Irritable Bowel Syndrome

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Presentation Transcript

Irritable Bowel Syndrome: 

Irritable Bowel Syndrome Dr Bruce Davies

Introduction: 

Introduction First described in 1771. 50% of patients present <35 years old. 70% of sufferers are symptom free after 5 years. GPs will diagnose one new case per week. GPs will see 4-5 patients a week with IBS. Point prevalence of 40-50 patients per 2000 patients.

What Is IBS?: 

What Is IBS? A syndrome. One man’s constipation is another man’s normality. Cause unknown. 20% seem to start after an episode of gastroenteritis.

Diagnostic Criteria: 

Diagnostic Criteria Rome 11 Diagnostic criteria. Manning’s Criteria.

Rome 11 Diagnostic Criteria.: 

Rome 11 Diagnostic Criteria. At least 12 weeks history, which need not be consecutive in the last 12 months of abdominal discomfort or pain that has 2 or more of the following: Relieved by defecation. Onset associated with change in stool frequency. Onset associated with change in form of the stool.

Rome 11 Diagnostic Criteria.: 

Rome 11 Diagnostic Criteria. Supportive symptoms. Constipation predominant: one or more of: BO less than 3 times a week. Hard or lumpy stools. Straining during a bowel movement. Diarrhoea predominant: one or more of: More than 3 bowel movements per day. Loose [mushy] or watery stools. Urgency.

Rome 11 Diagnostic Criteria.: 

Rome 11 Diagnostic Criteria. General: Feeling of incomplete evacuation. Passing mucus per rectum. Abdominal fullness, bloating or swelling.

Manning’s Criteria.: 

Manning’s Criteria. Three or more features should have been present for at least 6 months: Pain relieved by defecation. Pain onset associated with more frequent stools. Looser stools with pain onset. Abdominal distension. Mucus in the stool. A feeling of incomplete evacuation after defecation.

Associated Symptoms: 

Associated Symptoms In people with IBS in hospital OPD. 25% have depression. 25% have anxiety. Patients with IBS symptoms who do not consult doctors [population surveys] have identical psychological health to general population. In one study 70% of women IBS sufferers have dyspareunia.

Associated Symptoms: 

Associated Symptoms Stressful life events are associated. Compared with controls people with IBS are less well educated and have poorer general health. Women:Men = 3:1.

Reasons to Refer: 

Reasons to Refer Age > 45 years at onset. Family history of bowel cancer. Failure of primary care management. Uncertainty of diagnosis. Abnormality on examination or investigation.

Urgent Referral: 

Urgent Referral Constant abdominal pain. Constant diarrhoea. Constant distension. Rectal bleeding. Weight loss or malaise.

Subtypes: 

Subtypes Diarrhoea predominant. Constipation predominant. Pain predominant.

Differential Diagnosis: 

Differential Diagnosis Inflammatory bowel disease. Cancer. Diverticulosis. Endometriosis. A positive diagnosis, based on Manning’s criteria may provoke less anxiety than extensive tests.

Examination: 

Examination Results should be normal or non-specific. Abdomen and rectal examination. FBC, CRP. No consensus as to whether FOBs or sigmoidoscopy is needed.

Treatment: 

Treatment Patients’ concerns. Explanation. Treatment approaches.

Patients’ Concerns.: 

Patients’ Concerns. Usually very concerned about a serious cause for their symptoms. Take time to explore the patients agenda. Remember that investigations may heighten anxiety.

Explanation.: 

Explanation. Must offer a plausible reason for symptoms. Even if cause is unknown, patients require some explanation. Drawing a parallel with baby colic may help. Stress is currently a socially acceptable explanation for many symptoms in life.

Treatment Approaches.: 

Treatment Approaches. Placebo effect of up to 70% in all IBS treatments. Treatment should depend on symptom sub-type. Often considerable overlap between sub-groups.

Antidepressants: 

Antidepressants Poor evidence for efficacy. Better evidence for tricyclics. Very little evidence for SSRIs.

Diarrhoea Predominant.: 

Diarrhoea Predominant. Increasing dietary fibre is sensible advice. Fibre varies, 55% of patients will get worse with bran. “Medical fibre” adds to placebo effect. Loperamide may help.

Constipation Predominant.: 

Constipation Predominant. Increased fibre. Osmotic laxatives helpful. Ispaghula husk is one. Stimulant laxatives make symptoms worse. Lactulose may aggravate distension and flatulence.

Pain Predominant.: 

Pain Predominant. Antispasmodics will help 66%. Mebeverine is probably first choice. Hyoscine 10mg qid can be added. Bloating may be helped by peppermint oil. Nausea may require metoclopramide.

Diet: 

Diet Dietary manipulation may help. Food intolerance is common food allergy is rare. Relaxation therapies may be useful adjunct.

Referral: 

Referral About 15% of patients seen by GPs with IBS are referred. Gastroenterology – Mainly upper GI symptoms. General Surgical – Lower GI symptoms.

Self-help: 

Self-help IBS network, St John’s House, Hither Green Hospital, Hither Green Lane, London SE13 6RU

Audit?: 

Audit? Numbers on repeat prescription for anti-spasmodics. Do they use their drugs as prescribed? What other medications do they use? Referral rates? What investigations are done? Protocol? Formulary?

Psychological Thoughts: 

Psychological Thoughts Should a mental health assessment always be done? Should all therapy be directed at psychological causes? Is IBS a physical or a somatisation disorder?

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