Dr. Charnoff raises interesting questions regarding the incidence of hospitalization and surgery in patients with the irritable bowel syndrome. Our study was not designed to address these issues directly [1], but we are pleased to respond in more general terms and to correct any misinterpretations.

First, our study did elaborate on these data as they relate to the physician-patient interaction. We found no association between the number of either general or abdominal surgeries and the strength of the physician-patient relationship. A significant association was noted, however, between our scoring of the physician-patient interaction and the number of hospitalizations (a weaker interaction was related to more hospitalizations over time).

Second, although surgeries done in 100 of 112 patients included appendectomy, hysterectomy, cholecystectomy, and laparotomy, these groups were neither all-inclusive (that is, these were only the most common or relevant procedures done) nor mutually exclusive (overlap existed among groups). Other procedures included hemorrhoidectomy (17 patients) and polypectomy (5 patients), as well as other miscellaneous surgeries (orthopedic, cardiovascular, periodontal, and dermatologic) over the 32-year study span. As an anecdotal example, one patient had 10 surgeries (8 periodontal, 1 basal cell carcinoma, and 1 squamous cell carcinoma) but no return visits for symptoms related to the irritable bowel syndrome. We do not view the numbers of hospitalizations (median, 3), total number of surgeries (median, 3), or number of gastrointestinal surgeries (median, 0) to be excessive, given the duration of the study. Moreover, the surgeries listed above had indications other than nonspecific abdominal pain.

Third, the aim of our study was to follow a cohort of patients with confirmed irritable bowel syndrome according to current criteria, recognizing that definitions have evolved over time [1, 2]. Great care was taken to exclude patients who did not meet current diagnostic criteria. These included 5 patients whose symptoms disappeared after cholecystectomy and 3 patients whose diagnoses were superseded within 4 months by colon cancer or colonic infarction. These cases might legitimately be considered misdiagnoses. As discussed, organic diseases developed in 10 patients, but long enough (median, 15 years) after the diagnosis of the irritable bowel syndrome to reasonably exclude their contribution to symptoms of the syndrome.

Finally, we agree that it would be interesting to view our data in comparison with a matched control group, although it may be difficult to select an appropriate group to follow over the same 32 years. A more appropriate comparison might be made against the general population, in light of the many people in the community with symptoms resembling those of the irritable bowel syndrome who are never examined by a physician [3-5]. On the other hand, health care-seeking behavior is increased among patients with the syndrome [5], and this may ultimately result in more hospitalizations or surgeries.