1. Are patients with chronic diseases a new challenge to general practice? Patients with irritable bowel syndrome in general practice Patients with irritable bowel syndrome (IBS) in general practice Luise Mølenberg Begtrup The Departement of Gastroenterology, Odense University Hospital and Research Unit of General Practice, Institute of Public Health University of Southern Denmark 1 LuiseMølenberg Begtrup lmbegtrup@health.sdu.dk

2. Are patients with chronic diseases a new challenge to general practice? Patients with irritable bowel syndrome in general practice LuiseMølenberg Begtrup lmbegtrup@health.sdu.dk 2 ”How do we distinguish between the majority of people suffering from IBS and the minority of people suffering from organic disease” Colorectal cancer Inflammatory bowel disease Celiac sprue Lactose intolerance IBS - patients ”Where´s Wally”

3. Are patients with chronic diseases a new challenge to general practice? Patients with irritable bowel syndrome in general practice Diagnosis of exclusion Positive diagnosis LuiseMølenberg Begtrup lmbegtrup@health.sdu.dk 6 Diagnosis of a condition with no objective findings

4. Are patients with chronic diseases a new challenge to general practice? Patients with irritable bowel syndrome in general practice CRITERIA for DIAGNOSIS OF IBS Recurrent abdominal pain or discomfort associated with two or more of the following: 1)Improvement with defecation 2)Onset associated with change in frequency of stool 3)Onset associated with change in form (appearance) of stool Duration more than 3 months, onset more than 6 month ago. Frequency of symptoms: at least 3 days / month Rome III critea (2006) 4 LuiseMølenberg Begtrup lmbegtrup@health.sdu.dk

5. Are patients with chronic diseases a new challenge to general practice? Patients with irritable bowel syndrome in general practice A Positive diagnosis……. IBS criteria fulfilled 1.Age < 50 years 2.Alarm features 3.Physical examination 4.FBC, CRP, (screening for celiac sprue) NICE-guidelines 2008, AGA 2002, Clinical Services Committee of The British society of Gatroenterology 2007 LuiseMølenberg Begtrup lmbegtrup@health.sdu.dk 5

6. Are patients with chronic diseases a new challenge to general practice? Patients with irritable bowel syndrome in general practice Diagnosis of exclusion Positive diagnosis LuiseMølenberg Begtrup lmbegtrup@health.sdu.dk 6

7. Are patients with chronic diseases a new challenge to general practice? Patients with irritable bowel syndrome in general practice Diagnosis of exclusion Symptoms mimic symptoms of CRC and IBD The one young patient with cancer despite no alarm features Reassurance Patient´s wish / demand Positive diagnosis Diagnostic criteria + no alarm features has a positive predictive value = 98-100 % Vanner SJ, et al. AJG 1999 Pretest probability for organic disease < 1 % in patients meeting the criteria Cash et al. AJG 2002 1 : 1000 → perforation of the intestine 1 : 10.000 dies – when having diagnostic colonoscopy Anderson ML et. al. AJG 2000 LuiseMølenberg Begtrup lmbegtrup@health.sdu.dk 7 ”repeated testing suggests an unconfident doctor or a patient with persistent fears of organic disease, perhaps one fostering the other” Thompsom et al. GUT 2002

8. Are patients with chronic diseases a new challenge to general practice? Patients with irritable bowel syndrome in general practice If we suspect Irritabel bowel syndrome (IBS), only few investigations may be necessary. We cannot cure the IBS patients, but we can help them. LuiseMølenberg Begtrup lmbegtrup@health.sdu.dk 8

9. Are patients with chronic diseases a new challenge to general practice? Patients with irritable bowel syndrome in general practice Owens, D. M. et. al. Ann Intern Med 1995;122:107-112 IBS patient return visits compared with Phycisian-patient interaction

10. Are patients with chronic diseases a new challenge to general practice? Patients with irritable bowel syndrome in general practice Phycisian-patient interaction Psychosocial history Precipitating factors Involving the patient in the discussion of diagnosis and treatment Owens, D. M. et. al. Ann Intern Med 1995;122:107-112 LuiseMølenberg Begtrup lmbegtrup@health.sdu.dk 10

11. Are patients with chronic diseases a new challenge to general practice? Patients with irritable bowel syndrome in general practice Psychological THERAPY ANTIDEPRESSANTSSYMPTOMATIC MEDICAL TREATMENTLIFESTYLE MODIFICATION PROBIOTICS

12. Are patients with chronic diseases a new challenge to general practice? Patients with irritable bowel syndrome in general practice If we suspect irritabel bowel syndrome (IBS), only few investigations may be necessary. We cannot cure the IBS patients, but we can help them. LuiseMølenberg Begtrup lmbegtrup@health.sdu.dk 12