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Irritable Bowel Syndrome Flashcards

1
Q

When should you consider a diagnosis of IBS?

A

if the patient has had the following for at least 6 months:

  1. abdominal pain, and/or
  2. bloating, and/or
  3. change in bowel habit
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2
Q

After what time period of symptoms should you consider a diagnosis of IBS?

A

6 months

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3
Q

When should a positive diagnosis of IBS be made? What are the criteria?

A
  • abdominal pain relieved by defecation or associated with altered bowel frequency or stool form, PLUS 2 of the following 4:
    • altered stool passage (straining, urgency, incomplete evacuation)
    • abdominal bloating (more common in women than men), distension, tension or hardness
    • symptoms made worse by eating
    • passage of mucus
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4
Q

What are 4 more non-specific symptoms of IBS that may support the diagnosis?

A
  1. Lethargy
  2. Nausea
  3. Backache
  4. Bladder symptoms
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5
Q

What are 4 red flag features to ask about in suspected IBS?

A
  1. Rectal bleeding
  2. Unexplained/unintenstional weight loss
  3. Family history of bowel or ovarian cancer
  4. Onset after 60 years of age
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6
Q

What are 3 suggested primary care investigations for suspected IBS?

A
  1. FBC
  2. ESR/CRP
  3. Coeliac disease screen (tissue transglutaminase antibodies)
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7
Q

What is first-line pharmacological treatment for IBS dependent upon?

A

predominant symptom

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8
Q

What are 3 examples of predominant symptoms and their first line pharmacological management in IBS?

A
  1. Pain: antispasmodic agents
  2. Constipation: laxatives but avoid lactulose
  3. Diarrhoea: loperamide
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9
Q

What laxatives should you avoid for constipation in IBS?

A

lactulose

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10
Q

What drug might you consider for patients with IBS who are not responding to conventional laxatives?

A

Linaclotide - gyanylate cyclase-C agonists, increases luminal fluid secretion

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11
Q

What are 2 criteria that must be met for linaclotide to be considered for constipation in IBS?

A
  1. Optimal or maximum tolerated doses of previous laxatives from different classes have not helped AND
  2. They have had constipation for at least 12 months
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12
Q

What is the second-line pharmacological treatment of IBS (after predominant symptom treated as first line)?

A

low-dose tricyclic antidepressants e.g. amitriptyline 5-10mg (preferred to SSRIs)

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13
Q

What are 2 further aspects of the management of IBS in addition to pharmacological treatment?

A
  1. Psychological interventions
  2. General dietary advice
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14
Q

When should you consider psychological interventions for IBS?

A

if symptoms do not respond to pharmacological treatments after 12 months and who develop a continuing symptom profile (refractory IBS)

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15
Q

What are 3 types of psychological interventions that you should consider referring refractory IBS for?

A
  1. Cognitive behavioural therapy
  2. Hypnoherapy
  3. Psychological therapy
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16
Q

What are 4 forms of dietary advice regarding meals to give in IBS?

A
  1. Regular meals
  2. Take time to eat
  3. Avoid missing meals
  4. Avoid leaving long gaps between eating
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17
Q

What are 3 forms of dietary advice regarding meals for IBS?

A
  1. Drink at least 8 cups of fluid per day, especially water/non-caffeinated drinks such as herbal teas
  2. Restrict tea and coffee to 3 cups a day
  3. Reduce intake of alcohol and fizzy drinks
18
Q

What are 3 pieces of advice regarding food classes to eat in IBS?

A
  1. Consider limiting intake of high-fibre food e.g. wholemeal or high-fibre flour and breads, cereals high in bran, whole grains such as brown rice
  2. Reduce intake of resistant starch often found in processed foods
  3. limit fresh fruit to 3 portions a day
19
Q

What ingredient in food should be avoided for diarrhoea in IBS?

A

sorbitol

20
Q

What is a dietary change to make specifically for wind and bloating?

A
  • increasing intake of oats e.g. oat-based breakfast cereal or porridge
  • increase linseeds - up to 1 tablespoon per day
21
Q

What are 4 types of general dietary advice to give patients with IBS?

A
  1. Meal timings
  2. Specific food classes
  3. Avoid sorbital if diarrhoea
  4. Bloating and wind - oats and linseeds
22
Q

What are 5 types of triggers to explore if you suspect a patient has IBS?

A
  1. Explore any stress/anxiety or depression as this often triggers IBS, or can be made worse by IBS
  2. Ask to keep a food diary to see if certain foods trigger symptoms
  3. Review medications as many have side effects on the bowel
  4. Review level of exercise, fluid intake, and general lifestyle such as eating late, or not sitting down to eat as these can all impact on IBS symptoms
23
Q

If a patient’s predominant symptom is constipation, what are 6 lifestyle measures to suggest?

A
  1. Soluble fibre supplements (for example ispaghula) or foods high in soluble fibre (for example oats and linseed).
  2. Gradually increase fibre intake to minimize flatulence and bloating, and be aware that beneficial effects may be seen after several weeks.
  3. Recommend drinking an adequate fluid intake.
  4. For people who choose to take an over-the-counter probiotic supplement, advise that they do so for at least four weeks.
  5. Advise on the benefits of regular physical activity - recommended at leats 30 min moderate aerobic activity on 5 days of week
  6. Encourage weight loss if the person is overweight or obese. See the CKS topic on ObesityLinks to an external site. for more information.
24
Q

What type of laxatives are recommended for treatment of IBS when constipation is the first symptom?

A

Bulk-forming laxatives

25
Q

How do bulk forming laxatives work to treat constipation?

A

contain soluble fibre; act by retaining fluid within the stool and increasing faecal mass, stimulating peristalsis; also have stool-softening properties

26
Q

What are 2 examples of bulk-forming laxatives which may be used to treat IBS first line in those who find it hard to get adequate dietary fibre?

A

Ispaghula husk (also known as psyllium)

Sterculia e.g. Fybogel

27
Q

What are 4 pieces of advice to give when prescribing bulk-forming laxatives such as Fybogel and Ispaghula husk?

A
  1. Must not be taken immediately before bed.
  2. Adequate fluid intake is important to reduce the risk of intestinal obstruction.
  3. ot recommended for people taking constipating drugs.
  4. Typically takes 2–3 days to take effect.
28
Q

What type of anti-spasmodic drugs can be used when abdominal pain is the primary symptom of IBS?

A

Direct-acting smooth muscle relaxants e.g. mebeverine hydrochloride (immediate-release or modified-release), alverine citrate, and peppermint oil

29
Q

What other type of drug class of anti-spasmodics in addition to direct-acting smooth muscle relaxants are available, and why are direct-acting smooth muscle relaxants preferred?

A

Antimuscarinics such as hyoscine butylbromide and dicloverine

Direct-acting are less likely to cause side effects

30
Q

What are 2 examples of the drugs in the ant-muscarinic class of anti-spasmodics?

A
  1. Hyoscine butylbromide
  2. Dicloverine
31
Q

What prescription of alverine can be used to treat abdominal pain in IBS?

A

60–120 mg one to three times a day may be used.

32
Q

What prescription of mebeverine hydrochloride can be used to treat abdominal pains in IBS? Both immediate and modified-release preparations

A
  • Immediate-release: 135–150 mg three times a day, dose preferably taken 20 minutes before meals
  • Modified-release: 200 mg twice daily
33
Q

How can peppermint oil be prescribed/ directed to take for abdominal pain in IBS?

A

One to two capsules taken three times a day for up to 2–3 months if needed, dose to be taken before meals, swallowed whole with water.

34
Q

How can most of the anti-spasmodic types of drug, particularly the direct smooth muscle relaxants, be obtained by patients?

A

bought over the counter

35
Q

What evidence is there for the use of probiotics to help with abdominal pains associated with IBS?

A
  • The NICE clinical guideline found good-quality evidence that combination probiotics improve global IBS symptoms, pain, and bloating, however this is probiotic dose- and strain-dependent.
  • The guideline development group felt unable to recommend named bacteria or probiotic products, however it concluded they were a reasonable self-management option for people with IBS, and were unlikely to be harmful
36
Q

What are 2 examples of sources of information for patients to learn more about IBS?

A
  • Patient.co.uk Brief Decision Aid and PIL
  • Support groups e.g. Gut Trust
37
Q

When should you review a patient with IBS after starting amitriptyline? What action may be taken?

A

after 4 weeks

increase dose if needed

38
Q

If amitriptyline is ineffective at treating IBS, or CIed/not tolerated, what should be considered next?

A

selective serotonin reuptake inhibitor (SSRI), such as citalopram or fluoxetine (off-label indication).

Review the person after 4 weeks, and increase the dose if needed, according to symptom response and tolerability.

39
Q

After initially suggesting treatment for IBS how long shold you give to assess the response before trying something new?

A

3 months

40
Q

What are 3 types of referral that you may consider for a patient with IBS if there is no improvement after 3 months?

A
  1. Gastroenterologist if persistent or concerns about underlying cause
  2. Dietitian e.g. food exclusion diets like FODMAP foods
  3. Mental health services
41
Q

When should you consider referral to mental health services for patients with IBS?

A

ongoing symptoms for at least 12 months and/or health-related anxieties, depending on clinical judgement.

GP (43 decks)

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