1. Management of irritable bowel syndrome (IBS) WORKSHOP Dimitris Karanasios

2. Content Knowledge about pathogenesis and diagnosing IBS Strategies for achieving symptoms control Patients’ involvement in IBS self- management

3. PATHOGENESIS – GUIDELINES Pathogenesis of IBS Guidelines for IBS management (NICE, American Gastrenterology Society, ECPCG)

4. A 43-year-old woman attends your practice She complains about pain and discomfort in the abdomen as well as a change in the frequency of her stools. Defecation improved for the last three years but now “it’s not tolerable” as she says. History: –Smoking for 20 years (2p/d) –Does not consume alcohol –A history of major depression on her mother’s side Physical examination: –BP 126/84 mmHg –Weight 68 kg, Height 170 cm, WC 74 cm –No abdominal or rectal masses, bowels sound normal Additional examinations: –Abdominal x-rays, abdomen ultrasound (2 months ago) both normal

5. INDIVIDUAL EXERCISE  Establish the patient’s bowel habit.  Assess the patient’s risk for malignancy, paying attention to possible ‘’red flags.’’  Think of other conditions that could be excluded.  Establish the diagnosis if possible.  Use: IBS guidelines (NICE, American Gastrenterology Society, ECPCG), Rome III diagnostic criteria, Bristol Stool Chart

6. EXAMINATIONS The patient’s condition and common problems Necessary additional examinations when IBS criteria are met Aimless additional examinations

7. IBS EXAMINATIONS (Roma III criteria) RECOMMENDEDNOT RECOMMENDED 1. Full blood count (FBC)1. Ultrasound 2. Erythrocyte sedimentation rate (ESR) or plasma viscosity 2. Rigid/flexible sigmoidoscopy 3. C-reactive protein (CRP)3. Colonoscopy; Barium enema 4. Antibody testing for coeliac disease (endomysial antibodies [EMA] or tissue transglutaminase [TTG]) 4. Hydrogen breath test (for lactose intolerance and bacterial overgrowth) 5. Thyroid function test (TSH) 6. Faecal ova and parasite test 7. Faecal occult blood test

8. GROUP WORK (3 GROUPS) PREPARE A PROGRAM FOR :  Giving information that explains the importance of self-help in effectively managing the patient’s IBS (information on general lifestyle, physical activity, diet and symptom-targeted medication)  Pharmacological therapies (antispasmodic or/and laxatives, tricyclics, SSRIs)  Behavioural and alternative therapies

9. PRESENTATION OF THE PROGRAMS AND DISCUSSION

10. SUMMARY

11. The self-management of IBS ”People with IBS should be given information that explains the importance of self-help in effectively managing their IBS. This should include information on : general lifestyle physical activity diet and symptom-targeted medication.” Diagnosis and management of irritable bowel syndrome in primary care. National Institute for Health and Clinical Excellence (NICE) 2008

12. Pharmacological treatment of IBS ”Decisions about pharmacological management should be based on the nature and severity of symptoms. The recommendations made below assume that the choice of single or combination medication is determined by the predominant symptom(s).’’ Antispasmodic agents Laxatives Tricyclic antidepressants Selective serotonin reuptake inhibitors (SSRIs) Diagnosis and management of irritable bowel syndrome in primary care. National Institute for Health and Clinical Excellence (NICE) 2008

13. Behavioural and alternative therapies in IBS Psychological interventions Referral for cognitive behavioural therapy [CBT], hypnotherapy and/or psychological therapy should be considered for people with IBS who do not respond to pharmacological treatments after 12 months and who develop a continuing symptom profile (described as refractory IBS). Complementary and alternative medicine The use of acupuncture should not be encouraged for the treatment of IBS. The use of reflexology should not be encouraged for the treatment of IBS. Diagnosis and management of irritable bowel syndrome in primary care. National Institute for Health and Clinical Excellence (NICE) 2008

14. The Rome III Diagnostic Criteria* A SYSTEM FOR DIAGNOSING FUNCTIONAL GASTROINTESTINAL DISORDERS BASED ON SYMPTOMS FOR IBS: Recurrent abdominal pain or discomfort** at least 3 days per month over the last 3 months associated with 2 or more of the following: Improvement with defecation Onset associated with a change in frequency of stool Onset associated with a change in form (appearance) of stool * Criteria fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis. ** "Discomfort" means an uncomfortable sensation not described as pain.