Functional Gastrointestinal Disorders

Question 1

What is IBS?

Answer 1

• Denotes a mixed group of abdominal symptoms for which no organic cause can be found

Question 2

What features are required for a positive diagnosis of IBS?

Answer 2

• Abdo pain relieved by defacation or associated with altered bowel frequency stool form, in addition to 2/4 of:
  
  • altered stool passage (straining, urgency, incomplete evacuation)
  • abdo bloating, distension, tension or hardness
  • symptoms made worse by eating
  • passage of mucus
• Lethargy, nausea, backache and bladder symptoms also support diagnosis

Question 3

Which red flag features should be enquired about?

Answer 3

• Rectal bleeding
• Unexplained weight loss
• FHx of bowel or ovarian cancer
• Onset after 60 yrs of age

Question 4

Which investigations should be carried out?

Answer 4

• FBC, ESR, CRP + coeliac serology
• If >60yrs or any organic marker of idsease (blood PR, weight loss) → colonoscopy
• In females, exclude ovarian cancer (CA-125) + endometriosis often mimics IBS

Question 5

The management of irritable bowel syndrome (IBS) is often difficult and varies considerably between patients. Which 3 elements constitute management?

Answer 5

• Diet
• Psychological
• Pharmacological

Question 6

What are first-line pharmacological treatments, according to predominant symptoms?

Answer 6

• Pain → antispasmodics (eg. buscopan / hyoscine butylbromide)
• Constipation → laxatives but avoid lactulose
• Diarrhoea → loperamide 2mg

Question 7

What should be done for patients with constipation who are not responding to conventional laxatives?

Answer 7

• Linaclotide, if:
  
  • optimal or max tolerated doses of prev laxatives from diff classes not helped AND
  • they have had constipation for at least 12 months

Question 8

What is second-line pharmacological treatment?

Answer 8

• Low-dose tricyclic antidepressants (eg. amitriptyline 5-10mg)
• Used in preference to SSRIs

Question 9

What other psychological interventions can help IBS?

Answer 9

• If symptoms don’t respond to pharm treatments after 12 months and who develop continuing symptom profile (refractory IBS), consider referring for:
  
  • cognitive behavioural therapy
  • hypnotherapy
  • psychological therapy

Question 10

What is the general dietary advice for IBS?

Answer 10

• Have regular meals and take time to eat
• Avoid missing meals or leaving long gaps
• Drink 8 cups of fluid/day, esp water and herbal teas
• Restrict tea and coffee → max 3 cups/day
• Reduce intake of alcohol + fizzy drinks
• Consider limiting intake of high-fibre food
• Reduce intake of resistant starch (processed foods)
• Limit fresh fruit to 3 portions/day
• For diarrhoea, avoid sorbitol
• Wind + bloating → increase oats (cereal, porridge) + linseeds