Irritable Bowel Syndrome

Question 1

What 3 symptoms should make you consider that a patient may have IBS?`

Answer 1

1. Abdominal pain
2. Bloating
3. Change in bowel habit

Question 2

What primary care investigations should you do to exclude other causes of the patient’s symptoms?

Answer 2

• FBC
• ESR/CRP
• Coeliac disease screen (TTG)

Question 3

What are the criteria for making a diagnosis of IBS?

Answer 3

• Abdominal pain relieved by defecation OR associated with altered bowel frequency stool form AND 2 of the following 4 symptoms:
  
  • Altered stool passage (straining, urgency, incomplete evacuation)
  • Abdominal bloating (women > men), distension.
  • Symptoms made worse by eating
  • Passage of mucus

Question 4

What are some other features that support a diagnosis of IBS?

Answer 4

• Lethargy
• Nausea
• Backache
• Bladder symptoms

Question 5

What are some red flag questions you must ask about before diagnosing IBS?

Answer 5

• Rectal bleeding
• Unexplained weight loss
• FH of bowel or ovarian cancer
• Onset after 60 years of age is unusual

Question 6

What is your pharmacological management strategy in IBS?

Answer 6

1. First Line:
   
   • Pain: antispasmodic agents (Buscopan)
   • Constipation: laxatives but avoid lactulose
   • Diarrhoea: loperamide is first-line
2. Second Line - Low Dose TCA (Amitriptyline 5-10mg)
3. Third line - Psychological interventions
   
   • If pharmacological therapy fails after 12 months consider Psychological interventions (CBT, Hypnotherapy or Psychological therapy)

Question 7

What general dietary advice should you give to someone who has IBS?

Answer 7

• Have regular meals and take time to eat
• Avoid missing meals or leaving long gaps between eating
• Drink at least 8 cups of fluid per day, especially water or other non-caffeinated drinks such as herbal teas
• Restrict tea and coffee to 3 cups per day
• Reduce intake of alcohol and fizzy drinks
• Consider limiting intake of high-fibre food (for example, wholemeal or high-fibre flour and breads, cereals high in bran, and whole grains such as brown rice)
• Reduce intake of ‘resistant starch’ often found in processed foods
• Limit fresh fruit to 3 portions per day
• For diarrhoea, avoid sorbitol
• For wind and bloating consider increasing intake of oats (for example, oat-based breakfast cereal or porridge) and linseeds (up to one tablespoon per day).

Question 8

If a TCA is ineffective, what can you prescribe instead?

Answer 8

SSRIs

Question 9

If you have prescribed a TCA or SSRI for someone with IBS, what sort of follow up should you organize with them?

Answer 9

Follow up at 4 weeks and then every 6 to 12 months.

Question 10

If a patient has constipation and they are not responding to conventional laxatives, what can you prescribe and under what circumstances?

Answer 10

Linaclotide

• Optimal or maximum tolerated doses of previous laxatives from different classes have not helped AND
• They have had constipation for at least 12 months

Question 11

What is a useful thing to do to help patients manage their own constipation or diarrhoea?

Answer 11

Teach them to adjust their laxatives or antimotility agents to get a soft and well-formed stool. (You can use the Bristol Stool Chart - Type 4)