IBS

Question 1

What is IBS?

Answer 1

This is a syndrome (chronic) condition characterised by abdominal pain, bloating and altered bowel habit.

Question 2

How would you describe the pain associated with IBS?

Answer 2

The pain is colicky and is associated with bowel movements.

The pain or discomfort may be relieved by defecation.

Question 3

Sub-types of IBS

Answer 3

Diarrhoea or constipation-predominant.

Question 4

How has the diagnosis of IBS changed?

Answer 4

Positive diagnosis based on patient’s symptoms, exclusion of red flags and simple tests.

Question 5

Which symptoms warrants further investigation in IBS?

Answer 5

Anaemia
Weight loss
Fever

Question 6

Aetiology of IBS

Answer 6

No specific endoscopic, biochemical, anatomic, microbiological findings in IBS.

Question 7

Pathophysiology of IBS

Answer 7

Most evidence suggests that there is dysfunction with the motor and sensory aspects of the digestive tract in people with IBS.

Question 8

Classification of IBS

Answer 8

ROME-IV sub-types IBS based on predominant stool pattern.
IBS-C: Hard or lumpy stools >25% of bowel movements and loose (mushy) or watery stools for < 25% of bowel movements.
IBS with diarrhoea (IBS-D): loose (mushy) or watery stools for ≥25% of bowel movements and hard or lumpy stool for ≤25% of bowel movements.
Mixed IBS (IBS-M): hard or lumpy stools for ≤25% of bowel movements and loose (mushy) or watery stools for ≤25% of bowel movements.
Unspecified IBS: insufficient abnormality of stool consistency to meet criteria for IBS-C, IBS-D, or IBS-M.

Question 9

Signs and symptoms of IBS

Answer 9

Abdominal discomfort 
Changes in bowel habits associated with pain 
Abdominal bloating or distension 
Normal examination of the abdomen
Passage of mucus with stool
Extra-intestinal manifestations: 
Nausea 
Thigh pain 
Backache 
Lethargy 
Urinary symptoms

Question 10

Risk factors of IBS

Answer 10

Physical and sexual abuse 
Age < 50 years
Female sex 
Previous enteric infection 
Family and job stress

Question 11

Investigations of IBS

Answer 11

Stool studies (normal)
FBC (normal)
Anti-endomysial & anti-ETG antibodies (normal, raised in coeliac disease)
Plain abdominal x-ray (normal) - abnormal suggests obstruction
Flexible sigmoidoscopy (normal)- abnormal mucosa suggests IBD
Colonoscopy (normal)- mucosal inflammation or ulceration suggests IBD
Faecal calprotectin (differentiate between IBS & IBD)

Question 12

Differentials of IBS

Answer 12

Crohn's disease 
UC 
Lymphocytic and collagenous colitis 
Coeliac disease 
Colon cancer 
Bowel infections 
Non-coeliac gluten intolerance

Question 13

Management of IBS

Answer 13

The main goal is to decrease the severity of the symptoms and improve quality of life.

Question 14

Management of IBS-C

Answer 14

Without pain or bloating:
Lifestyle and diet (avoid caffeine, lactose or fructose. Add fibre to diet. Lessen stress)
Laxatives- Ispaghula, lactulose
2nd line: Lubiprostone or linaclotide or plecanatide can be used if laxatives are not tolerated
With pain or bloating:
Add antispasmodics PRN: dicycloverine and hyoscyamine (buzcopan) are anticholinergics and peppermint oil is an anti-smooth muscle drug.

Question 15

Management of IBS-D

Answer 15

Without pain or bloating:
Lifestyle and diet (avoid caffeine, lactose or fructose. Add fibre to diet. Lessen stress)
Antidiarrhoeals- loperamide, cholestyramine, alosteron
With pain or bloating:
Add antispasmodics PRN: dicycloverine and hyoscyamine (buzcopan) are anticholinergics and peppermint oil is an anti-smooth muscle drug.

Question 16

Management of IBS with alternating constipation and diarrhoea

Answer 16

Lifestyle modifications
Laxatives
Loperamide
(add antispasmodics for pain or bloating)

Question 17

How should you deal with an IBS patient’s concern?

Answer 17

A dismissive approach is harmful.
Deal with all their concerns.
Explain test results properly (i.e. why it can’t be other GI conditions like IBD)

Question 18

Lifestyle modifications for IBS patients.

Answer 18

Encourage patients to keep food diary and look for any obvious food triggers.
Limit alcohol intake.
Eat 3 regular meals ( don’t eat late at night)
Reduce caffeine
Reduce fizzy drinks, manufactured foods, rich or fatty foods.
Limit fresh fruit to 3 portions per day
Probiotics- not harmful and they may benefit people with IBS (NICE).

Question 19

What is the cornett’s sign?

Answer 19

This is to determine whether pain originates from the viscera or myofascial/abdominal wall.
The patient should lie down and raise their head or legs against gentle resistance from the physician.
The test is positive if this manoeuvre exacerbates pain, which indicates an abdominal wall, as opposed to visceral pain origin.

Question 20

Complications of IBS

Answer 20

Damage to family and work relationships.

Diverticulosis.