Irritable Bowel Syndrome

Question 1

Clinical Features

Answer 1

Diarrhoea

Constipation

Fluctuating bowel habit

Abdominal pain

Bloating

Symptoms are:

• Worse after eating
• Improved by opening bowels

Question 2

Criteria for Diagnosis (NICE guidelines)

Answer 2

Other pathology should be excluded:
- Normal FBC, ESR and CRP blood tests

• Faecal calprotectin negative to exclude inflammatory bowel disease
• Negative coeliac disease serology (anti-TTG antibodies)
• Cancer is not suspected or excluded if suspected

Symptoms should suggest IBS:

• Abdominal pain / discomfort:
• Relieved on opening bowels, or
  Associated with a change in bowel habit
  AND 2 of:

Abnormal stool passage
Bloating
Worse symptoms after eating
PR mucus

Question 3

Management

Answer 3

Making a positive diagnosis and providing reassurance that there is no serious pathology present is important.

CONSERVATIVE
General healthy diet and exercise advice:

• Adequate fluid intake
• Regular small meals
• Reduced processed foods
• Limit caffeine and alcohol
• Low “FODMAP” diet (ideally with dietician guidance)
• Trial of probiotic supplements for 4 weeks

MEDICAL
1. Loperamide for diarrhoea
Laxatives for constipation. Avoid lactulose as it can cause bloating. Linaclotide is a specialist laxative for patients with IBS not responding to first line laxatives
Antispasmodics for cramps e.g. hyoscine butylbromide (Buscopan)

2. Tricyclic antidepressants (i.e. amitriptyline 5-10mg at night)
3. SSRIs antidepressants

Cognitive Behavioural Therapy (CBT) is also an option to help patients psychologically manage the condition and reduce distress associated with symptoms.

Question 4

Truelove and Witt’s criteria

Answer 4

criteria to assess severity in ulcerative colitis

SEVERE EXACERBATION is defined by:

• copious blood in the stools OR
• 6 or more bowel movements per day
• PLUS at least one feature of systemic upset i.e. temperature above 37.8’C, pulse above 90 bpm, anaemia (haemoglobin below 10.5 g/dL), or ESR above 30 mm/hour.

MODERATE EXACERBATION is defined by:
- 4-6 motions per day
- mild-severe bloody diarrhoea.
There should be no pyrexia and pulse should be below 90 bpm. Haemoglobin and ESR are within the normal range.

MILD EXACERBATION is defined by:
- fewer than 4 motions per day
- no more than small amounts of blood in the stool.
There should be no pyrexia and pulse should be below 90 bpm. Haemoglobin and ESR are within normal limits.