Irritable bowel syndrome

Question 1

Diagnosis considered

Answer 1

6 months of
- abdominal pain and/or
- bloating and/or
- change in bowel habit

Question 2

Diagnosis made if

Answer 2

Abdo pain relieved by defecation or associated with altered bowel frequency stool storm and 2 of

• altered stool passage (straining, urgency, incomplete evacuation)
• abdominal bloating, distension, tension or hardness
• symptoms made worse by eating
• passage of mucus

Question 3

Red flag features

Answer 3

Rectal bleeding

Unexplained/ unintentional weight loss

Family history of bowel or ovarian cancer

Onset after 60 years

Question 4

Investigations in primary care

Answer 4

FBC

ESR/CRP

Coeliac disease screen

Question 5

First line pharmacological treatment

Answer 5

Pain- antisposmadic agents

Constipation- laxatives (avoid lactulose)

Diarrhoea- loperamide first line

Question 6

Not responding to conventional laxatives

Answer 6

Linaclotide if

• optimal or maximum tolerated doses of previous laxatives from 2 different classes not helped and
• had constipation for 12 months

Question 7

Second line pharmacological treatment

Answer 7

Low dose tricyclic antidepressants (amitriptyline) in preference to SSRIs

Question 8

Other management options

Answer 8

Psychological interventions- if pharmacological not worked after 12 months consider CBT, hypnotherapy, psychological therapy

Complementary and alternative medicines (not acupuncture or reflexology

Question 9

General dietary advice

Answer 9

Regular meals and enough time to eat

Avoid missing meals or leaving long gaps between eating

Drink at least 8 cups fluid per day

Restrict tea and coffee to 3 cups a day

Reduce alcohol and fizzy drinks

Consider limiting high fibre foods