1. Irritable Bowel Syndrome Sam Thomson 3 rd November 2010

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

3. IBS Very Common GI disorder Very Common GI disorder Prevalence 10-20% (estimated) Prevalence 10-20% (estimated) Presentation with wide range of symptoms, which may overlap with other GI disorders 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 Abdominal pain or discomfort Bloating Bloating Change in bowel habit Change in bowel habit

5. Positive Diagnostic Criteria for IBS Any thoughts? Any thoughts?

6. Positive Diagnostic Criteria for IBS Abdominal pain or discomfort that is: Relieved by defaecation Relieved by defaecationOr Associated with altered bowel frequency of stool form 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 Altered stool passage (straining, urgency, incomplete evacuation Abdominal bloating (more common in women than men), distension, tension or hardness Abdominal bloating (more common in women than men), distension, tension or hardness Symptoms made worse by eating Symptoms made worse by eating Passage of mucus Passage of mucus

8. Positive Diagnostic Criteria for IBS Lethargy, nausea, backache and bladder symptoms may be used to support diagnosis 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 In people who meet the diagnostic criteria to exclude other diagnoses

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

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

14. General Dietary Advice Regular meals, take time to eat Regular meals, take time to eat Avoid missing meals or leaving long gaps between eating Avoid missing meals or leaving long gaps between eating Drink at least 8 cups of fluid a day Drink at least 8 cups of fluid a day Restrict tea and coffee to 3 cups a day Restrict tea and coffee to 3 cups a day Reduce intake of alcohol and fizzy drinks Reduce intake of alcohol and fizzy drinks Limit fresh fruit to 3 portions (of 80g each) per day 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 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 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 diarrhoea avoid sorbitol If wind and bloating consider increased intake of oats and linseeds (up to 1 tbs) 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 Refer for single food avoidance and exclusion diets Only a dietician should supervise treatment Only a dietician should supervise treatment

17. Pharmacological treatment First Line: Antispasmodic Agents Antispasmodic Agents Consider laxatives for constipation, but not lactulose Consider laxatives for constipation, but not lactulose Offer loperamide for diarrhoea Offer loperamide for diarrhoea Advise how to adjust doses of laxative or loperamide according to response, aiming for Bristol Stool type 4 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 1 st line treatments do not help. Consider TCA for their analgesic effect if 1 st line treatments do not help. Start at low dose (5-10mg Amitriptyline nocte), review regularly, increasing if required but not normally above 30mg Start at low dose (5-10mg Amitriptyline nocte), review regularly, increasing if required but not normally above 30mg Consider SSRI if TCA ineffective Consider SSRI if TCA ineffective Follow up recommended after 4 weeks then every 6-12 months 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 CBT Hypnotherapy Hypnotherapy Psychological Therapy Psychological Therapy Do not encourage use of acupuncture of reflexology 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 Unintentional and unexplained weight loss Rectal bleeding Rectal bleeding FH of Ca bowel or ovary FH of Ca bowel or ovary Change in bowel habit to looser &/or more frequent stools for > 6 weeks if > 60 years Change in bowel habit to looser &/or more frequent stools for > 6 weeks if > 60 years

22. Any Questions Any Questions