IBS

Question 1

What is IBS?

Answer 1

IBS denotes a mixed group of abdominal symptoms for which no organic cause can be found. Most are probably due to disorders of intestinal motility, enhanced visceral perception, or microbial dysbiosis

Question 2

Which condition is associated with IBS?

Answer 2

Fibromyalgia

Question 3

What are symptoms of IBS?

Answer 3

IBS is a syndrome comprising abdominal pain, bloating and altered bowel habit. The pain is colicky and is associated with the bowel movements. It is sub-typed into diarrhoea or constipation predominant.

Other features: urgency; incomplete evacuation; abdominal bloating/distension; mucus PR; worsening of symptoms after food, lethargy, nausea, backache and bladder symptoms

Symptoms are chronic (>6 months), and often exacerbated by stress, menstruation, or gastroenteritis (post-infectious IBS).

Question 4

How is it diagnosed clinically?

Answer 4

Diagnosis is clinical in nature and can be made confidently in most patients using the Rome criteria combined with the absence of alarm symptoms

If the person has abdominal pain or discomfort that is:
- relieved by defaecation, or
- associated with altered bowel frequency or stool form
and at least 2 of the following
- altered stool passage (straining, urgency, incomplete evacuation)
- abdominal bloating, distension, tension or hardness
- symptoms made worse by eating
- passage of mucus

Question 5

What are tests used to help diagnose IBS?

Answer 5

FBC, CRP, ESR
Coeliac Serology - IgA, IgA tissue transglutaminase antibody (tTG) 
Faecal calprotectin
Stool Culture
Dietary History

Question 6

What are the red flag symptoms that mandate an urgent referral to secondary care?

Answer 6

• > 60
• Rectal bleeding
• Anaemia
• Weight loss
• FH of CRC
• Abdominal/rectal mass
• Raised CRP/ESR or faecal calprotectin
• Additionally, in women over 50 with persistent bloating an USS of the ovaries and Ca125 level is mandated to rule out ovarian cancer.

Question 7

What is the management for constipation IBS? (4)

Answer 7

• Food diary to identify triggers
• Regular meals and take time to eat
• Insure adequate water and fibre intake and promote physical activity
• Simple laxatives (senna, ducolax, picloax). If they fail - try prucalopride, linaclotide, or lubiprostone; or self-administered anal irrigation

Question 8

What is the management for diarrhoea IBS? (13)

Answer 8

• Consider limiting intake of high-fibre food
• avoid sorbitol
• food diary
• reduce caffeine intake
• avoid alcohol
• diet therapy - low FODMAP diet.
• Psychological interventions: CBT, hypnotherapy, psychological therapy

Medications:

• anti-spasmodics (mebeverine)
• Bulking agents
• Loperamide
• TCAs (amitryptyline)
• SSRIs
• Eluxadoline

Question 9

What is the management for bloating/colic? (3)

Answer 9

oral antispasmodics: mebeverine 135mg/8h or hyoscine butyl- bromide 10mg/8h (over the counter).

Combination probiotics in sufficient doses (eg VSL#3®) may help flatulence or bloating.

Diets low in fermentable, poorly absorbed saccharides and alcohols may provide benefit (the low FODMAP diet).

Question 10

What is the management of psychological symptoms and visceral hypersensitivity?

Answer 10

emphasize the positive! You have excluded sinister pathology and over time, symptoms tend to improve.

Consider cognitive behavioural therapy, hypnosis, and tricyclics, eg amitriptyline 10–20mg at night

Question 11

According to NICE, when should IBS be considered?

Answer 11

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