Treat primary. symptoms. Offer general lifestyle advice. Manage IBS according to the dominant symptom. Follow up. Symptoms do not improve

Transcription

1 Treat primary symptoms Background information for clinicians Offer general lifestyle advice Background information for patients Manage IBS according to the dominant symptom Provenance Psychological symptoms Constipation and/or diarrhoea Pain Bloating, distension, and flatulence Follow up Symptoms do not improve Consider referral to gastroenterology Page 1 of 5

2 1 Treat primary symptoms Establish patients' most dominant symptom(s) it should be recognised that in some patients the non GI symptoms are the most dominant management is often complex and multimodal both physical and psychological components of the disorder need to be addressed 2 Background information for clinicians Scope of this pathway: diagnosis and management of irritable bowel syndrome (IBS) in adults over age 18 years Key points: IBS is a functional bowel disorder characterised by more than 6 months of recurrent abdominal pain / discomfort which may be relieved by defecation and associated with an alteration in stool form or frequency In the majority of cases IBS can be confidently diagnosed and treated in primary care Prognosis: for most patients with IBS, symptoms are likely to persist although some worsen and some get better Approaches by the physician that positively affect the treatment outcome are: a good doctor-patient relationship acknowledging the disease educating the patient about IBS and exploring ideas, concerns and expectations reassuring the patient 3 Offer general lifestyle advice Diet: British Dietetic Association information here neatly summarises the basic advice: Refer to a dietician before starting single food exclusion diets - either post to dietetics dept, RCH or fax to Physical activity levels: promote Probiotic use available to the public try for 1-2 months, stop if no benefit e.g Activia 4 Background information for patients IBS network here (costs 24 to join) patient.co.uk IBS information here Understanding NICE IBS guidance for patients here British Dietetic Association information here Page 2 of 5

3 6 Provenance Last updated 17th Nov 2011 Authors: Dr J Huddy GPSI gastro Drs Michell, Murray, Hussaini, Dalton, Beckly, Fortun, Stableforth. Consultant Gastroenterologists, Royal Cornwall Hospital, Psychological symptoms Stress and psychological factors are common in IBS patients. Self help / talking therapies and pharmacotherapy (low dose tricyclics / SSRIs) have a solid evidence base 8 Constipation and/or diarrhoea Constipation lifestyle measures - adequate intake of fluids and physical exercise laxatives fybogel or movicol (up to 6 per day) +/- short course stimulant (senna) NOT lactulose advise patients to adjust the dose of laxative according to response the aim is to produce a soft, well-formed stool each day Diarrhoea some patients will be improved with a bulking agent e.g. fybogel antimotility drug: loperamide codeine is second line consider low dose tricyclic antidepressant (TCA) which has a mild constipating and sedative effect e.g. amitriptyline or nortriptyline (which has less side effects) 10mg at night increasing slowly to 50mg depending on response Alternating constipation and diarrhoea: is the most challenging group to treat we suggest a trial and error approach of the above e.g. amitriptyline for it's pain relieving and constipating effect then bulking agents / macrogols as and when constipation occurs 9 Pain If an analgesic is required use paracetamol not NSAIDs or opioids First-line treatments Antispasm - hyoscine (buscopan) or peppermint (colpermin) have the best evidence base Second-line treatment: low dose amitriptyline / nortriptyline 10mg slowly up to 50mg, tend to have a constipating effect SSRIs can produce a softer stool hence are preferable in those prone to constipation 10 Bloating, distension, and flatulence Page 3 of 5

4 Bloating, distension, and flatulence can be challenging to treat: probiotics are worth a try e.g. Activia twice a day for a month adjust dietary fibre as per British Dietetic Association sheet here 12 Symptoms do not improve If symptoms do not respond to first-line treatment, consider a trial of low dose tricyclic SSRI psychological therapies Review patient frequently 13 Consider referral to gastroenterology if the diagnosis is in doubt if there are any alarm or atypical features Be aware that specialists have little to offer over the above recommendations, assuming the diagnosis is sound Page 4 of 5

5 Key Dates Published:, by Valid until: Evidence summary for IBS - management Page 5 of 5