Irritable Bowel Syndrome (IBS)

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1 Irritable Bowel Syndrome (IBS) Dr Rex J Polson 17 th January 2018

2 Overview Description of the condition Discussion of symptoms and investigations that may be required Discussion of management and treatment Questions Please ask if anything is unclear

3 What is IBS? A symptom-based diagnosis characterized by chronic abdominal pain, discomfort, bloating, and alteration of bowel habits. As a functional bowel disorder, IBS has no known organic cause. Although there is no cure for IBS, there are treatments that may relieve symptoms

4 Epidemiology Diagnosis of exclusion vs. disease entity Affects 10-25% of the population. 75% don t seek medical care 50% of GI consults 1/3 diarrhoea 1/3 constipation 1/3 pain predominant symptom 2:1 F:M (4:1 in secondary care) Oscillating course

5 Epidemiology Great effect on QOL Large drain on healthcare and economy Accounts for 20% self certification Average 14.8 sick days vs. 8.7 average 3-4 times more chance of abdominal surgery

6 Symptoms of IBS Pain and discomfort Different parts of the abdomen Variable duration and intensity May vary with eating or opening bowels Bloating Variable degrees Sometimes with wind, gurgling and rumbling

7 Symptoms of IBS Bowel habit Bouts of diarrhoea (IBS-D) Bouts of constipation (IBS-C) Bouts of diarrhoea alternating with constipation Urgency; morning rush Feeling of incomplete emptying Rarely / never have bowel action at night

8 Symptoms of IBS Stools (motions, faeces or poo) Small and pellet-like Watery and ribbon-like Sometimes mixed / streaked with mucus Variable colour and small Passing blood is not a symptoms of IBS (but occasional fresh red blood often from piles, tears and fissures)

9 Bristol Stool Chart

10 Symptoms of IBS Other symptoms which sometimes occur Poor appetite, feeling full after eating Belching, nausea, Heartburn Headache, backache and muscle pains Bladder symptoms (associated irritable bladder) +/- Gynaecological symptoms Fibromyalgia, chronic fatigue syndrome

11 Tests for diagnosis No test confirms the diagnosis of IBS Blood samples to exclude other conditions FBC; for anaemia and inflammation ESR / CRP; for inflammation Antibodies to look for coeliac Consider faecal calprotectin

12 Diagnostic Criteria Manning criteria (1978) Rome IV diagnostic criteria (June 2012) NICE guideline (Feb 2008, revised Apr 2017)

13 Manning Criteria Three or more features should have been present for at least 6 months: 1. Onset of pain linked to more frequent bowel movements 2. Looser stools associated with onset of pain 3. Pain relieved by passage of stool 4. Noticeable abdominal bloating 5. Sensation of incomplete evacuation >25% of the time 6. Diarrhoea with mucus >25% of the time

14 Rome IV Diagnostic Criteria Recurrent abdominal pain (discomfort) at least 1 day/week in last 3 months, with onset at least 6months previously with 2 or more of the following: Related to (improved with) defaecation (Onset) associated with change in stool frequency (Onset) associated with change in form of stool

15 NICE Diagnostic Criteria Consider IBS if person has any of the following symptoms for at least 6months Abdominal pain or discomfort Bloating Change in bowel habit

16 NICE IBS Algorithm red flags Ask for any of red flag indicators; if present consider referral for further investigation Unintentional and unexplained weight loss Rectal bleeding >6weeks Family history of bowel or ovarian cancer Change of bowel habit to looser or more frequent stools for >6weeks in person >60years Anaemia, abdominal or rectal masses

17 Hydrogen breath test (for lactose intolerance / bacterial overgrowth) NICE IBS Algorithm Following tests are usually NOT necessary Ultrasound Rigid / Flexible sigmoidoscopy Colonoscopy / barium enema Thyroid function test Faecal ova and parasite test Faecal occult blood

18 Cause of IBS Cause is not clear Over activity of muscles or sensitivity of nerves of parts of digestive tract. Over activity of messages from gut to and from brain Intolerance to certain foods Plays a part in small number of cases only

19 Cause of IBS Infection and bacteria in the gut 1 in 6 cases follow a bout of gastroenteritis; could this be sensitising or trigger the gut to induce IBS Rifaximin may provide relief for some IBS patients; but Sometimes symptoms worse after antibiotics

20 Differential Diagnosis Inflammatory bowel disease, cancer, coeliac, infections including giardiasis and H.pylori, diverticulosis, endometriosis and bile acid malabsorption. IBS doesn t protect from other illnesses A positive diagnosis, based on diagnostic criteria may provoke less anxiety than extensive tests

21 Associated Symptoms Women : Men = 3:1 Stressful life events are associated Pressure also important Patients with IBS symptoms who do not consult doctors (population surveys) have identical psychological health to general population

22 Associated Symptoms In people with IBS in hospital OPD 25% have depression 25% have anxiety 38% attending a tertiary centre had considered suicide because of hopelessness of any relief from their symptoms

23 Treatment Address an individuals concerns Provide explanation for symptoms Discuss approaches to treatment

24 Possible Concerns Usually concerned about a serious cause for the different symptoms Take time to explore these and the impact they are having on an individual s life Investigations and inappropriate referral and treatment may increase anxiety and worsen symptoms

25 Explanation Offer an understandable reason for symptoms Even when the cause is unknown, some explanation will usually help Seeing a parallel with baby colic may help Pressure and stress are understood to aggravate many symptoms in life

26 Approaches to treatment Importance of self management of symptoms Importance of general lifestyle; e.g. increased physical activity regular exercise Diet Symptom targeted medication

27 Diet Reduce insoluble fibre Bran, wholegrain bread, cereals, nuts and seeds Increase soluble fibre Ispaghula, oats, barley, rye, fruits such as banana and apples, root vegetables such as carrots and potatoes and golden linseed

28 Diet Regular meals at leisurely pace Avoid missing meals, avoid long gaps between meals Drink >8 cups fluid / day; especially water Restrict tea and coffee to up to 3 cups / day Restrict fizzy drinks Don t drink too much alcohol Adjust fibre in diet depending on symptoms Limit fresh fruit to 3 portions (80g) / day

29 Diet For diarrhoea (IBS-D) Avoid sorbitol, artificial sweetener, found in sugar-free sweets (including chewing gum) and drinks, and some diabetic / slimming products. For wind and bloating Increase oats (e.g. porridge) and linseeds

30 Diet Food intolerance is common, food allergy is rare IBS may be aggravated by Wheat (in bread and cereals), rye, barley, dairy products, coffee (and caffeine in tea and cola) and onions. Food diary may help If diet is thought to be a major factor; consider referral to dietician for single food avoidance or exclusion diets e.g. low FODMAP diet

31 Probiotics Probiotics are nutritional supplements that contain good bacteria (that normally live in the gut) and seem to be beneficial. Lactobacillus, bifidobacter

32 Medication Constipation predominant IBS-C Treat with soluble fibre (e.g. Ispaghula) Adequate fluid Regular exercise Bulking or osmotic laxatives e.g. Macrogol (not lactulose) Drugs Prucalopride 5-HT4 receptor agonist in adult women; Lubiprostone ClC chloride channel activator Linaclotide guanylate cyclase agonist (F/U at 3/12) (Elobixibat modulates bile acid recirculation)

33 Medication Diarrhoea predominant IBS-D Treat with soluble fibre (e.g. Ispaghula) Adequate fluid Regular exercise Drugs Loperamide Diphenoxylate, Codeine Eluxadoline mu-opioid receptor agonist (review at 4/52) Bile acid sequestrants, Cholestyramine, colestipol, colesevelam

34 Medication Antispasmodics Peppermint oil Hyoscine Alverine / mebeverine / dicycloverine May ease not cure symptoms Can be used for a week or so; or longer term Timing of doses not crucial

35 Efficacy of therapy Soluble fibre (NNT-11) Antispasmodic will help 66% (NNT-5) Consider hyoscine as first line (NNT-3.5) alverine / dicycloverine / mebeverine Peppermint oil (NNT-2.5) especially bloating Nausea may require metoclopramide

36 Antidepressants Second line treatment when laxatives, loperamide or antispasmodics not helped sufficiently Limited evidence for efficacy; need to be taken regularly and longer term Better evidence for tricyclics; e.g. amitriptyline 5 to 30mg nocte Tricyclics are used to treat pain in other settings Less evidence for SSRI s

37 Psychological Interventions Consider for refractory IBS >12months not responding to other treatment Relaxation therapy, stress counselling Cognitive behavioural therapy (CBT) Hypnotherapy Psychological therapy Important but complex relationship between mind, brain, nerve impulses and over activity of gut

38 Self-help No benefit shown for Reflexology, Acupuncture, Aloe vera and colonic irrigation Diary of symptoms with treatments may help show benefits Self-help groups IBS Network: The Gut Trust:

39 Thank you, any questions?

Irritable bowel syndrome in adults

Irritable bowel syndrome in adults NICE provided the content for this booklet which is independent of any company or product advertised Welcome In February 2008, NICE published a clinical guideline on