syndrome (IBS) is considerably higher in persons under the age of 40 compared to those beyond the age of 40 [4]. Healthcare 2023, 11, 1084. https://doi.org/10.3390/healthcare11081084 https://www.mdpi.com/journal/healthcare Healthcare 2023, 11, 1084 2 of 11 The diagnosis of IBS is a matter of debate. Most community health providers believe that IBS is a diagnosis of exclusion; however, the guidelines emphasize that IBS is not a diagnosis of exclusion, and they encourage clinicians to make a positive diagnosis using the Rome criteria alone [5,6]. One of the most important differential diagnoses of IBS is colon cancer [7]. IBS and colon cancer share similar symptoms. Some patients with colon cancer may be misdiagnosed as having IBS. Nevertheless, with colon cancer, a person may experience unexplained weight loss and blood in their stool from the rectum. These symptoms do not occur in IBS. Despite similar symptoms, IBS does not put a person at a higher risk of developing colon cancer [8]. IBS frequently presents with serious symptoms that may be even more frequent than diabetes or hypertension [9]. However, the treatment of IBS is difficult because of its diversity and complexity. Although there are various guidelines related to its management, the main focus remains on the efficacy of medications using high-priority endpoints, leaving those of lower priority to be largely unreported. There is poor knowledge about its prevalence, precipitating factors, and associated factors in Saudi Arabia [10]. To the best of our knowledge, there has been no study evaluating the knowledge of the general population regarding IBS. Thus, it is highly essential to have the basic knowledge and awareness of related symptoms and management of IBS. Hence, with this background, this study was conducted aiming to assess the knowledge, and related factors regarding IBS among the general population of the Saudi community in Aseer Region. 2. Methods 2.1. Study Design The present study followed a cross-sectional research design. The study population included all Saudi adults (aged >18 years). However, those with a history of IBS, or who worked in the healthcare field were excluded. Following a convenience sample, a total of 779 participants could be included during the period from January to March 2021. 2.2. Data Collection Tool Based on a thorough review of the relevant literature, a self-administered structured questionnaire was constructed by the researchers to assess participants’ personal characteristics (i.e., age, gender distribution, body mass index, marital status, residence, employment profile, and educational level), in addition to well-constructed questions regarding participants’ knowledge and attitude about IBS. The study questionnaire’s content validity was assessed by an expert panel comprising two physicians and one research consultant. Moreover, the Cronbach α-coefficient was applied to measure its internal consistency, which proved to be appropriate (α = 0.84). 2.3. Data Collection The study was conducted in accordance with the Declaration of Helsinki and was approved by the local ethics committee of the institute (ECM#2020-2402). Informed written consent was obtained from all subjects prior to their enrollment in the study. Patients were clearly informed about the questionnaire and the responses to all questions were recorded and analyzed. The questionnaire was shared as an online questionnaire via various social media applications such as WhatsApp, Facebook, Twitter, Instagram, and Telegram, so as to achieve maximum responses from the general public and cover all types of education groups and subjects with a varied demographic profile. Moreover, face-to-face data collection was also performed by trained medical students in the form of direct interviews of the general population visiting public places, such as shopping malls and parks. Healthcare 2023, 11, 1084 3 of 11 2.4. Outcomes We evaluated participants’ personal characteristics (i.e., age, gender distribution, body mass index, marital status, residence, employment profile, and educational level) and their knowledge and attitude regarding IBS. 2.5. Statistical Analysis All data were attained and recorded in a pre-designed and validated Excel sheet. Collected data were statistically analyzed using the Statistical Package for Social Sciences (IBM, SPSS, version 20.0). Descriptive statistics (i.e., mean, standard deviation, frequencies, and percentages) were computed. Testing the significance of differences was performed using the chi-square test. The level of significance was set at a p-value < 0.05. Testing the significance of differences was performed using the chi-square test. Binary logistic regression was applied to identify the independent variable significantly associated with public awareness of IBS. The level of significance was set at a p-value < 0.05. 3. Results A combined total of one thousand people were invited through the use of social media and personal invitations. There were 822 responses that were accurate, which equates to 82.2%. Notwithstanding this, more participants with IBS and healthcare staff, totaling 43 patients, were excluded from the study. The total number of respondents was 779, which equates to a response rate of 77.9%. Table 1 shows the personal characteristics of participants, with 43.3% being males. The age group of 36.7% was 21–30 years, while 8.6% were aged <20 years. Most participants (79.2%) were living in the Aseer Region, Saudi Arabia, while 20.8% were temporary visitors to the area. More than half of the participants (58.0%) were married. More than two-thirds of the participants (68.7%) were university graduates, while 20.3% were secondary school qualified. Almost one-third of the participants (32%) were students, while 27.9% were teachers. More than one-third of the participants (39.5%) were overweight, while 24.1% were obese. Table 1. Demographic data (n = 779). Parameters Residence Gender Age (years) Marital status Education level No. of Subjects Percentage Within Aseer Region 617 79.2 Outside Aseer Region 162 20.8 Male 337 43.3 Female 442 56.7 <20 67 8.6 21–30 286 36.7 31–40 180 23.1 ≥40 246 31.6 Married 452 58.0 Single 327 42.0 Illiterate 2 0.3 Primary (finished 6 years of school education) 13 1.7 Intermediate (finished 9 years of school education 27 3.5 Secondary (finished 12 years of school education) 158 20.3 University 535 68.7 Postgraduate 44 5.6 Healthcare 2023, 11, 1084 4 of 11 Table 1. Cont. Parameters Job Body mass index (kg/m2 ) No. of Subjects Percentage Student 249 32.0 Teacher 217 27.9 Administrative 13 1.7 Military 21 2.7 Not employed/housewife 168 21.6 Govt employee 12 1.5 Retired 35 4.5 Private sector employee 42 5.4 2.8 Other 22 Underweight 42 5.4 Normal weight 241 30.9 Overweight 308 39.5 Obese 188 24.1 Figure 1 shows that most participants (70.5%) were aware of IBS, while 29.5% were not aware of it. Figure 1. General public’s awareness regarding irritable bowel syndrome. Table 2 shows participants’ responses regarding their awareness and knowledge of IBS. Almost half of the participants (49.4%) became aware of IBS from their friends or relatives, followed by the Internet and social media (36%). Almost one-third of participants (31.5%) stated that the most common symptoms of IBS include bouts of diarrhea, constipation, and abdominal cramps, while 60.8% stated that IBS is due to a colon infection. Healthcare 2023, 11, 1084 5 of 11 Table 2. Participants’ responses to knowledge items related to IBS. Parameters 1. Have you ever heard about irritable bowel syndrome? Options No. of Subjects Percentage The Internet and social media 200 36.0 Competent person/specialized facility 76 13.7 Relatives or friends 274 49.4 Yes (n = 555, 71.2%) Others 2. 3. 4. 5. 6. Irritable bowel syndrome includes the following: Irritable bowel syndrome is more common than diabetes or hypertension. Do you think Irritable bowel syndrome affects the quality of life? Irritable bowel syndrome can lead to rapid mood changes. What do you think is the most irritating symptom that makes the patient uncomfortable? (more than one option is allowed) 7. 8. 9. 10. 11. Irritable bowel syndrome is a result of the following: (you can choose more than one) Irritable bowel syndrome can lead to the following: (you can choose more than one) Irritable bowel syndrome attacks/episodes are triggered by the following: (you can choose more than one) Dietary changes could improve irritable bowel syndrome symptoms. Prescription medications could improve irritable bowel syndrome symptoms. 6 1.1 No 224 28.8 Diarrhea/constipation/abdominal cramps 245 31.5 Colon infection 474 60.8 Change in appetite 14 1.8 Ulcers in the bowel 46 5.9 Inflammation of the bowel 0 0 True 224 28.8 False 130 16.7 I do not know 425 54.6 Yes 619 79.5 No 39 5.0 I do not know 121 15.5 Yes 719 92.3 1.0 No 8 I do not know 52 6.7 Abdominal pain 486 62.4 Excess gases 439 56.4 Diarrhea 63 8.1 36.6 Constipation 285 Genetic factors 297 38.1 Infections 137 17.6 Dietary factors/food allergy 381 48.9 Anxiety/depression/stress 243 31.2 Motility problem 12 1.5 Cancer 353 45.3 Ulcer 414 53.1 Malnutrition 163 20.9 Absorption disorders 237 30.4 Hemorrhoid 137 17.6 A combination of multiple factors 340 43.6 Eating spicy foods 40 5.1 Frequent and excessive intake of meals 127 16.3 Eating a lot of meals containing saturated fat 43 5.5 By coffee 104 13.4 By stress at work or in relationships 240 30.8 Yes 623 80.0 No 18 2.3 I do not know 138 17.7 Yes 558 71.6 No 33 4.2 I do not know 188 24.1 Healthcare 2023, 11, 1084 6 of 11 Table 2. Cont. Parameters 12. 13. 14. 15. Surgery could improve the irritable bowel syndrome status. Counselling (a gastroenterologist, psychiatrist, or psychologist) could improve the irritable bowel syndrome status. Advanced age is a major cause of irritable bowel syndrome. If one of your relatives has symptoms of irritable bowel syndrome and he/she seeks your advice, what would you do? (more than one option is allowed) 16. What would you like to know about irritable bowel syndrome? No. of Subjects Percentage Yes Options 83 10.7 No 146 18.7 I do not know 550 70.6 Yes 630 76.64 No 26 3.3 I do not know 600 77.0 Yes 170 21.8 No 249 32.0 May be 360 46.2 Offer them some herbal medications 128 16.4 Tell them to change their diet 293 37.6 Tell them to visit a gastroenterologist 302 38.8 You will not tell them anything 151 19.4 What irritable bowel syndrome is 527 67.7 What causes irritable bowel syndrome 36 4.6 What foods should I avoid 91 11.7 Medications to prevent attack 1 0.1 Nothing 124 15.9 More than half of the participants (54.6%) were not aware of the prevalence of IBS, while 28.8% correctly stated that IBS was more common than diabetes or hypertension, whereas 16.7% denied that. More than three-quarters of participants (79.5%) indicated that IBS affects the quality of life, while 92.3% stated that it could cause rapid mood changes. More than half of the participants stated that abdominal pain and excess gas are the most irritating symptoms of IBS that make the patient uncomfortable (62.4% and 56.4%, respectively), followed by constipation (36.6%), and diarrhea (8.1%). Almost half of the participants (48.9%) stated that dietary habits or food allergies are the most common etiological factors affecting patients with IBS, followed by genetic factors (38.1%), anxiety/depression/stress, infection (31.2%), and motility problems (1.5%). More than half of the participants stated that IBS can lead to ulcers and cancer (53.1% and 45.3%, respectively), followed by absorption disorders (30.4%), malnutrition (20.9%), and hemorrhoids (17.6%). A combination of multiple factors was stated by 43.6% of participants to be the most common triggering factor for IBS, followed by stress (31.2%), frequent and excessive intake of meals (16.3%), excessive intake of coffee (13.4%), excessive eating of meals containing saturated fats (5.5%), and eating spicy foods (5.1%). Most participants stated that dietary changes and medications could improve IBS symptoms (80% and 71.6%, respectively), whereas knowledge about the role of the surgery was not particularly known by most participants (70.6%). Most participants (76.6%) stated that counseling a physician could significantly improve the IBS status. The impact of advanced age was not well known by participants (46.2%), whereas only 21.8% confirmed its impact, and 32% denied its impact. About one-third of participants (38.8%) stated that they advocate consulting a gastroenterologist for a relative who seeks advice regarding IBS, followed by recommending a change in diet (37.6%) or offering herbal medications (16.4%). About two-thirds of participants (67.7%) wished to know more about IBS, followed by which foods are to be avoided (11.7%), what causes IBS (4.6%), and lastly medications to prevent IBS attacks (0.1%). Table 3 shows that participants’ awareness of IBS was significantly less common among females (p = 0.004), those aged more than 40 years (p < 0.001), married (p < 0.001), those with less than a university educational level (p = 0.037), and overweight and obese participants (p = 0.005). Healthcare 2023, 11, 1084 7 of 11 Table 3. Participants’ awareness regarding IBS according to their personal characteristics. Unaware (n = 230) Personal Characteristics Residence Aware (n = 549) % No. % Outside Aseer Region 53 32.7 109 67.3 Within Aseer Region 177 28.7 440 71.3 Male 81 24.2 256 75.8 Female 149 33.6 293 66.4 <20 19 28.0 48 72.0 21–30 47 16.4 239 83.6 31–40 49 27.3 131 72.7 > 40 115 46.7 131 53.3 Married 166 36.7 286 63.3 Single 64 19.6 263 80.4 Illiterate 1 50.0 1 50.0 Primary 5 28.6 8 71.4 Gender Age (in years) Marital status Intermediate 12 42.9 15 57.1 Secondary 59 37.6 99 62.4 University 144 26.9 391 73.1 Postgraduate 9 21.3 35 78.7 Educational level Body mass index No. Underweight 13 31 29 69 Normal weight 50 20.7 191 79.3 Overweight 102 33.1 206 66.9 Obese 65 34 123 66 p Value 0.318 0.004 <0.001 <0.001 0.037 0.005 Table 4 shows the binary logistic regression model for predictors of participants’ awareness of IBS. The odds ratio, i.e., Exp(B) for the significant independent variables was 6.4 for the participants’ gender, 5.37 for their age groups, 4.49 for their qualification, 3.69 for their marital status, and 3.54 for their body mass index. All the independent variables included had a statistically significant association with participants’ awareness of IBS (p < 0.001). Table 4. Binary logistic regression for independent variables affecting awareness of IBS. Exp p Variables B Standard Error Wald (B) Value Lower 95% CI for Exp(B) Upper Gender 1.86 0.32 34.52 6.40 <0.001 3.45 11.89 Age groups 1.68 0.19 76.92 5.37 <0.001 3.69 7.83 Marital status 1.31 0.37 12.39 3.69 <0.001 1.78 7.63 Educational level 1.50 0.19 62.91 4.49 <0.001 3.10 6.50 Body mass index 1.26 0.18 50.37 3.54 <0.001 2.50 5.02 Constant −13.72 1.28 115.67 0.00 <0.001 4. Discussion The disorders of brain–gut interactions are a category of functional gastrointestinal disorders that are defined by a complicated relationship between the brain and the gut. They are also known as DGBIs. These conditions are characterized by a number of symptoms, including pain in the abdominal region, bloating, diarrhea, and constipation, all of which can have a major influence on a person’s quality of life [11]. Increasing pieces of evidence point to the possibility that alterations in the microbiota of the gut, the function of the intestinal barrier, and the immune system may all play a role in the pathogenesis of DGBIs. In addition, the impact that stress, worry, and depression has on the gut–brain axis have the potential to make the symptoms of DGBIs worse [12]. Recent developments in our knowledge of DGBIs have resulted in the creation of new diagnostic and therapeutic approaches for the treatment of these illnesses [13]. These include the use of probiotics, prebiotics, and dietary modifications in order to improve the composition and function of Healthcare 2023, 11, 1084 8 of 11 gut microbiota. Additionally, psychological therapies such as cognitive behavioral therapy and mindfulness-based interventions are utilized in order to target the psychological components of DGBIs [14]. In addition, there is evidence to suggest that novel pharmacological treatments, such as inhibitors of selective serotonin reuptake and certain neuromodulators, may have therapeutic benefits in the treatment of DGBIs [15]. In general, these new methods show promise for boosting the management of DGBIs and the quality of life of those who are afflicted by them. Irritable bowel syndrome is a prevalent, commonly occurring, functional chronic gastrointestinal disorder that carries a considerably negative impact on social functioning and quality of life; thus, the condition should not be underestimated [16]. It is observed that during a person’s lifetime, one in every five persons suffers from IBS. Moreover, the number of persons taking medical advice regarding IBS is also increasing, which accounts for around 12% of the total patients visiting primary health care clinics. This group constitutes a major part of patients reporting to clinics of the gastroenterology department [10]. Anxiety and stress are known to make symptoms of irritable bowel syndrome (IBS) worse, which makes it more difficult to control the disease [17]. Anxiety and stress are known to trigger the release of hormones, such as adrenaline and cortisol, both of which have the potential to irritate and inflame the digestive tract [18]. In addition, anxiety and stress can upset the balance of bacteria in the gut, which can make the symptoms of irritable bowel syndrome (IBS) worse. Alterations to one’s diet, which can be brought on by anxiety and stress in certain people, might make the symptoms of irritable bowel syndrome (IBS) worse [19]. The incidence of irritable bowel syndrome (IBS) continues to vary greatly across the globe. The prevalence of irritable bowel syndrome (IBS) is significantly higher in females than it is in males. Individuals between the ages of 20 and 40 years old were affected the most frequently [10]. The prevalence of irritable bowel syndrome (IBS) is estimated to range anywhere from 9–40%, according to the findings of a number of studies that have been carried out all over the world [20–22]. Insufficient data are available regarding the prevalence of irritable bowel syndrome (IBS) and the factors that put people at risk in Saudi Arabia’s general population. Studies have also proposed that the incidence of IBS can also be affected by various genetic factors, where family history plays an important role in the development of IBS in around 30% of patients [22]. Most of the studies have focused on the prevalence of IBS among different populations [10,23,24], rather than the awareness and knowledge about IBS among the general public. The present study was performed as the first study to evaluate the public’s knowledge about IBS and its risk factors in the Aseer Region, Saudi Arabia. The questionnaire used in the study was validated and revised to focus on knowledge about the cause, nature, risk factors, and management of this syndrome. Thus, this study did not replicate the questionnaires or data of the previous published. The etiology of IBS remains unknown, lacking confirmed or known factors. It has been advocated that the pathophysiology of IBS is not yet properly understood. For explaining the pathogenesis of diseases, various linked risk factors have been proposed. Recently, a “biopsychosocial” model has been proposed in an endeavor to harmonize and integrate various factors (such as environmental, genetic, and psychological) that work together synergistically to generate different signs and symptoms [24]. According to the findings of this study, most of the adults in the Aseer Region of Saudi Arabia are familiar with irritable bowel syndrome (IBS), and the vast majority of these individuals have accurate knowledge regarding the disorder’s etiology, symptoms, risk factors, prognosis, and management, particularly among university-educated subjects. On the other hand, the results of the bivariate and multivariate analyses suggested that knowledge of IBS was considerably lower among participants who were obese, younger, married, and had a lower level of education. However, the study by Hakami et al., which aimed to assess the knowledge, attitude, and practices of medical students in Saudi Arabia toward IBS, reported that most par- Healthcare 2023, 11, 1084 9 of 11 ticipants had misconceptions about its etiology and nature [25]. Similarly, several other national [26,27] and international studies [28–30] reported low awareness of IBS among the study populations, as most of the subjects had improper knowledge about the etiology and risk factors of IBS and its symptoms. The present study also revealed that the general public has adequate knowledge about the risks and aggravating factors of IBS. Most subjects will seek medicinal treatment and professional counseling for the management of IBS. Similar findings were reported in several studies [27–29], whose participants advocated the need for awareness about IBS and various factors related to the disease. Strengths and Limitations The present study was the first to explore the knowledge and related risk factors for IBS among the general public in Aseer Region, Saudi Arabia. However, this study has a few limitations, such as the cross-sectional nature of the study design, and the non-probability sampling used to include participants, which may reflect a selection bias. Moreover, the majority of participants were of young and middle age, and most respondents were highly educated, which may reflect some degree of response bias. In addition, the study did not inquire about the relatives of the participants who may suffer from IBS. Further studies should be conducted on a larger sample size, involving different parameters and variables to study the knowledge, attitude, and awareness among study subjects in relation to IBS. 5. Conclusions Most of the adult Saudi general public has good knowledge about the etiology, symptoms, risk factors, prognosis, and management of IBS. However, further observational studies need to be conducted with an elaborated sample size that includes an equal distribution of subjects of different age groups, genders, and educational levels from different areas of Saudi Arabia to assess the knowledge and awareness regarding IBS and the actual prevalence of the disease among the general population in Saudi Arabia. It is also recommended to conduct various healthcare programs to enhance knowledge and raise the public’s awareness about IBS. Author Contributions: All the authors contributed to the study conception and design. Material preparation, data collection was performed by F.N.M.A., K.A.M.A., A.M.A., B.A.A. and M.M.A. Analysis’ was performed by M.J.B., M.A.B. and R.M.E. The first draft of the manuscript was written by M.A.B. and M.J.B. All authors have read and agreed to the published version of the manuscript. Funding: This research received no external funding. Institutional Review Board Statement: The research protocol was approved by the Research Ethics committee at King Khalid University(approval number:(ECM#2020-2402) and all necessary precautions were taken. Informed Consent Statement: Informed written consent was obtained from all subjects prior to their enrollment in the study. Patients were clearly informed about the questionnaire and the responses to all questions were recorded and analyzed. Data Availability Statement: The data will be available with the corresponding author to be releases on reasonable request. Conflicts of Interest: The authors declare no conflict of interest. Healthcare 2023, 11, 1084 10 of 11 References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. Loosen, S.H.; Kostev, K.; Jördens, M.S.; Luedde, T.; Roderburg, C. Overlap between irritable bowel syndrome and common gastrointestinal diagnoses: A retrospective cohort study of 29,553 outpatients in Germany. 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