Irritable Bowel SyndromeIrritable Bowel SyndromeSam ThomsonSam Thomson

33rdrd November 2010 November 2010

NICE Guideline 61NICE Guideline 61

• Diagnosis and management of IBS in Diagnosis and management of IBS in primary care.primary care.

• Issue Date: February 2008Issue Date: February 2008

IBSIBS• Very Common GI disorderVery Common GI disorder• Prevalence 10-20% (estimated)Prevalence 10-20% (estimated)• Presentation with wide range of Presentation with wide range of

symptoms, which may overlap with symptoms, which may overlap with other GI disordersother GI disorders

Initial PresentationInitial PresentationFollowing symptoms for at least 6 Following symptoms for at least 6

months:months:• AAbdominal pain or discomfortbdominal pain or discomfort• BBloatingloating• CChange in bowel habithange in bowel habit

Positive Diagnostic Criteria for Positive Diagnostic Criteria for IBSIBS• Any thoughts?Any thoughts?

Positive Diagnostic Criteria for Positive Diagnostic Criteria for IBSIBSAbdominal pain or discomfort that is:Abdominal pain or discomfort that is:

• Relieved by defaecationRelieved by defaecationOrOr• Associated with altered bowel Associated with altered bowel

frequency of stool formfrequency of stool form

Positive Diagnostic Criteria for Positive Diagnostic Criteria for IBSIBSAND at least 2 of the following:AND at least 2 of the following:• Altered stool passage (straining, Altered stool passage (straining,

urgency, incomplete evacuationurgency, incomplete evacuation• Abdominal bloating (more common Abdominal bloating (more common

in women than men), distension, in women than men), distension, tension or hardnesstension or hardness

• Symptoms made worse by eatingSymptoms made worse by eating• Passage of mucusPassage of mucus

Positive Diagnostic Criteria for Positive Diagnostic Criteria for IBSIBS• Lethargy, nausea, backache and Lethargy, nausea, backache and

bladder symptoms may be used to bladder symptoms may be used to support diagnosissupport diagnosis

InvestigationsInvestigations

• In people who meet the diagnostic In people who meet the diagnostic criteria to exclude other diagnosescriteria to exclude other diagnoses

InvestigationsInvestigations• FBCFBC• ESR or Plasma ViscosityESR or Plasma Viscosity• CRPCRP• Coeliac screen (Endomysial Coeliac screen (Endomysial

antibodies (EMA) or Tissue antibodies (EMA) or Tissue transglutaminase (TTG))transglutaminase (TTG))

Do not do these tests to confirm Do not do these tests to confirm IBSIBS• USSUSS• Rigid/flexible sigmoidoscopyRigid/flexible sigmoidoscopy• Colonoscopy; barium enemaColonoscopy; barium enema• TFTTFT• Faecal ova and parasite testFaecal ova and parasite test• FOBFOB• Hydrogen breath test (for lactose Hydrogen breath test (for lactose

intolerance and bacterial overgrowth)intolerance and bacterial overgrowth)

Lifestyle AdviceLifestyle Advice• Provide info about self help covering Provide info about self help covering

lifestyle, physical activity, diet and lifestyle, physical activity, diet and symptom targeted medicationsymptom targeted medication

• Encourage to identify and make most Encourage to identify and make most of leisure time and to create relaxation of leisure time and to create relaxation timetime

• Assess physical activity levels, ideally Assess physical activity levels, ideally using the General Practice Physical using the General Practice Physical Activity Questionnaire (GPPAQ) –if low Activity Questionnaire (GPPAQ) –if low level, counsel to increase activitylevel, counsel to increase activity

Lifestyle AdviceLifestyle Advice• If patient wants to try probiotics, If patient wants to try probiotics,

advise to take dose recommended by advise to take dose recommended by manufacturer for at least 4 weeks manufacturer for at least 4 weeks while monitoring effectwhile monitoring effect

• Discourage use of aloe veraDiscourage use of aloe vera

General Dietary AdviceGeneral Dietary Advice• Regular meals, take time to eatRegular meals, take time to eat• Avoid missing meals or leaving long Avoid missing meals or leaving long

gaps between eatinggaps between eating• Drink at least 8 cups of fluid a dayDrink at least 8 cups of fluid a day• Restrict tea and coffee to 3 cups a dayRestrict tea and coffee to 3 cups a day• Reduce intake of alcohol and fizzy drinksReduce intake of alcohol and fizzy drinks• Limit fresh fruit to 3 portions (of 80g Limit fresh fruit to 3 portions (of 80g

each) per dayeach) per day

General Dietary AdviceGeneral Dietary Advice• Consider limiting high fibre food e.g Consider limiting high fibre food e.g

wholemeal, brown ricewholemeal, brown rice• Reduce intake of ‘resistant starch’ (resists Reduce intake of ‘resistant starch’ (resists

digestion in small intestine and reaches digestion in small intestine and reaches colon intact), often found in processed or colon intact), often found in processed or re-cooked foodsre-cooked foods

• If diarrhoea avoid sorbitolIf diarrhoea avoid sorbitol• If wind and bloating consider increased If wind and bloating consider increased

intake of oats and linseeds (up to 1 tbs)intake of oats and linseeds (up to 1 tbs)

Dietician ReferralDietician ReferralIf diet a major factor in symptoms and If diet a major factor in symptoms and

dietary/lifestyle advice is being dietary/lifestyle advice is being followed:followed:

• Refer for single food avoidance and Refer for single food avoidance and exclusion dietsexclusion diets

• Only a dietician should supervise Only a dietician should supervise treatmenttreatment

Pharmacological treatmentPharmacological treatmentFirst Line:First Line:• Antispasmodic AgentsAntispasmodic Agents• Consider laxatives for constipation, Consider laxatives for constipation,

but not lactulosebut not lactulose• Offer loperamide for diarrhoeaOffer loperamide for diarrhoea• Advise how to adjust doses of laxative Advise how to adjust doses of laxative

or loperamide according to response, or loperamide according to response, aiming for Bristol Stool type 4aiming for Bristol Stool type 4

Bristol Stool ChartBristol Stool Chart

Second LineSecond Line• Consider TCA for their analgesic effect Consider TCA for their analgesic effect

if 1if 1stst line treatments do not help. line treatments do not help.• Start at low dose (5-10mg Amitriptyline Start at low dose (5-10mg Amitriptyline

nocte), review regularly, increasing if nocte), review regularly, increasing if required but not normally above 30mgrequired but not normally above 30mg

• Consider SSRI if TCA ineffectiveConsider SSRI if TCA ineffective• Follow up recommended after 4 weeks Follow up recommended after 4 weeks

then every 6-12 monthsthen every 6-12 months

Psychological InterventionsPsychological InterventionsFor those who do not respond after 12 For those who do not respond after 12

months, consider referral for:months, consider referral for:• CBTCBT• HypnotherapyHypnotherapy• Psychological TherapyPsychological Therapy

• Do not encourage use of acupuncture Do not encourage use of acupuncture of reflexologyof reflexology

Referral to Secondary CareReferral to Secondary CareRefer people with possible IBS symptoms Refer people with possible IBS symptoms

if any red flag indicators:if any red flag indicators:• Unintentional and unexplained weight Unintentional and unexplained weight

lossloss• Rectal bleedingRectal bleeding• FH of Ca bowel or ovaryFH of Ca bowel or ovary• Change in bowel habit to looser &/or Change in bowel habit to looser &/or

more frequent stools for > 6 weeks if > more frequent stools for > 6 weeks if > 60 years60 years

• Any QuestionsAny Questions