Transcript Irritable Bowel Syndrome

Irritable Bowel Syndrome
Sam Thomson
3rd November 2010
NICE Guideline 61
• Diagnosis and management of IBS in
primary care.
• Issue Date: February 2008
IBS
• Very Common GI disorder
• Prevalence 10-20% (estimated)
• Presentation with wide range of
symptoms, which may overlap with other
GI disorders
Initial Presentation
Following symptoms for at least 6 months:
• Abdominal pain or discomfort
• Bloating
• Change in bowel habit
Positive Diagnostic Criteria for IBS
• Any thoughts?
Positive Diagnostic Criteria for IBS
Abdominal pain or discomfort that is:
• Relieved by defaecation
Or
• Associated with altered bowel frequency
of stool form
Positive Diagnostic Criteria for IBS
AND at least 2 of the following:
• Altered stool passage (straining, urgency,
incomplete evacuation
• Abdominal bloating (more common in
women than men), distension, tension or
hardness
• Symptoms made worse by eating
• Passage of mucus
Positive Diagnostic Criteria for IBS
• Lethargy, nausea, backache and bladder
symptoms may be used to support
diagnosis
Investigations
• In people who meet the diagnostic criteria
to exclude other diagnoses
Investigations
• FBC
• ESR or Plasma Viscosity
• CRP
• Coeliac screen (Endomysial antibodies
(EMA) or Tissue transglutaminase (TTG))
Do not do these tests to confirm IBS
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USS
Rigid/flexible sigmoidoscopy
Colonoscopy; barium enema
TFT
Faecal ova and parasite test
FOB
Hydrogen breath test (for lactose intolerance
and bacterial overgrowth)
Lifestyle Advice
• 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
• Assess physical activity levels, ideally
using the General Practice Physical Activity
Questionnaire (GPPAQ) –if low level,
counsel to increase activity
Lifestyle Advice
• 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
General Dietary Advice
• Regular meals, take time to eat
• Avoid missing meals or leaving long gaps
between eating
• Drink at least 8 cups of fluid a day
• Restrict tea and coffee to 3 cups a day
• Reduce intake of alcohol and fizzy drinks
• Limit fresh fruit to 3 portions (of 80g
each) per day
General Dietary Advice
• Consider limiting high fibre food e.g wholemeal,
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brown rice
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 wind and bloating consider increased intake of
oats and linseeds (up to 1 tbs)
Dietician Referral
If diet a major factor in symptoms and
dietary/lifestyle advice is being followed:
• Refer for single food avoidance and
exclusion diets
• Only a dietician should supervise
treatment
Pharmacological treatment
First Line:
• Antispasmodic Agents
• Consider laxatives for constipation, but not
lactulose
• Offer loperamide for diarrhoea
• Advise how to adjust doses of laxative or
loperamide according to response, aiming
for Bristol Stool type 4
Bristol Stool Chart
Second Line
• Consider TCA for their analgesic effect if
1st line treatments do not help.
• Start at low dose (5-10mg Amitriptyline
nocte), review regularly, increasing if
required but not normally above 30mg
• Consider SSRI if TCA ineffective
• Follow up recommended after 4 weeks
then every 6-12 months
Psychological Interventions
For those who do not respond after 12
months, consider referral for:
• CBT
• Hypnotherapy
• Psychological Therapy
• Do not encourage use of acupuncture of
reflexology
Referral to Secondary Care
Refer people with possible IBS symptoms if
any red flag indicators:
• Unintentional and unexplained weight loss
• Rectal bleeding
• FH of Ca bowel or ovary
• Change in bowel habit to looser &/or more
frequent stools for > 6 weeks if > 60
years
• Any Questions