CHAPTER 1: INTRODUCTION

1.1 INTRODUCTION TO IBS

Irritable bowel syndrome is classified as a gastrointestinal disorder that
can be
chronic, continuous or remittent in function. The common symptoms
include
abdominal pain, bloating and bowel disturbances (Clark and DeLegge,
2008). A more discrete definition of IBS is made by the Rome Committee
for the Classification of Functional Gastrointestinal Disorders where
abdominal and bowel symptoms occur with sufficient frequency in
affected patients. In a more accurate manner, the
abdominal discomfort or pain has to be present for at least 3 days every
month, for 3
months consecutively. The pain also has to have either two of the
following three
features:
1) Relieved by defecation.
2) Onset associated with a change in the frequency of stool.
3) Onset associated with a change in the form of the stool (Rey and Talley,
2009).

1.2 EPIDEMIOLOGY
A study showed that the ethnic distribution of IBS among Malaysian
Medical
Students were 278 (52.2%) Malays, 179 (33.6%) Chinese, 46 (8.6%)
Indians, and 30
(5.6%) were others. 84 (15.8%) were reported to have symptoms
consistent with the
diagnosis of IBS and were predominantly women.
It has been observed that community surveys were the commonest
studies done
in addressing the prevalence of IBS. 65 (77.4%) and 6 (7.1%) were of the
constipation predominant and diarrhoea-predominant IBS subgroups,
respectively. 13 (15.5%) subjects fell into the mixed IBS subgroup. (TAN et
al., 2003)
It was also observed that majority of the studies were conducted in
countries such
as Europe, Southeast Asia, and North America. In relation to differences in
the
geographic region, meta-analysis indicated that the pooled estimation of
international IBS prevalence was 11.2% (95% confidence interval [CI] 9.8
12.8). According to this analysis, the lowest prevalence occurred in
Southeast Asia (7.0%) whereas the highest prevalence occurred in South
America (21.0%). Across comparable iterations, it was observed that the
prevalence reported to be the utmost for the Manning criteria whereas the
lower prevalence for the Rome iterations (Canavan et al., 2014).

The almost accurate prevalence of IBS, had been studied in detailed over
the
years by quite a number of epidemiological studies. Although there were
many
challenges faced especially from the methodological point and the
dissimilarities
between these studies, the table below clearly states the prevalence that
in North
America, it's about 10% to 20% in the United States and Canada. It's
almost the same, perhaps slightly different, in Europe. Looking at Asia, it
was relatively desperate, Australia being 12%, Singapore quite low, Japan
and China being relatively high, and South America and Africa being
exceptionally high, at least based on the data coming from other
countries.
Due to limited availability, it was difficult to deduce some of the studies
conducted. In order to obtain the most accurate global prevalence, extra
studies should be conducted instead of the limited studies done so far
where most of the results were obtained by one study. However, it is
harmless to say that the IBS prevalence worldwide is between 10% to 20%
(Camilleri and CHOI, 1997).
Table 1.1 Prevalence of IBS
Country Prevalence of IBS (%)
Nigeria 30
Japan 25
China 23
UK 22
US 10-20
Peru 18
New Zealand 17
Canada 13.5
Spain 13
Sweden 13
Australia 12
Germany 12
France 9.4
Netherlands 8.3
Denmark 6.6
Singapore 4

1.3 RISK FACTORS

1. Sex :
Regardless of the diagnostic criteria, majority of populations reported that
women exhibited more IBS symptoms than men. The impact of the
disorder is 1.5-3
times as many women than men and this had also contributed to the
effects of

diminished quality of life and was related with psychological distress,

altered work and sleep habits and sexual dysfunction (Quigley et al.,
2006).
2. Age:
There was no relationship of age factor in the prevalence of IBS as it is
seen to occur in all age groups, including children and the elderly. There is
no difference witnessed
even in the frequency of subtypes by age. However, 50% of patients with
IBS reported having first symptoms before the age of 35 years, and
prevalence is 25% lower in those aged over 50 years than in those who
are younger (Canavan et al., 2014).
3. Socioeconomic status :
In relation to the socioeconomic status, one study proposed that IBS was
linked by a
string of events that had a connection between lower earnings leading to
poorer health care outcomes, lower general quality of life, and amplified
life stressors (Canavan et al., 2014).
4. Family Studies :
The relative risk of IBS was double the number of persons with a genetic
relative with IBS. In twin studies, having a parent with IBS is an
autonomous risk factor for an
individual having IBS and a stronger predictor than having a twin with IBS
(Canavan
et al., 2014).

1.4 OUTCOME OF IBS

Young Malaysians often experienced supportive symptoms for the
diagnosis of
IBS with a prevalence rate of 15.8%. The constipation-predominant IBS
subgroup,
lead the highest number within the IBS population was found in persons
with IBS had an advanced prevalence of psychological and psychosomatic
symptoms seen (TAN et al., 2003).
1. Misdiagnosis:
A significant number of patients, 10% to around 40%, with no red flag
indications,
showed no difference in the rates of organic lesions found on colonoscopy
compared to healthy controls. Even most patients with apprehension
symptoms have no organic pathology. The mean time between diagnosis
of IBS and IBD was 23 years, signifying that, in some, IBS symptoms
maybe initial signs of IBD before lesions were noticeable (Canavan et al.,
2014).
2. Symptom patterns:
There was an alteration of symptoms experienced by patients of IBS over
time. Over

short episodes of time, symptoms may resolve in some individuals

whereas in some
there may be new development, indicating the prevalence of symptomatic
IBS remains steady over 12 years follow-up. In the first 3 months after
diagnosis, patients experienced four separate incidents of symptoms per
month on average. The lengthiest of these incidents lasts around 5 days,
and most patients experienced symptoms on more than half of the days. If
all gastrointestinal symptoms resolve, then many develop symptoms of
other functional diseases. Those with poorer quality of life and higher
levels of apprehension were more likely to suffer with other functional
comorbid circumstances (Canavan et al., 2014).
3. Co-existing functional conditions:
Estimated that almost 50% of IBS patients complained of fibromyalgia,
chronic fatigue syndrome, chronic back pain, chronic pelvic pain, chronic
headache, and
temporomandibular joint dysfunction. It was double the occurrence in the
overall
population. However these disorders, characterized by their symptoms,
have extensive overlay and their understanding of aetiologies are below
par (Canavan et al., 2014).
4. Quality of life :
Quality of life among IBS patients were reduced when compared to normal
patients.
When the quality of life (measured through 8 domains) was done, it was
found that the patients with Constipation predominant IBS had a
significantly better quality of life than diarrhea predominant IBS patients.
The mixed subtype had a varied quality of life, with some reporting to be
on both end of the scales.

1.5 BACKGROUND OF MAHSA

MAHSA was recognized in earnest in the year 2005 in Pusat Bandar
Damansara, Damansara Heights, Kuala Lumpur with the certainty that
higher
education in the field of healthcare is a vital cog in the advance of the
country.
Medicine, Dentistry, Pharmacy, Nursing and Allied Health Sciences
education in this
region were thereby developed with competent and empathetic
healthcare experts to

aid the needs of our prodigious nation. Within a short duration of time, our
students
matured their original locations and thereby a second campus was set up
in Jalan
University, Kuala Lumpur. The Jalan University Campus or JUC is now titled
as the
main campus. In 2009, MAHSA was promoted from College to University
College
rank. This advancement in class in a mere four years is verification to the
standard
commitment of the educational and executive staff united by the
conveyance of greater
programs.
Reference Population:
The selected individuals for this research were registered students from
MAHSA
University in the current year of 2015.
Target Population:
The target population was the Degree students chosen from 4 different
faculties
consisting of the Medicine Faculty, Dentistry Faculty, Pharmacy Faculty
and
Physiotherapy Faculty were selected as the target population. The
students aimed;
aged varied from 18-35 years old. Questionnaires were distributed as a
method of
research conduct to the students according to their corresponding faculty
in their
respective classes. There are a total of 1534 students.

1.6 BACKGROUND OF QoL

According to the World Health Organization (WHO), quality of life (QoL) is
defined as "individuals' perception of their position in life in the context of
culture and
value systems in which they live and in relation to their goals,
expectations, standards and concerns". Quality of life was a broad-ranging
concept affected in complex way by many factors including the person's
physical health, psychological state, social relationships, level of
independence, personal beliefs and their relationship to salient features of
their environment.
Quality of life, when considered in the context of healthcare, was referred
to
commonly as health-related quality of life (HRQoL), separating HRQoL
from the other aspects of QoL. HRQoL was a multidimensional concept,
comprising domains related to physical, mental, emotional and social
functioning; it focuses mainly the consequences of the status of an
individual's health. Healthcare workers usually utilized HRQoL to measure
the effects of chronic illnesses, treatments and disabilities on patients

(Ferrans, 2005). There were three types of HRQoL measurement available

which are the global assessment, generic or general instruments and
disease-specific instruments. A generic measure such as Medical
Outcomes Study Short Form 36 (SF-36) designed to evaluate aspects of
functional status and well-being applicable to a population in general. This
measure can help in screening the subjects and providing a basis of
comparing a sample of subjects with chronically ill or with normative
general population (Gralnek et al., 2000).
Irritable Bowel Syndrome-Quality of Life Questionnaire (IBSQoL) was a
disease-specific questionnaire which has 8 different domains consisting of:
Domains Items (No. Of Questions
Asked)
- Dysphoria 8
-Interference with activity 7
-Body Image 4
-Health worry 3
-Food avoidance 3
-Social Reaction, 4
-Sexual 2
-Relationships. 3
IBS has a significant impact on quality of life. As a consequence, the
assessment of HRQoL is paramount in patients with IBS, especially
regarding severity and treatment outcomes of IBS.

1.7 PROBLEM STATEMENT

The purpose of this study was to identify the Quality of Life among the
students
with IBS in MAHSA University, as there is not enough research being done
in
Malaysia amongst university students.Based on a study done by Tan et al
in 2003 in University Malaya, the distribution of IBS was more in the Malay
ethnicity as compared with the other ethnic groups due to the study
population being mostly composed of Malays with 278 out of 533
participants (52.2%), followed by Chinese comprising of 178 (33.6%),
Indians making up for 46 out of 533 (8.6%) an others 3 out of 533
participants (5.6%). As for the IBS subtypes, IBS-C was found to be more
common with 65 people (77.4%)suffering from it, followed by the nonspecific subgroup with 13 people (15.5%) reporting it, and IBS-D with 6
people (7.1%). 84 women (15.8%) predominantly reported having
symptoms that were consistent with the diagnosis of IBS. Patients below
the age of 50 years old were more commonly diagnosed with IBS based on
the Rome II criteria across Asia. The prevalence of IBS among those below
50 years in Singapore was 9.7 % while the prevalence amongst those
above 50 years old was 5.8%. In Taiwan, the prevalence of IBS among the
age group below 50 years old was 38% compared to the prevalence of IBS
among the age group above 50 years old was only 18% (Gwee et al.,
2009)

These theories came from a lot of studies in the other parts of the world
and
there are not enough studies that have been done in Malaysia to support
these theories. Apart from that, no study has been done yet in MAHSA
University regarding the association of IBS with the quality of life amongst
MAHSA students.
According to the study conducted in the United States using the SF-36, it
was
found that that there was significant decreased of Health Related Quality
of Life
(HRQol) in patients with IBS on all scales of SF-36 as compared to the
general
population. Energy, fatigue, and role limitations caused by the physical
health
problems, bodily pain, and general health perception were the most
prominent
decrement in HRQoL.(Gralnek et al., 2000) From this research we can
identify the quality of life amongst MAHSA university students who have
IBS. We can increase awareness in the student community and the
authorities can consider developing supportive measures to increase the
quality of life amongst students with IBS.

1.8 PROBLEM ANALYSIS

Although IBS was common among young adult Malaysians, especially
students,
its implications to the quality of the students daily life were been taken
too lightly.
Besides that, information of IBS on QoL amongst students was barely
sufficient. In
addition, only a limited number of studies have been conducted amongst
student in
Malaysia. Up till 2015, only 2 researches of IBS in Malaysia been
published. More
research is needed to assess the distribution of age, gender, race and
faculty in relation with QoL among university students in Malaysia. Only a
minority of students will seek medical advice for their symptoms.
Furthermore, students and the university themselves need adequate
information regarding IBS as it may affect the academic performances.
Therefore, the impairment caused by IBS on QoL of university students
needs to be highlighted to inform the society, especially young adult
Malaysians, on the impact of IBS

1.9 CONCEPTUAL FRAMEWORK

Figure 2.1 provides a conceptual model of the role of a few factors on
illness

and outcome of IBS. Socio-demographic ,family history ,medication

,lifestyle ,stress
,low level of academic performance and infectioous factors influence the
physiologic
functioning, and susceptibility of one individual to develop IBS. Somehow,
several
factors may contributed to IBS development or may be the consequence
of IBS itself. Therefore, while some factors are not etiologic to IBS, they are
somehow relevant in order to understand the patients adjustment to IBS
and how IBS can affect several aspects of their life due to its clinical
course.

1.10 RESEARCH QUESTIONS

1. What is the prevalence of IBS among MAHSA University students?
2. What is the distribution of IBS across age, gender, race and various
faculties
among MAHSA University students?
3. What are the factors that could contribute to the prevalence of IBS
among
MAHSA University students?
4. What are the common subtypes of IBS among MAHSA University
students?
5. Which subtypes of IBS has the most effect in the quality of life among
MAHSA University students ?
6. What is the level of quality of life across 7 domains among MAHSA
University
students with IBS?

1.11 RATIONALE
The rationale for carrying out this research lie in the documented
findings in the literature that IBS prevalence among students of Tehran
University
was 4.75%.There was also documented literature that most patients with
IBS have
reduced their quality of life in several aspects in their life. IBS also most
commonly
being diagnosed among women.(Jahangiri P et al., 2012) However, this
theories
most of it came from the other part of the world and only a few studies
was done in
Malaysia itself. A comprehensive study was yet to be done to analyze the
prevalence of irritable bowel syndrome (IBS) among students in MAHSA
University. A study was yet to be done to reflect the quality of life among
MAHSA student with irritable bowel
syndrome (IBS). This research can also increase the awareness of IBS
among MAHSA students as IBS often has a tendency to develop into
chronic clinical course.(Whorwell)

From this research, some preventive methods or some measures can be

designated by the upper management or the authorities to increase the
quality of life among MAHSA student with IBS.

1.12 OBJECTIVES
1.12.1 General objectives
The general objective was to determine the prevalence and distribution of
IBS
and its subtypes and as well as it relationship between QOL among
MAHSA
University students.
1.12.2 Specific objectives:
1. To estimate the prevalence of IBS among the MAHSA University
students.
2. To compare the prevalence of IBS across various faculties in MAHSA
University students.
3. To determine the distribution and the prevalence of subtypes of irritable
bowel
syndrome among the MAHSA University students.
4. To determine the factors associated with IBS (demographic, social,
behavior).
5. To determine the level of quality of life across 7 domains within the
subtypes
of IBS among the MAHSA University student.
6. To determine the association between IBS subtype and the quality of
life.

1.13 HYPOTHESIS
1. There was significant association between IBS and age group.
2. There was significant association between IBS and gender.
3. There was significant association between IBS and faculty.
4. There was significant association between irritable bowel syndrome
across
various faculties in MAHSA University
5. There was significant association between IBS and the quality of life
across the 7
domains (dysphoria, body image, relationship, health worry, social
reaction,
food avoidance and interference with activity.)

1.14 SUMMARY
In this research, the aim was to identify the Quality of Life among the
students
with IBS in MAHSA University since there was not enough research being
done in
Malaysia among university students. Although IBS is common among
young adult

Malaysians especially students, the information regarding IBS and its

implications
towards the quality of life are inadequate. By doing this research, the
prevalances of
IBS among university students, especially in MAHSA University can be
obtained and
the level of quality of life among the students with IBS also can identified
for further
plan and action. This research also will increase the awareness of IBS and
factors
related to IBS among MAHSA students and upper management as IBS may
lead to
low level of quality of life in the students with IBS and may affect the
quality of
academic performance of the individual.