2. Irritable Bowel Syndrome Dr Bruce Davies

3. Sept 2001Bruce Davies2 Introduction First described in 1771. 50% of patients present <35 years old. 70% of sufferers are symptom free after 5 years. GPs will diagnose one new case per week. GPs will see 4-5 patients a week with IBS. Point prevalence of 40-50 patients per 2000 patients.

4. Sept 2001Bruce Davies3 What Is IBS? A syndrome. One mans constipation is another mans normality. Cause unknown. 20% seem to start after an episode of gastroenteritis.

5. Sept 2001Bruce Davies4 Diagnostic Criteria Rome 11 Diagnostic criteria. Mannings Criteria.

6. Sept 2001Bruce Davies5 Rome 11 Diagnostic Criteria. At least 12 weeks history, which need not be consecutive in the last 12 months of abdominal discomfort or pain that has 2 or more of the following: –Relieved by defecation. –Onset associated with change in stool frequency. –Onset associated with change in form of the stool.

7. Sept 2001Bruce Davies6 Rome 11 Diagnostic Criteria. Supportive symptoms. –Constipation predominant: one or more of: BO less than 3 times a week. Hard or lumpy stools. Straining during a bowel movement. –Diarrhoea predominant: one or more of: More than 3 bowel movements per day. Loose [mushy] or watery stools. Urgency.

8. Sept 2001Bruce Davies7 Rome 11 Diagnostic Criteria. –General: Feeling of incomplete evacuation. Passing mucus per rectum. Abdominal fullness, bloating or swelling.

9. Sept 2001Bruce Davies8 Mannings Criteria. Three or more features should have been present for at least 6 months: –Pain relieved by defecation. –Pain onset associated with more frequent stools. –Looser stools with pain onset. –Abdominal distension. –Mucus in the stool. –A feeling of incomplete evacuation after defecation.

10. Sept 2001Bruce Davies9 Associated Symptoms In people with IBS in hospital OPD. –25% have depression. –25% have anxiety. Patients with IBS symptoms who do not consult doctors [population surveys] have identical psychological health to general population. In one study 70% of women IBS sufferers have dyspareunia.

11. Sept 2001Bruce Davies10 Associated Symptoms Stressful life events are associated. Compared with controls people with IBS are less well educated and have poorer general health. Women:Men = 3:1.

12. Sept 2001Bruce Davies11 Reasons to Refer Age > 45 years at onset. Family history of bowel cancer. Failure of primary care management. Uncertainty of diagnosis. Abnormality on examination or investigation.

13. Sept 2001Bruce Davies12 Urgent Referral Constant abdominal pain. Constant diarrhoea. Constant distension. Rectal bleeding. Weight loss or malaise.

14. Sept 2001Bruce Davies13 Subtypes Diarrhoea predominant. Constipation predominant. Pain predominant.

15. Sept 2001Bruce Davies14 Differential Diagnosis Inflammatory bowel disease. Cancer. Diverticulosis. Endometriosis. A positive diagnosis, based on Mannings criteria may provoke less anxiety than extensive tests.

16. Sept 2001Bruce Davies15 Examination Results should be normal or non-specific. Abdomen and rectal examination. FBC, CRP. No consensus as to whether FOBs or sigmoidoscopy is needed.

17. Sept 2001Bruce Davies16 Treatment Patients concerns. Explanation. Treatment approaches.

18. Sept 2001Bruce Davies17 Patients Concerns. Usually very concerned about a serious cause for their symptoms. Take time to explore the patients agenda. Remember that investigations may heighten anxiety.

19. Sept 2001Bruce Davies18 Explanation. Must offer a plausible reason for symptoms. Even if cause is unknown, patients require some explanation. Drawing a parallel with baby colic may help. Stress is currently a socially acceptable explanation for many symptoms in life.

20. Sept 2001Bruce Davies19 Treatment Approaches. Placebo effect of up to 70% in all IBS treatments. Treatment should depend on symptom sub-type. Often considerable overlap between sub-groups.

21. Sept 2001Bruce Davies20 Antidepressants Poor evidence for efficacy. Better evidence for tricyclics. Very little evidence for SSRIs.

22. Sept 2001Bruce Davies21 Diarrhoea Predominant. Increasing dietary fibre is sensible advice. Fibre varies, 55% of patients will get worse with bran. Medical fibre adds to placebo effect. Loperamide may help.

23. Sept 2001Bruce Davies22 Constipation Predominant. Increased fibre. Osmotic laxatives helpful. Ispaghula husk is one. Stimulant laxatives make symptoms worse. Lactulose may aggravate distension and flatulence.

24. Sept 2001Bruce Davies23 Pain Predominant. Antispasmodics will help 66%. Mebeverine is probably first choice. Hyoscine 10mg qid can be added. Bloating may be helped by peppermint oil. Nausea may require metoclopramide.

25. Sept 2001Bruce Davies24 Diet Dietary manipulation may help. Food intolerance is common food allergy is rare. Relaxation therapies may be useful adjunct.

26. Sept 2001Bruce Davies25 Referral About 15% of patients seen by GPs with IBS are referred. Gastroenterology – Mainly upper GI symptoms. General Surgical – Lower GI symptoms.

27. Sept 2001Bruce Davies26 Self-help IBS network, St Johns House, Hither Green Hospital, Hither Green Lane, London SE13 6RU

28. Sept 2001Bruce Davies27 Audit? Numbers on repeat prescription for anti- spasmodics. Do they use their drugs as prescribed? What other medications do they use? Referral rates? What investigations are done? Protocol? Formulary?

29. Sept 2001Bruce Davies28 Psychological Thoughts Should a mental health assessment always be done? Should all therapy be directed at psychological causes? Is IBS a physical or a somatisation disorder?