IBS Flashcards
Symptoms:
- Abdominal pain or discomfort
- Bloating
- Change in bowel habit
Cautions and when to refer:
• Children • Older adult (over 45 years old) presenting with symptoms for the first time • Loss of appetite • Fever • Nausea and vomiting • Rectal bleeding may indicate inflammatory bowel disease, gastric ulcer or gastric carcinoma • Weight loss
Treatment
• Antispasmodics (e.g. alverine citrate, mebeverine, peppermint oil) work by
relaxing the smooth muscle in the gut, thereby reducing abdominal pain.
Symptomatic relief should be achieved within a few days
• Antimuscarinics (e.g. hyoscine, dicycloverine) also relax smooth muscle
spasm
• Bulking agents (e.g. ispaghula, see Constipation chapter) may help some
patients
Commonly used OTC preparations:
Colofac, Colpermin, Buscopan, Kolanticon
Counselling points:
Symptoms can be prevented by minimising certain foods and additives including
caffeine, alcohol, dairy products and artificial sweeteners.
What age does IBS affect
- IBS usually affects people under the age of 45
- Particular care is required in labelling middle-aged (i.e., over 45 years old) and elderly patients
with IBS when presenting with bowel symptoms for the first time. Such patients are best
referred for further evaluation to eliminate organic bowel disease
Location of pain
Pain from IBS is normally located in the left lower quadrant.
TRIGGER POINTS indicative of referral: IBS
- Blood in the stool: The presence of blood in the
stool is unusual in IBS and
can suggest inflammatory
bowel disease - Fever, Nausea and/or vomiting, Severe abdominal pain: Not usually associated with IBS. Suggests origin of
symptoms from other
abdominal causes - Children under age 16, Patients over age 45 with recent change to bowel habit: IBS is unusual in these age
groups. Refer for further
investigation. - Steatorrhoea: Associated with
malabsorption syndromes
firstline pharmacological intervention for IBS
Antispasmodics are considered first- line pharmacological intervention for IBS, although the evidence base for them is weak; these include mebeverine, alverine, hyoscine and peppermint oil. In addition, bulk-forming and stimulant laxatives can be used to treat constipation-predominant IBS and loperamide for diarrhoea-predominant IBS. Both laxatives and diarrhoeals can be taken on a regular basis using the lowest effective dose.
Hyoscine - age, SE, interactions, patients in which care is exercised, preg + BF
- Age: >6 years
- Common SE: Constipation
and dry mouth - Drug interactions: TCAs,
neuroleptics, antihistamines and disopyramide - Patients in which care
is exercised: Glaucoma, myasthenia
gravis and prostate
enlargement - Preg + BF: Avoid if possible,
although single doses in BF are acceptable
Mebeverine - age, SE, interactions, patients in which care is exercised, preg + BF
- Age: >10 years
- Common SE: None
- Drug interactions: None
- Patients in which care
is exercised: None - Preg + BF: OK
Peppermint oil - age, SE, interactions, patients in which care is exercised, preg + BF
- Age: >15 years
- Common SE: Heartburn
- Drug interactions: None
- Patients in which care
is exercised: None - Preg + BF: OK in pregnancy;
try to avoid in BF as it may reduce milk supply
Alverine - age, SE, interactions, patients in which care is exercised, preg + BF
- Age: >12 years
- Common SE: Rash
- Drug interactions: None
- Patients in which care
is exercised: None - Preg + BF: OK
Dietary advice (taken from NICE CG61)
- Have regular meals and avoid missing meals
- Drink at least eight cups of fluid per day, especially non-caffeinated drinks
- Reduce intake of alcohol and fizzy drinks
- Consider limiting intake of high-fibre food
- Reduce intake of ‘resistant starch’ often found in processed or re-cooked foods
- Limit fresh fruit to 3 portions per day
- People with diarrhoea should avoid sorbitol, an artificial sweetener found in sugar‑free sweets (including chewing gum) and drinks, and in some diabetic and slimming products.
- People with wind and bloating may find it helpful to eat oats (such as oat‑based breakfast cereal or porridge) and linseeds (up to 1 tablespoon per day).
Hyoscine butylbromide (Buscopan IBS Relief, Buscopan Cramps)
The recommended starting dose for adults is one tablet
three times a day, although this can be increased to two
tablets four times a day if necessary. Buscopan Cramps
can be given to children over the age of 6 (one tablet three
times a day) It is a quaternary derivative of hyoscine,
so it does not readily cross the blood-brain barrier and
therefore sedation is not normally encountered, although
it might cause dry mouth and constipation. Because of
its anticholinergic effects, it is best avoided with other
medicines that also have anticholinergic effects, for ex-
ample, antihistamines, tricyclic antidepressants, neurolep-
tics and disopyramide. It can be given during pregnancy
and breastfeeding but avoided if possible. It should also be
avoided in patients with glaucoma, myasthenia gravis and
prostate enlargement.
Mebeverine (Colofac IBS)
Adults and children over 10 should take one tablet
three times a day, preferably 20 minutes before meals.
Mebeverine is not known to interact with other medicines,
has no cautions in its use and can be given in pregnancy
and breastfeeding although there is a lack of detailed stud-
ies. It is associated with very few side effects although
allergic reactions have been reported.
Alverine (Spasmonal)
Adults and children over 12 years of age should take
one or two capsules three times a day before food.
Like mebeverine, it is not known to interact with other
medicines, has no cautions in its use and can be given
in pregnancy and whilst breastfeeding. It has no interac-
tions with other medicines and can be used by all patient
groups. Rash is the most common side effect, although
nausea, headache, dizziness, itching and allergic reac-
tions have been reported.
Peppermint oil (e.g., Colpermin IBS Relief)
Adults and children over 15 years of age can take pepper-
mint oil. The dosage is one capsule three times a day before
food, which can be increased to two capsules three times
a day in severe symptoms. It often causes heartburn and
rarely allergic rashes have been reported. It is safe to use
in pregnancy but in theory can decrease breast milk pro-
duction. It has no drug interactions and can be used by all
patient groups.
Laxatives should be considered for the treatment of constipation in people with IBS, but people should be discouraged from taking
lactulose.
the first choice of antimotility agent for diarrhoea in people with IBS
Loperamide
second‑line treatment for people with IBS if laxatives, loperamide or antispasmodics have not helped.
Consider TCAs. Start treatment at a low dose (5–10 mg equivalent of amitriptyline), taken once at night, and review regularly. Increase the dose if needed, but not usually beyond 30 mg
- Consider SSRIs for people with IBS only if TCAs are ineffective.
