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Irritable Bowel Syndrome

Irritable Bowel Syndrome. Sam Thomson 3 rd November 2010. NICE Guideline 61. Diagnosis and management of IBS in primary care. Issue Date: February 2008. IBS. Very Common GI disorder Prevalence 10-20% (estimated)

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Irritable Bowel Syndrome

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  1. Irritable Bowel Syndrome Sam Thomson 3rd November 2010

  2. NICE Guideline 61 • Diagnosis and management of IBS in primary care. • Issue Date: February 2008

  3. IBS • Very Common GI disorder • Prevalence 10-20% (estimated) • Presentation with wide range of symptoms, which may overlap with other GI disorders

  4. Initial Presentation Following symptoms for at least 6 months: • Abdominal pain or discomfort • Bloating • Change in bowel habit

  5. Positive Diagnostic Criteria for IBS • Any thoughts?

  6. Positive Diagnostic Criteria for IBS Abdominal pain or discomfort that is: • Relieved by defaecation Or • Associated with altered bowel frequency of stool form

  7. Positive Diagnostic Criteria for IBS AND at least 2 of the following: • Altered stool passage (straining, urgency, incomplete evacuation • Abdominal bloating (more common in women than men), distension, tension or hardness • Symptoms made worse by eating • Passage of mucus

  8. Positive Diagnostic Criteria for IBS • Lethargy, nausea, backache and bladder symptoms may be used to support diagnosis

  9. Investigations • In people who meet the diagnostic criteria to exclude other diagnoses

  10. Investigations • FBC • ESR or Plasma Viscosity • CRP • Coeliac screen (Endomysial antibodies (EMA) or Tissue transglutaminase (TTG))

  11. Do not do these tests to confirm IBS • USS • Rigid/flexible sigmoidoscopy • Colonoscopy; barium enema • TFT • Faecal ova and parasite test • FOB • Hydrogen breath test (for lactose intolerance and bacterial overgrowth)

  12. Lifestyle Advice • Provide info about self help covering lifestyle, physical activity, diet and symptom targeted medication • Encourage to identify and make most of leisure time and to create relaxation time • Assess physical activity levels, ideally using the General Practice Physical Activity Questionnaire (GPPAQ) –if low level, counsel to increase activity

  13. Lifestyle Advice • If patient wants to try probiotics, advise to take dose recommended by manufacturer for at least 4 weeks while monitoring effect • Discourage use of aloe vera

  14. General Dietary Advice • Regular meals, take time to eat • Avoid missing meals or leaving long gaps between eating • Drink at least 8 cups of fluid a day • Restrict tea and coffee to 3 cups a day • Reduce intake of alcohol and fizzy drinks • Limit fresh fruit to 3 portions (of 80g each) per day

  15. General Dietary Advice • Consider limiting high fibre food e.g wholemeal, brown rice • Reduce intake of ‘resistant starch’ (resists digestion in small intestine and reaches colon intact), often found in processed or re-cooked foods • If diarrhoea avoid sorbitol • If wind and bloating consider increased intake of oats and linseeds (up to 1 tbs)

  16. Dietician Referral If diet a major factor in symptoms and dietary/lifestyle advice is being followed: • Refer for single food avoidance and exclusion diets • Only a dietician should supervise treatment

  17. Pharmacological treatment First Line: • Antispasmodic Agents • Consider laxatives for constipation, but not lactulose • Offer loperamide for diarrhoea • Advise how to adjust doses of laxative or loperamide according to response, aiming for Bristol Stool type 4

  18. Bristol Stool Chart

  19. Second Line • Consider TCA for their analgesic effect if 1st line treatments do not help. • Start at low dose (5-10mg Amitriptyline nocte), review regularly, increasing if required but not normally above 30mg • Consider SSRI if TCA ineffective • Follow up recommended after 4 weeks then every 6-12 months

  20. Psychological Interventions For those who do not respond after 12 months, consider referral for: • CBT • Hypnotherapy • Psychological Therapy • Do not encourage use of acupuncture of reflexology

  21. Referral to Secondary Care Refer people with possible IBS symptoms if any red flag indicators: • Unintentional and unexplained weight loss • Rectal bleeding • FH of Ca bowel or ovary • Change in bowel habit to looser &/or more frequent stools for > 6 weeks if > 60 years

  22. Any Questions

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