Improving IBS and Chronic Constipation Care in Primary Practice
In this expert Q&A, previewing their 2025 Practical Updates in Primary Care Conference presentation Bridging Practice Gaps in Irritable Bowel Syndrome and Chronic Idiopathic Constipation: Strategies to Advance Diagnosis, Treatment, and Patient-Centered Care, Shanti L. Eswaran, MD, Clinical Professor of Gastroenterology at the University of Michigan, and Joel J. Heidelbaugh, MD, Professor of Family Medicine at the University of Michigan, explore best practices for diagnosing and managing irritable bowel syndrome (IBS) with constipation and chronic idiopathic constipation in the primary care setting.
They highlight the prevalence of IBS as one of the most common gastrointestinal diagnoses, affecting approximately one in five primary care visits. Drawing from their combined expertise in gastroenterology and family medicine, Dr. Eswaran and Dr. Heidelbaugh underscore the value of evidence-based diagnostic criteria, confidence in managing these conditions in primary care, and the importance of coordinated referral and collaboration with subspecialists when appropriate.
Key Highlights
- Irritable bowel syndrome (IBS) is one of the most common GI diagnoses, accounting for about 1 in 5 primary care visits.
- Evidence-based criteria such as the Rome criteria allow primary care providers to confidently diagnose and treat IBS with constipation (IBS-C) and chronic constipation.
- Most patients can be successfully managed in primary care, with gastroenterology referral reserved for moderate to severe cases and collaboration emphasized for best outcomes.
Additional Resource:
- Eswaran S, Heidelabaugh J. Bridging practice gaps in irritable bowel syndrome and chronic idiopathic constipation: Strategies to advance diagnosis, treatment, and patient-centered care. Presented at: Practical Updates in Primary Care Conference; September 19, 2025; Virtual. Accessed September 15, 2025. https://www.hmpglobalevents.com/pupc
TRANSCRIPTION
Shanti Eswaran, MD: Sure. So I'm Shanti Eswaran, and I am a gastroenterologist at University of Michigan in Ann Arbor, Michigan. I am co-presenting on IBS with constipation and chronic constipation at PUPS.
Joel Heidelbaugh, MD: And I'm Joel Heidelbaugh, also at the University of Michigan. I'm in the Department of Family Medicine, and I'm the current co-chair for the primary care group for the Rome Foundation. Together with Dr Eswaran, we do a lot of work in IBS, and I’m also a co-presenter with Dr Eswaran today.
Consultant360: What are some of the key themes of your presentation at PUPC?
Dr Heidelbaugh: The purpose of this lecture is really to highlight a lot of the key diagnostic and treatment provisions for IBSC, or a constipation predominant irritable bowel syndrome, and then coupling that with some of the similarities and differences with chronic idiopathic constipation. We're going to talk about some evidence-based diagnostic provisions, and then certainly current treatment paradigms.
Dr Eswaran: So, as we're tag-teaming this, we're gonna come at it from a primary care standpoint, and we're initially, putting it in a very loose case-based, presentation. And from that we'll kind of use how the patient might present, to a primary care office, and then moving that into pertinent questions that you might answer or ask. And then we’ll talk about thinking about when to refer, and then after that referral, what the next steps would be, from a specialist standpoint.
C360: Why do you feel this topic is particularly relevant right now?
Dr Eswaran: Irritable bowel syndrome is really the most common GI diagnosis, both that primary care providers see, as well as gastroenterologists, regardless of what practice setting you're in, where you are in the country, and even the world. And there is actually some interesting statistics that IBS accounts for about one in fie PCP visits, so just from the volume, and the prevalence of the disease.
Dr Heidelbaugh: I totally agree. I think if we do this well, and hopefully we will, we're going to present a lot of information that's going to make primary care providers feel more comfortable in making what we often call a safe or accurate diagnosis of IBS. Oftentimes, people, which I understand, are concerned about making that diagnosis for fear that they may miss something. I think that impacts primary care practices, I think that certainly increases burden of referrals to gastroenterology colleagues, so our goal really is to present the burden of illness, to present the impact of illness, and then go through some key evidence-based diagnostic provisions from the Rome criteria, and, and then obviously treatment that can be started in primary care with, like Dr Eswaran said, really goals on when to refer.
C360: What do you feel the most important takeaways for clinicians in practice will be from this presentation?
Dr Eswaran: For me in particular, like Dr. Heidelbaugh said, knowing how to make that diagnosis with confidence, and being okay with sometimes some of the unknowns surrounding that. Really, irritable bowel syndrome and chronic constipation is not a GI-specific condition, it's really a primary care diagnosis and condition that I would say 50-75% of those of patients with that illness can be managed very successfully in the primary care setting. There's certainly a role for the moderate to severe population for GI to see them. But really what I'm doing in my clinic is no different, than what someone with the right knowledge can do in their own clinic, as a primary care clinician. And so, I think that is what I hope that attendees will take away from that.
Dr Heidelbaugh: I never like saying that patients with IBS or chronic constipation are complex patients or complicated patients. I try to not say that. What we often say is these patients deserve a lot of time. They deserve the time to be able to offer reassurance that we can help them symptomatically. Certainly in the primary care world, we have big agendas in our visits. It's rare that somebody's going to come in and have one issue. These things take a lot of time and deserve a lot of time, not only for initial diagnosis, but for also for follow-up. I think we also still live in a world where IBS is really thought of as a diagnosis of exclusion, and so if we can make one really key point here, is that there are diagnostic criteria, and people can fit into this criteria, or people may fit out of this criteria, but that's going to help you guide appropriate treatment.
C360: Obviously this is a broad topic, but what gaps in knowledge or opportunities for future research do you feel still remain in this topic?
Dr Eswaran: That's a great question. I think that given how prevalent the disease is, there is always a lot more to be done. It’s interesting because IBS has many, many different I causes or drivers for their symptoms, and it's really different for each patient. And so in some patients, it might be more like medication-induced, or diet-induced, or stress, anxiety, etcetera. But not all patients have that same driver. And so for me, what I think would be really interesting is, let's try to figure out if there's some sort of way to see what one individual patient's main cause for their symptoms is, and then be able to direct their care more to in that way.
For example, if I could say, “Oh, this patient has more dietary drivers of their symptoms, perhaps,” we would focus initially on that, versus medication, because every patient is going to respond differently, and we just don't understand why some patients respond to one treatment versus the other. Sometimes it's often a combination of multiple therapeutic endeavors before you figure out what’s going to benefit that patient.
Dr Heidelbaugh: And I would add a couple things to that. Obviously, I agree completely with everything Dr. Eswaran said. In primary care, we see a lot of people who have symptoms that aren't necessarily related to the GI tract. However, there's a big interplay between chronic pelvic pain, mood. We'll make the disclaimer that this is not all mood-driven. I think we've moved beyond understanding that IBS equals depression and anxiety, certainly sometimes, but one can cause the other. We see a lot of patients with chronic pain, we see a lot of patients with urinary issues, gynecologic issues, a lot of other, outside of GI system issues that have a lot of interplay, and so I think, especially through the cases that we've put together, we can talk about some of this and talk about good strategies.
I would add that we're going to talk about a lot of different treatment paradigms. And sometimes in primary care, it can certainly be intimidating when you hear new drugs, new classes of drugs, you may or may not have any familiarity with using them. In primary care, I always say that we see a lot of patients who are on a lot of medications that we may not prescribe, but we need to know about them, we need to know how they work, we need to know if they're working, etcetera. But I think many of them probably could be used in primary care in the right situations. And then, of course, I'm gonna say, like I always say in primary care, the most important thing is communication with patients, but also communication with our subspecialty colleagues, because we don't take care of these patients in silos, we communicate a lot, because it's a team-based approach.
Shanti Eswaran, MD, is a clinical professor of gastroenterology and internal medicine at the University of Michigan. She specializes in celiac disease, irritable bowel syndrome, diseases of gut-brain interaction, peptic ulcer disease, gastrointestinal bleeding, constipation, and pelvic floor disorders. Dr Eswaran is board certified in gastroenterology and is a member of the American College of Gastroenterology and the American Gastroenterology Association. (Ann Arbor, MI)
Joel Heidelbaugh, MD, is a professor in the department of family medicine at the University of Michigan. He has practiced the full scope of family medicine for nearly 24 years, with a focus on preventive care, acute and chronic disease management, and dermatologic procedures. His research interests include men’s health, gastroenterology, medical student education, and cost-effective care delivery. He is also a member of the Institute for Healthcare Policy and Innovation. (Ann Arbor, MI)