Irritable Bowel Syndrome Flashcards
IBS - Mx
Irritable bowel syndrome: management
The management of irritable bowel syndrome (IBS) is often difficult and varies considerably between patients. NICE updated it’s guidelines in 2015.
First-line pharmacological treatment - according to predominant symptom
pain: antispasmodic agents
constipation: laxatives but avoid lactulose
diarrhoea: loperamide is first-line
For patients with constipation who are not responding to conventional laxatives linaclotide may be considered, if:
optimal or maximum tolerated doses of previous laxatives from different classes have not helped and
they have had constipation for at least 12 months
Second-line pharmacological treatment
low-dose tricyclic antidepressants (e.g. amitriptyline 5-10 mg) are used in preference to selective serotonin reuptake inhibitors
Other management options
psychological interventions - if symptoms do not respond to pharmacological treatments after 12 months and who develop a continuing symptom profile (refractory IBS), consider referring for cognitive behavioural therapy, hypnotherapy or psychological therapy
complementary and alternative medicines: ‘do not encourage use of acupuncture or reflexology for the treatment of IBS’
IBS - General Dietary Advice
General dietary advice
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).
IBS and Linaclotide - Example Question
A 33-year-old lady has a diagnosis of irritable bowel syndrome (IBS). She has previously been seen in the gastroenterology clinic and all investigations including colonoscopy were normal. She is mainly troubled by abdominal pain, bloating and constipation. She continues to have symptoms despite the use of antispasmodics, regular Movicol (macrogol laxative) and input from a dietician. She has tried other laxatives in the past with limited benefit. What would be the next most appropriate option?
Lactulose > Linaclotide Loperamide Acupuncture Reflexology
NICE have written guidance on the diagnosis and management of IBS.
First line pharmacological treatments include antispasmodics e.g. hyoscine or mebeverine; loperamide for diarrhoea and laxatives for constipation. Lactulose should be avoided.
2nd line options include tricyclic antidepressants e.g. up to 30mg amitriptyline if above treatments have not helped
3rd line: serotonin selective reuptake inhibitors
Linaclotide can be considered if there has been no benefit from different laxatives and the patient has had constipation for at least 12 months.
Other management options include dietary advice and psychological treatments.
Acupuncture and reflexology are not recommended for managing IBS.
IBS Mx: Example Question
A 24-year-old female presents to general practice with a several week history of diarrhoea, passage of mucus, lethargy and abdominal discomfort relieved by defecation. A blood test is arranged showing the following:
Na+ 138 mmol/l
K+ 4.0 mmol/l
Urea 4.5 mmol/l
Creatinine 80 µmol/l
Hb 11 g/dl Platelets 320 * 109/l WBC 4.0 * 109/l CRP 1.0 mg/l Tissue transglutaminase antibody neg
Which one of the following agents would be most suitable for her?
Linaclotide Codeine Sertraline > Loperamide Amitriptyline
This is a clinical diagnosis of irritable bowel syndrome, supported by relief on defaecation as well as a panel of normal blood tests. The first-line anti-motility agent for this presentation of diarrhoea would be loperamide, as recommended by NICE guidelines. Whilst codeine may be effective in minimising diarrhoea, it has no established roles in the management of IBS.
Linaclotide is a laxative that is recommended in use of IBS if symptoms of constipation predominate, if the patient has had constipation for 12 months and if a trial of the more conventional laxatives fail.
Sertraline and amitriptyline are second-line pharmacological treatments if anti-motility treatment, laxatives and antispasmodics have failed to improve symptoms.
IBS 2nd Line Mx: Example Question
A 25-year-old female undergraduate student presented to the gastroenterology outpatient clinic after referral from her GP. The referral letter stated that the patient had a three-year history of irritable bowel syndrome (IBS) and was complaining mainly of constipation. The GP had tried dietary advice and different laxatives, including senna and sodium docusate in full doses and a trial of macrogol with no benefit. The patient stated that the problem was mainly happening during exams. She underwent appendectomy 5 years ago with no postoperative complications. Blood investigations were as follows:
Hb 120 g/l
Platelets 310* 109/l
WBC 8* 109/l
Na+ 140 mmol/l
K+ 4.4 mmol/l
Urea 6.5 mmol/l
Creatinine 100 µmol/l
What is the next step in management?
Add tricyclic anti-depressant (TCA) Add selective serotonin re-uptake inhibitor (SSRI) Increase the dose current laxatives and advice to relax Add lactulose > Add linaclotide
Recent changes in NICE guidelines suggested that when a patient with IBS has resistant constipation despite using multiple laxatives with proper doses, linaclotide (which is a guanylate cyclase-C receptor agonist) should be used as the next step in management. It works by increasing intestinal fluid secretion and transit and decreases visceral pain.
Lactulose is not advised by NICE to be given in patients with IBS.
Adding a TCA or SSRI is the next step after linaclotide if it is found to be of no benefit.
IBS Red Flags
When considering a diagnosis of IBS, Red flag fx should always be enquired about
- Rectal bleeding
- Unexplained/unintentional weight loss
- FHx of bowel or ovarian Ca
- Onset > 60 years
IBS Diagnosis
NICE published clinical guidelines on the diagnosis of IBS in 2008
Ix in IBS:
- FBC
- ESR/CRP
- Coeliac screen
Diagnosis should be considered if the patient has had the following for at least 6m
- abdo pain and/or
- bloating and/or
- change in bowel habit
A positive diagnosis of IBS should be made if pt has abdo pain relieved by defecation or assoc w altered bowel frequency/stool form in addition to 2 of the following:
1) Altered stool passage (straining, urgency, incomplete evacuation)
2) Abdominal bloating (more common in women than men), distension, tension or hardness
3) Sx made worse by eating
4) Passage of mucus
Features such as lethargy, nausea, backache, bladder Sx may also support diagnosis
