CBL_5 IBS

Question 1

When do we suspect IBS?

Answer 1

The diagnosis of IBS should be considered if the patient has had the following for at least 6 months:

• abdominal pain, and/or
• bloating, and/or
• change in bowel habit

Question 2

What may be presenting complaint in relation to bowel habits in a person with potential IBS?

Answer 2

• incomplete evacuation
• rectal hypersensitivity
• urgency (increased in “diarrhoea‑ predominant IBS”)

Question 3

Features required to make a diagnosis of IBS

Answer 3

A positive diagnosis of IBS should be made if:

• abdominal pain relieved by defecation or associated with altered bowel frequency stool form
• in addition to 2 of the following 4 symptoms:
• 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

Features such as lethargy, nausea, backache and bladder symptoms may also support the diagnosis

Question 4

Red flags to inquire about in suspicion of IBS

Answer 4

Red flag features should be enquired about:

• rectal bleeding
• unexplained/unintentional weight loss
• family history of bowel or ovarian cancer
• onset after 60 years of age

Question 5

Primary care Ix for IBS

Answer 5

Suggested primary care investigations are:

• full blood count
• ESR/CRP
• coeliac disease screen (tissue transglutaminase antibodies)

Question 6

What’s an average diameter of a small bowel?

The diameter of what would indicate a dilation?

Answer 6

Average diameter: 1.5 - 2.5 cm

Dilation: > or = 5 cm

Question 7

What tool is used to describe the faeces?

Answer 7

Question 8

Possible complications of IBS

Answer 8

• dehydration
• lack of sleep
• anxiety and lethargy
• time off work
• avoidance of stressful or social situations
• reduction in quality of life

Question 9

Possible causes of IBS

Answer 9

• Causes of IBS unknown: gut hypersensitivity, disturbed colonic motility, post-infective bowel dysfunction or a defective anti-nociceptive system are possible causes
• Stress commonly aggravates the disorder

Question 10

Criteria for an urgent (2 ww) referral in suspected colorectal ca (4)

Answer 10

• patients >= 40 years with unexplained weight loss AND abdominal pain
• patients >= 50 years with unexplained rectal bleeding
• patients >= 60 years with iron deficiency anaemia OR change in bowel habit
• occult blood in the faeces

Question 11

When to consider an urgent 2ww referral for colorectal Ca (3)?

Answer 11

• rectal or abdominal mass
• there is an unexplained anal mass or anal ulceration
• patients < 50 years with rectal bleeding AND any of the following unexplained symptoms/findings:
• -→ abdominal pain
• -→ change in bowel habit
• -→ weight loss
• -→ iron deficiency anaemia

Question 12

Red flags for colorectal Ca

Answer 12

• Rectal bleeding and looser stool and/or increased frequency of ≥ 3 weeks duration (age 40 and over)
• Rectal bleeding without change in bowel habit with no obvious cause ≥ 3 weeks duration (age 50 years and over)
• Change of bowel habit (tendency to looser stools) persisting for 3 weeks or more without bleeding (age 50 years and over)
• Abdominal mass thought to be large bowel cancer (any age)
• Palpable rectal mass (any age)

Question 13

Red flag anaemia criteria for suspicion of colorectal Ca for men

Answer 13

Males of any age with iron deficiency picture:

• Hb ≤ 11g/100ml
• Ferritin ≤30 mg/dL
• MCV ≤ 79

Question 14

Red flag anaemia criteria for suspicion of colorectal Ca for women

Answer 14

Non menstruating female with iron deficiency picture:

• Hb ≤ 10g/100ml
• Ferritin ≤30 mg/dL
• MCV ≤ 79

Question 15

Ix for IBS in young healthy patient

Answer 15

In people who meet the IBS diagnostic criteria investigate with:

• FBC
• ESR
• CRP
• Antibody testing for coeliac disease; endomysial antibodies (EMA) or tissue transglutaminase (TTG)

Question 16

Management of IBS 1 st step (apart from lifestyle)

Answer 16

• *First-line pharmacological treatment** - according to predominant symptom
• pain: antispasmodic agents
• constipation: laxatives but avoid lactulose
• diarrhoea: loperamide is first-line

For patients with constipation who are not responding to conventional laxatives linaclotide may be considered, if:

• optimal or maximum tolerated doses of previous laxatives from different classes have not helped and
• they have had constipation for at least 12 months

*linaclotide is of guanylate cyclase = C class - new class Rx of constipation

Question 17

Who is offered Faecal Occult blood test as a part of screening?

Answer 17

• every 2 years to all men and women aged 60 to 74 years
• Patients aged over 74 years may request screening.

Question 18

Who can be offered faecal occult blood test (apart from screening)? (3)

Answer 18

In addition FOBT should be offered to:

• patients >= 50 years with unexplained abdominal pain OR weight loss
• patients < 60 years with changes in their bowel habit OR iron deficiency anaemia
• patients >= 60 years who have anaemia even in the absence of iron deficiency

Question 19

2nd line management of IBS

Answer 19

Second-line pharmacological Rx:

• low-dose tricyclic antidepressants
  (e. g. amitriptyline 5-10 mg) are used in preference to selective serotonin reuptake inhibitors

Question 20

Other option in IBS management (if med fails)

Answer 20

• psychological interventions - if symptoms do not respond to pharmacological treatments after 12 months and who develop a continuing symptom profile (refractory IBS), consider referring for cognitive behavioural therapy, hypnotherapy or psychological therapy

Question 21

General diet advice in IBS

Answer 21

• have regular meals and take time to eat
• avoid missing meals or leaving long gaps between eating
• drink at least 8 cups of fluid per day, especially water or other non-caffeinated drinks such as herbal teas
• restrict tea and coffee to 3 cups per day
• reduce intake of alcohol and fizzy drinks
• consider limiting intake of high-fibre food (for example, wholemeal or high-fibre flour and breads, cereals high in bran, and whole grains such as brown rice)
• reduce intake of ‘resistant starch’ often found in processed foods
• limit fresh fruit to 3 portions per day
• for diarrhoea, avoid sorbitol
• for wind and bloating consider increasing intake of oats (for example, oat-based breakfast cereal or porridge) and linseeds (up to one tablespoon per day)

Question 22

How does FODMAP diet work?

Answer 22

• eating/ drinking FODMAPs increases the delivery of readily fermentable substrates and water to the distal small intestine and colon—which results in luminal distention and gas
• reduction of FODMAPs in a patient’s diet may improve functional gastrointestinal symptoms

Question 23

The differential diagnosis for IBS symptoms

• young women
• any age woman
• older women

Answer 23

A. Younger women:

• think pregnancy
• pelvic inflammatory disease
• endometriosis

B. Woman any age:

• chronic pelvic pain

C. Older Women:

Possibly ovarian cancer……

• frequent or persistent bloating in women > 50 usually, feeling full, reduced appetite, pelvic or abdo. pain, increased urgency, frequency of PU.
• >50 with new onset IBS
• symptoms are non- specific

Question 24

Possible symptoms of ovarian ca

Answer 24

• frequent or persistent bloating in women > 50 usually, feeling full, reduced appetite, pelvic or abdo. pain, increased urgency
• >50 with new onset IBS
• symptoms are non- specific