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Diagnosis and management of irritable bowel syndrome in general practice
Clinical Lecturer in General Practice, Department of Primary Care, University of Southampton School of Medicine, UK
E-mail: hae1{at}soton.ac.uk
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Abstract |
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 TOP Abstract The GP curriculum and...Definition of IBSAetiology and natural history...History, examination and...ManagementReferral to specialist servicesReferences |
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Irritable bowel syndrome (IBS) is one of the commonest causes of gastrointestinal (GI) consultations in primary and secondary care—it accounts for approximately 3% of all GP consultations. IBS has a prevalence of between 10% and 20%; however, most people (75%) never consult a GP. It is a relapsing and remitting condition and those who do present to general practice have a wide range of symptoms including abdominal pain, bloating, change in bowel habit, fatigue, nausea, backache and bladder symptoms. IBS symptoms can be distressing, leading to time off work, reduced social functioning and a reduced quality of life. This article will outline the key aspects of diagnosing and managing IBS in general practice including highlighting the new NICE guidelines for the diagnosis and management of IBS in adults (published February 2008).
The GP curriculum statement 15.2 outlines GPs roles and responsibilities in digestive problems. It states that GPs in training must:
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Definition of IBS |
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TOPAbstractThe GP curriculum and...Definition of IBSAetiology and natural history...History, examination and...ManagementReferral to specialist servicesReferences |
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IBS is diagnosed on clinical grounds. There is no single test or investigation that can provide a positive diagnosis. Diagnostic criteria have been developed and refined over the years to try and enable a positive diagnosis and exclude other conditions. The first set of diagnostic criteria were described by Manning and his colleagues in the 1970s and defined IBS as characterized by pain relieved by defecation, more frequent stools at the onset of pain, looser stools at the onset of pain, visible abdominal distension, passage of mucus per rectum and a sense of incomplete evacuation. Since that time, various working parties have elaborated the criteria, the Rome I criteria were published in 1990, Rome II in 1999 and the Rome III criteria in 2006. Below are listed the NICE criteria for IBS.
NICE describes the Positive diagnostic criteria for IBS as:
- Abdominal pain or discomfort that is:
- relieved by defecation or;
- is associated with altered bowel frequency or stool form and at least two 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
- relieved by defecation or;
They also state that lethargy, nausea, backache and bladder symptoms may be used to support the diagnosis.
Thus, there are several currently used criteria for the diagnosis of IBS that have similar but different components. Patients fulfilling any of these criteria should be considered to have IBS. The main symptoms patients experience with IBS varies from patient to patient and can vary with time. There are three categories of predominant symptoms: a third of patients tend to have constipation predominant IBS (IBS-C), a third have diarrhoea predominant IBS (IBS-D) and a third have alternating diarrhoea and constipation symptoms (IBS-M). Different management strategies can be tried preferentially depending on the predominant symptom.
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Aetiology and natural history of IBS |
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TOPAbstractThe GP curriculum and...Definition of IBSAetiology and natural history...History, examination and...ManagementReferral to specialist servicesReferences |
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IBS prevalence peaks in the third and fourth decades of life and it is more common in females. There is approximately a 2 : 1 female to male ratio in younger patients (though this is less apparent in older patients). IBS is found in all countries with fairly similar prevalence. IBS symptoms tend to be longstanding with more than 50% still having symptoms 7 years after diagnosis. Ongoing life stresses and length of history are features that indicate a poor chance of recovery. Fortunately, IBS has not been shown to be associated with the development of any serious disease; however, it can have a significant impact on quality of life.
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There is a familial tendency in IBS, with first degree relatives of IBS patients being twice as likely to have IBS as the relative of the IBS patients’ spouse. However, it seems that genetic factors have a minor role and that environmental influences are more important.
The cause of IBS is unknown, though numerous theories have been proposed including alterations in GI motility, visceral hypersensitivity and that it is a response to stress. A small subgroup (approximately 10%) seem to have a post-infective aetiology (i.e. the onset symptoms are related to a bout of gastroenteritis).
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History, examination and investigations |
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TOPAbstractThe GP curriculum and...Definition of IBSAetiology and natural history...History, examination and...ManagementReferral to specialist servicesReferences |
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NICE advises that IBS should be considered if patients present with any of the following symptoms for at least 6 months: Abdominal pain or discomfort, Bloating, Change in bowel habit. The positive diagnostic criteria for IBS should be assessed and ‘red flag’ symptoms or indicators need to be excluded (see Box 1). Examination should include abdominal and rectal examination to look for masses. If there is concern that symptoms suggest ovarian cancer, consider undertaking a pelvic examination. Patients who meet the diagnostic criteria for IBS should have FBC, ESR, CRP and antibody testing for coeliac disease (endomysial antibodies or tissue transglutaminase) to exclude other diagnoses. NICE recommends that other tests such as: ultrasound, sigmoidoscopy, colonoscopy, barium enema, thyroid function tests (TFTs), faecal occult blood testing and hydrogen breath testing (for lactose intolerance and bacterial overgrowth) are not necessary to confirm the diagnosis in patents who meet the IBS diagnostic criteria. However, any red flag symptoms or indications warrant referral to secondary care for further investigation.
Box 1. Red flag symptoms warrant referral to secondary care for further investigations
Red flag indicators warrant referral to secondary care for further investigations
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Management |
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TOPAbstractThe GP curriculum and...Definition of IBSAetiology and natural history...History, examination and...ManagementReferral to specialist servicesReferences |
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Once a positive diagnosis of IBS has been made, it is important to explore any anxieties and concerns that the patient may have and provide verbal and written information on IBS. A good supportive relationship between the patient and doctor is beneficial. An explanation of the importance of self-help measures in managing IBS can help patients take control of their symptoms. Patient information leaflets are available at Patient UK (www.patient.co.uk) and The Gut Trust (formerly called the IBS network)—a self-help group that provides support and advice for people with IBS (www.theguttrust.org.uk). Reassure the patient of the benign nature of IBS—many patients fear serious disease such as cancer—make sure you seek and address these fears. Look for signs of stress, depression or low mood as these may coexist with IBS, exacerbate IBS symptoms and reduce patients’ quality of life and ability to cope with their IBS. Understanding that stress can exacerbate IBS symptoms is very helpful to patients in understanding and coping with the fluctuations in their symptoms.
Advice should be given on general lifestyle, physical activity, diet and medications. NICE advises assessment of the patient's level of physical activity—measurement tools such as the GP Physical Activity Questionnaire can be used—and encouragement of increased activity in those with low activity levels.
Regular follow up (at least annually) should be arranged to assess symptoms and ensure that no red flag symptoms have appeared.
Dietary treatments
Take dietary history. General dietary advice may help reduce symptoms (see Box 2).
Box 2. NICE recommendations on General dietary advice
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Particularly, review fibre intake and advise adjusting this (usually this means reducing) while monitoring the effect on symptoms. Discourage insoluble fibre (e.g. bran) and if an increase in fibre is required, advise soluble fibre, for example isphagula husk or oats. Consider referral to a dietician to discuss exclusion diets if symptoms persist after dietary advice and diet seems to have a significant effect on symptoms (exclusion of lactose, wheat or insoluble fibre can sometimes help but should be supervised by a dietician to maintain a healthy diet). NICE recommends that if the patient would like to try probiotics, advise them to undertake a 4-week trial while monitoring the effect.
Drug therapies
Pharmacological agents can be used individually or in combination to try to alleviate symptoms but should always be used with information, lifestyle and dietary advice. The effect of the currently available drugs is often limited and a large placebo response (up to 40–50%) is often seen in drug trials which complicates interpretation of results from trials. The currently used drugs target relaxation of the smooth muscle of the gut, alteration of gut transit times and alteration of sensation from the gut. The potential options are as follows:
- Antispasmodics, for example mebeverine 135 mg tds, may help abdominal pain by reducing gut contractility after eating. As required (rather than regular) dosing is recommended by NICE.
- Soluble fibre supplements, for example isphagula husk (fybogel) 1 sachet once or twice a day, can accelerate gut transit and may benefit those with constipation symptoms.
- Antidiarrhoeal preparations, for example loperamide, can help urgency and frequency but may aggravate abdominal pain/discomfort. Pre-emptive doses can be used to cover difficult situations (e.g. air travel). Codeine phosphate may cause dependence so should be avoided if possible.
- Antidepressants may help to modulate pain in low doses. NICE recommends that antidepressants can be considered second line for IBS. Tricyclic antidepressants are usually tried first, for example amitriptyline 5–10 mg at night increasing the dose gradually up to 30 mg as needed. selective serotonin reuptake inhibitors (SSRIs), for example fluoxetine, can also show some benefit. The potential side effects of antidepressants should be considered and regular follow up should be undertaken (NICE recommends review 4 weeks after initiating and then every 6–12 months).
5-HT4 receptor agonists (e.g. tegaserod) and 5-HT3 antagonists (e.g. alosetron) have been developed for the treatment of IBS and are licensed in the USA but not licensed in the UK or Europe. They have been shown to improve symptoms but have potential problems such as diarrhoea with the 5-HT4 and constipation with the 5-HT3 and there are concerns regarding rare possible side effects such as bowel ischaemia and increased myocardial infarction (MI) and stroke.
Psychological therapies
NICE recommends considering referral for psychological therapies (cognitive behavioural therapy, hypnotherapy or psychotherapy therapy) in patients with ongoing symptoms that have not responded to pharmacological therapies after 12 months. Unfortunately, the availability of these therapies within the NHS is limited.
However, if services are available, first line use of psychological therapies may be appropriate if anxiety, panic attacks and depression are prominent.
Complementary therapies
NICE does not recommend the use of acupuncture or reflexology for IBS. There is some limited evidence that hypnotherapy may help.
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Referral to specialist services |
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TOPAbstractThe GP curriculum and...Definition of IBSAetiology and natural history...History, examination and...ManagementReferral to specialist servicesReferences |
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You should refer to secondary care for specialist review if red flag signs or symptoms are present (Box 1), there is diagnostic uncertainty, patients’ symptoms fail to respond to management strategies, there is disabling health-related anxiety or longstanding symptoms that significantly impact on quality of life.
Key points
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References |
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TOPAbstractThe GP curriculum and...Definition of IBSAetiology and natural history...History, examination and...ManagementReferral to specialist servicesReferences |
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British Society of Gastroenterology. Guidelines for the management of irritable bowel syndrome. (2007) Accessed via www.bsg.org.uk/pdf_word_docs/man_ibd.pdf [date last accessed 15.04.2008].
NICE. Irritable bowel syndrome in adults: diagnosis and management. (2008) www.nice.org.uk/guidance/index.jsp?action=byID&;o=11927 [date last accessed 15.04.2008].
The Gut Trust. Accessed via www.theguttrust.org.uk.
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