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Irritable Bowel Syndrome

 

We have written a patient information leaflet for IBS in Cornwall – HERE

  • The best approach for patients with IBS is to make a confident diagnosis with the least investigation possible then to teach and enable them to self-manage the condition.
  • In this way patients learn control over their condition and we minimise exposure to unpleasant and unnecessary tests which is a win-win
  • Luckily in Cornwall we have county wide coverage with the dietetic and psychological and specialist services that our patients need


CLINICAL CONSIDERATIONS:

Consider IBS in those with:

Abdominal pain (maybe related to defecation)

Bloating

Change in bowel habit (alteration in stool form or frequency)

 

 

The current Rome IV criteria are designed to standardise the diagnosis of IBS for research purposes but are useful as a reference point. 

Rome IV Criteria

 

Recurrent abdominal pain, on average, at least 1 day/week in the last 3 months, associated with two or more of the following criteria:

  • Related to defecation
  • Associated with a change in frequency of stool
  • Associated with a change in form (appearance) of stool.

Criteria fulfilled for the last 3 months with symptom onset at least 6 months before diagnosis.

 

 

Other typical features

Less typical features

Onset under age 45

Onset over age 45

Passage of mucus

Pain at night

Pain related to defecation

Any alarm symptoms

Disordered defecation (straining, urgency, incomplete evacuation)

Right iliac fossa pain

Symptoms worse after eating

Family history of IBD

Diarrhoea or constipation or alternating

Mild blood abnormalities e.g. low ferritin

Sometimes worse at times of stress

 

 

 

SUGGESTED INVESTIGATIONS:

Typical features only:

  • At GPs discretion, consider any of these as clinically indicated:
  • FBC UE LFT BONE TFT CRP GLUCOSE COELIAC STOOL CULTURE

With less typical features

  • As above as clinically indicated
  • Ca125 in women over 50
  • Could be IBD?Send faecal calprotectin if age 18-60- pathway link HERE
  • Could be colon cancer? For “low risk but not no risk” cases send qFIT test in people who DO NOT HAVE RECTAL BLEEDING but are:
  • Over 50 with unexplained abdominal pain or weight loss
  • 50 to 60 with changes in bowel habit or iron-deficiency anaemia
  • 60 or over with anaemia without iron deficiency
  • Further information link HERE (RMS page)

 

You might end up sending calprotectin and qFIT – that’s fine BUT we suggest do the qFIT first since if that’s +ve the calprotectin is reduntant.

 

And, of course, if they fit 2ww criteria then refer as appropriate


Primary care management:


Consultation skills – a strong trusting Dr-patient relationship is needed with acknowledgement of and compassion towards the condition. Remember many IBS patients have worse QOL scores than organic disease. Educate, reassure and explore ideas concerns and expectations


Dietary changes – Patients with symptoms of irritable bowel syndrome (IBS) will be directed to first line advice upon referral to Dietetic department:

Webinar can be found at: https://www.nhs.uk/conditions/irritable-bowel-syndrome-ibs/further-help-and-support/?a=1

Patients will also be signposted to second line advice (should it be required), 'The Low FODMAP Diet' webinar - https://patientwebinars.co.uk/condition/ibs/webinars/

Patients will be supplied with contact details by which to self refer for a Dietetic appointment if:

  • There has been no improvement despite following first and second line advice for a minimum of 8 weeks at each stage
  • Patient has identified a particular FODMAP food causing symptoms or have further concerns
  • Patient is unable to access or interpret digital resources

 

Cognitive interventions – also covered in the patient information leaflet at the top of this page. In summary, the way we think affects the IBS and the IBS affects the way we think  - sometimes in a positive and sometimes in a negative way.  Learning skills like acceptance, self-compassion, relaxation, mindfulness and meditation can put patients back in control.

  • Healthy Outlook is a new service which covers all Cornwall and are part of Outlook Southwest. They provide psychological and emotional support for patients with one of four long term conditions – cardiovascular disease, COPD, diabetes and IBS. Further infomation on this service is available here

 

Medications – some meds help some people whether that’s from a biological effect or placebo.  NNTs are in the region of 3-8. There’s only one way to find out - try them - but STOP if no benefit. Consider:

  • pain – buscopan / colpermin / amitriptyline (off label indication)/ SSRIs (off label indication)
  • diarrhoea – loperamide up to 8 x 2mg capsules per day. If one is too much can titrate using the syrup form
  • constipation – fybogel / laxido not lactulose (ferments producing gas)
  • bloating – Probiotics- Evidence has been published suggesting that probiotics are of benefit in IBS. NICE/BDA recommend a trial period of minimum 4 weeks. Bifidobacteria has been shown to improve symptoms but other products with alternative probiotics are also available . Patients should buy their own probiotics from the supermarket or health food shops, examples include VSL#3® probiotic supplements or Alflorex® Precision Biotics; these products should NOT be prescribed on the NHS.

 

NICE CKS IBS management here

 

Self management skills - The IBS network describe themselves as the “UK’s national charity for IBS”, offering information, advice and support to patients with IBS and working with health care professionals to facilitate IBS self management” (costs £24 to join)?- details on the patient information leaflet


Specialists – there are colorectal surgeons and gastroenterologists at the Royal Cornwall Hospital with expertise in cases of complex IBS but most patients should be helped with the information sheet.


If you are going to refer to secondary care, please:

  • FBC, CRP, U&E, calcium, TSH, coeliac screen and IgA
  • Ca125, calprotectin and qFIT as appropriate
  • Explain what treatments have been tried and for how long
  • Explain your and your patient’s ideas concerns and expectations

 

Reference/Further Reading

https://www.nice.org.uk/guidance/cg61

https://www.theibsnetwork.org/

http://patient.info/doctor/irritable-bowel-syndrome-pro

 

Date Reviewed          03/02/2020

Date Next Review      03/03/2021

Author                        Dr Jim Huddy GPSI gastro

 

Contributors              RMS GP Sifter name Dr Rebecca Harling

Lisa Ledger, Lead Dietician, North East Cornwall Dietetics Team

Dr John Beckly, Consultant Gastroenterologist, Royal Cornwall Hospital

 

Version No.                4.0