Management of IBS in Primary Care – Haringey Guidelines Clive Onnie BSc(Hons) MSc PhD MRCP Consultant Physician and Gastroenterologist Whittington Hospital

Osler, 1901 Mucous colitis ‘ This Disease is a secretion neurosis of the colon…. Marked nervous symptoms, hysterical outbreaks, hypochondriasis and melancholia. Cases are invariably seen in nervous or hysterical women or in men with neurasthenia….. The diagnosis is rarely doubtful but important not to mistake membranes of other substances thus; the external cuticle of the asparagus and undigested portions of meat or sausage skins not unlike mucus casts….. Treatment is very unsatisfactory. Drugs are of doubtful benefit…. Measures directed to nervous condition are perhaps most important. Sometimes local treatment with Kelly’s long rectal tubes is beneficial. Systematic irrigation of colon should be practiced. Right inguinal colotomy has been performed for intractable cases.….

Aetiology Visceral hypersensitivity Altered gut flora (SIBO) Post infective IBS Brain-gut axis

Diagnosis Wide array of symptoms, making diagnosis frustrating Chronic abdominal pain and altered bowel habits remain the central characteristic of IBS. There are no biochemical markers Based on symptom based criteria

Subtyping IBS by predominant pattern IBS with constipation – hard or lumpy stools IBS with diarrhoea – loose, mushy or watery Mixed IBS (alternators) Post infectious IBS

Make a positive diagnosis Identify abdominal pain as dominant symptom with altered bowel function Look for ‘red flags’ Perform diagnostic tests/physical exam to rule out organic disease Make/confirm diagnosis Initiate treatment programme as part of diagnostic approach Follow up in 3-6 weeks

Red flag symptoms Iron deficiency anaemia Fever Persistent diarrhoea Rectal bleeding Weight loss Palpable mass Nocturnal symptoms Fhx of IBD, CRC, ovarian cancer, Coeliac New onset in patients > 50yrs

Diagnostic tests FBC,electrolytes, inflammatory markers, TFT, Coeliac serology + IgA ? Faecal calprotectin

Diagnostic tests – faecal calprotectin Found in cytoplasm of neutrophils Influx of neutrophils into bowel lumen at site of inflammation Dead neutrophils release calprotectin, detected in stool Cost: £35 ( vs colonoscopy £700) Validated + NICE approved

Diagnostic tests: What? When? Who? FBC,electrolytes, inflammatory markers, TFT, Coeliac serology + IgA, stool Faecal calprotectin ?sigmoidoscopy/colonoscopy

Therapeutic Approach Establish an empathetic physician-patient relationship Education Reassurance Chronic benign nature

Treatment strategy for IBS End-organ and dietary treatment –Exploration of dietary triggers –Low FODMAP diet –Anti-diarrhoeals and low dose TCA –Smooth-muscle relaxants for pain Centrally targeted treatment –Physiological explanation of symptoms / education + reassurance –Hypnotherapy / pyschotherapy / CBT / biofeedback –antidepressants Receptor-active agents –5HT4 receptor agonists, linaclotide, lubiprostone Probiotics / Antibiotics – metronidazole / rifaximin Herbal / aloe vera

End organ treatment - diet Many patients benefit from caffeine and alcohol exclusion Lactose intolerance: ‘milk challenge’ Wheat exclusion 20-70% response from exclusion diets – usefulness of dietician

Diet

What are FODMAPs? Fermentable Oligosaccharides – fructans, galactans D M A P

What are FODMAPs? Fermentable O Disaccharides - lactose M A P

What are FODMAPs? Fermentable O D Monosaccharides A P

What are FODMAPs? Fermentable O D M And Polyols

FODMAPs – mechanisms of action FructoseFructans Lactose GalactansPolyols

FODMAPs – mechanisms of action Osmotic load Rapidly fermented CH 4  H 2 FructoseFructans Lactose GalactansPolyols

FODMAPs – mechanisms of action Osmotic load Rapidly fermented CH 4  H 2  water delivery  gas production Luminal distension Motility changeBloatingPain/discomfortWind FructoseFructans Lactose GalactansPolyols

Low FODMAP foods

Low FODMAP diet Validated Rationale is attractive and easily understood Advice given in the context of usual diet Messages delivered positively High adherence (> 70%)

End organ: Anti-diarrhoeals and TCA Loperamide – single or divided doses on regular basis Tricyclic antidepressants: exert an end- organ effect on small-intestinal motility and to prolong orocaecal and whole-gut transit time SSRI – less evidence. Shortens transit time. Cholestyramine 4g 1-6x/day

End organ: Laxatives and IBS Osmotic preferably Lactulose is avidly metabolised  gas and bloating Polyethylene glycol preparations (movicol / laxido) Stimulants – bisacodyl/senna Alternatives: –Prucalopride –Linaclotide –Lubiprostone

End organ: Smooth muscle relaxants Direct smooth muscle relaxants or antimuscarinic drugs eta-analysis does suggest usefulness in treatment of abdominal pain Peppermint oil – RCT suggests benefit Patients often benefit from combination treatment e.g laxative + antispasmodic

Centrally targeted treatment Most results of centrally targeted therapies show a beneficial effect on IBS Emphasizes multi-disciplinary approach Relaxation therapy – reduces symptoms and number of medical consultations

Hypnotherapy

Haringey IBS care pathway

Graduated Treatment Approach Multidisciplinary approach Referral to pain management + Pharmacotherapy Pyschological treatments + Education Reassurance Dietary modification

Summary Important to establish a positive diagnosis of IBS Most patients will respond to therapy Optimum medical management will involve a multi-modality approach NICE and GUT guidelines

Case scenario 1 36 yr old male 2yr history significant bloating, cramp relative constipation then explosive diarrhoea Dietary changes no help following dietetic review Otherwise well

Case scenario 1 Blood tests, Coeliac serology normal OGD/colon normal Previous review by dietician

Case scenario 1 Blood tests, Coeliac serology normal OGD/colon normal Previous review by dietician Low FODMAP diet PRN mebeverine Education

Case scenario 1 Low FODMAP diet: Much better Able to identify precipitants More in control Uses mebeverine PRN basis

Case scenario 2 30yr old female Longstanding abdominal pain Endometriosis – most recent laparoscopy NAD Weight loss Previous CBT for depression/anxiety Chronic constipation – BO every 2/52, nausea

Case scenario 2 Multiple previous investigations – bloods/OGD/colon/CT/laparoscopy Transit study – slow transit Multiple laxatives – senna,movicol, dulcolax

Case scenario 2 Prescribed prucalopride 2mg od 2/12 f/u: bowels open most days Weight increased Eating more