1. GHNHSFT/CCG Collaboration: Ibs clinical pathway and Direct Access service
Dr Alex di Mambro – Consultant Gastroenterologist
Claire Oldale – Specialist Dietitian
2015/16

2. Objectives
Recognize the symptoms of IBS and how to differentiate from IBD
Optimize non invasive investigations
To identify the role of new referral pathways and diagnostics in Primary Care in patients with GI symptoms
Discuss treatments and dietary manipulation in the management of IBS

3. IBS
IBS affects 5-10 % of adults aged 25 to 55, resulting in approximately 1 to 3 million patients being affected in the UK.
Each year there are approximately 78,000 new patients diagnosed with IBS
Each GP will have approximately patients on their register
IBS most commonly affects people between the ages of 20 and 30 years and is twice as common in women as in men. Recent evidence shows that there is also a significant prevalence of IBS in older people. (NICE 2013)

4. IBS
Rome III
Recurrent abdominal pain or discomfort at least 3 days per month in the last 3 months. Associated with two or more of the following:
Pain is relieved by a bowel movement
Onset of pain is related to a change in frequency of stool
Onset of pain is related to a change in the appearance of stool.

5. IBS – the costs £45.6 million per year spent by NHS on IBS
Cost per patient per year
Up to £5341 direct costs
Up to £2041 indirect costs (e.g. absenteeism)
Up to 15 visits to physician
8-21 days off work
(Maxion-Bergemann et al. 2006)
35% of disorders seen by Gastroenterologists
(Russo et al., 1999)

6. Subtypes of IBS IBS-D, where diarrhoea is the predominant bowel habit,
IBS-C, where constipation predominates; hard or lumpy stools (scored as 1 or 2 on the Bristol Stool Form Scale) ≥25% of defecations and, in conjunction, loose or watery stools (scored as 6 or 7 on the Bristol Stool Form Scale <25% of defaecations
IBS-M (mixed), where both diarrhoea and constipation occur, and,
IBS-U (unclassified), does not fit into one of the above categories (!)

7. Drug Treatments
Diarrhoea Predominant: Mebeverine, Buscopan, Peppermint, Amitriptylline (10-20mg on increasing as tolerated)
Constipation predominant:
Linaclotide (guanylate cyclase-C agonist) 290mcg od (NICE guidance)
Lubiprostone (chloride channel activator) 8mcg bd for 2/52
Prucalopride 1-2mg od ( a highly selective serotonin 5-HT4 receptor agonist which has been shown to stimulate gut motility in vitro and in vivo [Sanger and Quigley, 2010])

8. Faecal Calprotectin A biomarker of bowel inflammation
Calprotectin is a 36kDa calcium and zinc binding protein expressed by the gene S100 calcium-binding protein. It accounts for 30 to 40% of neutrophils' cytosol. In vitro studies show it has bacteriostatic and fungistatic properties.
Resistant to enzymatic degradation, and can be easily measured in faeces
FC levels above 150 mg/g will point towards the existence of active IBD rather than IBS, with a sensitivity of 100% and a specificity of 97%

9. Dietary Management of IBS9

10. Current dietary advice – BDA 2011/NICE 2015
1st line :
2nd line:
Short term single exclusion
Lactose
Wheat
3rd LINE: Complex exclusion
low FODMAP
NICE recommend exclusion diets are undertaken with appropriate dietetic support

11. What are FODMAPs and how do they trigger symptoms?

12. FODMAP Fermentable Oligosaccharides fructans / galactans
Disaccharides lactose
Monosaccharides fructose
And
Polyols sorbitol / mannitol

13. FODMAPs Group of short chain carbohydrates
Poorly absorbed leading to fermentation and osmotic changes in the bowel
Barrett JS et al (2010) Dietary poorly absorbed, short-chain carbohydrates increase delivery of water and fermentable substrates to the proximal colon. Aliment Pharmacol Ther 31,
Ong DK et al (2008) The intestinal fermentative response to dietary FODMAPs; failure to switch to methane production in patients with irritable bowel syndrome. J Gastroenterol Hepatol 23(s4), A219.

14. How do they trigger symptoms?
Fructose
Fructans
Lactose
Galactans
Polyols
DIETARY COMPONENT
Osmotically active
Rapidly fermented 
water
delivery
PHYSIOLOGICAL
EFFECTS
 gas production
Motility changes
Bloating
Pain/discomfort
Wind
SYMPTOM
INDUCTION
Luminal
distension

15. Does it work in clinical practice?
Shephard and Gibson 2006: Fructose malabsorption and symptoms of irritable bowel syndrome: guidelines for effective dietary management .J Am Diet Assoc 106:
Shephard et al 2008: Dietary triggers of abdominal symptoms in patients with irritable bowel syndrome: randomized placebo-controlled evidence. Clin Gastroenterol and Hepatol 6:
Staudacher et al 2011: Comparison of symptom response following advice for a diet low in fermentable carbohydrates (FODMAPs) versus standard dietary advice in patients with irritable bowel syndrome. J Hum Nutr Diet.;24(5):487-95
Halmos et al (2014)A diet low in FODMAPs reduces symptoms of irritable bowel syndrome Gastroenterology 2014;146:67–75

16. Halmos et al (2014) A Diet Low in FODMAPs Reduces Symptoms of Irritable Bowel Syndrome Gastroenterology 2014;146:67–75
Randomised crossover trial - 21 days low FODMAP diet or typical Australian diet with washout period of at least 21 days
<0.5 g intake of FODMAPs per meal for the low-FODMAP diet. Equivalent nutritional quality in both diets.
Subjects had lower overall gastrointestinal symptom scores (100mm VAS)
low FODMAP diet 22.8mm; 95% CI 16.7–28.8 mm
Typical Australian diet 44.9mm; 95% CI 36.6–53.1 mm; P < .001
Bloating, pain, and wind reduced.
Patients of all IBS subtypes had greater satisfaction with stool consistency
Objective effect of low FODMAP diet on stool modest – improvement in frequency / consistency in IBS-D sub-group only.

17. IBS Care Pathway Collaboration between GCCG and GHNHSFT
G-Care: Comprehensive NICE based guidance including:
Diagnosis, differential diagnosis and red flags
Medications
First line dietary advice with patient information available to download.
Signposting to other sources of support
2gether Trust ‘Lets Talk’ IBS course
IBS Network
Criteria for referral to Complex IBS Service

18. DIAGNOSIS OF IRRITABLE BOWEL SYNDROME
ROME CRITERIA
1. >3 months continuous or
recurrent symptoms of abdominal pain.
Relieved by defaecation and/or associated
with change in stool frequency +/- change
in stool consistency
2. >/=2 of the following for at least ¼
occasions or days:
Altered stool consistency >3/day
or <3/week
Altered stool form
Altered stool passage
(strain/urgency/incomplete evacuation)
Passage of mucus
Bloating or abdominal distension
Patient aged presenting with symptoms
Consistent with IBS (Rome Criteria)
Alarm Symptoms/Signs?
Blood in stool
Unintentional/unexplained weight loss
Nocturnal symptoms
Anaemia
OR significant FHx of bowel or ovarian cancer
YES NO
Refer to
gastroenterology
CRP, LFT, U&E, FBC, TTG, TSH
Haematinics and stool culture
NAD
Measure Faecal
Calprotectin
No response to
treatment algorithm
Manage in Primary Care
as per Gloucestershire IBS Care Pathway
including diet, physical activity, medication
(eg. Mebeverine, colpermin,
Amitriptylline, linaclotide)
FC >150
FC <149
Refer to
gastroenterology
Refer to Direct Access
Dietetic IBS Service

19. Complex IBS Service E-referral service (link to referral form)
Information on Trust website
and phone queries accepted.
Referrals triaged and allocated to dietetic led clinic if accepted.
Regualar liaison with Cons. Gastroenterolgist.

20. Dietetic led clinics 2-3 face to face appointments.
1st appt – 1 hour - nutritional and symptom assessment and dietary exclusion as appropriate.
Review appt – 30minutes – symptom review and food re-challenge /further advice
2nd review (if needed) – 30 minutes.
Comprehensive accredited supporting literature provided.
Patient access to and telephone support between appointments.

21. Faecal Calprotectin – the rules
Age 18-45
No red flags
No nocturnal symptoms
No NSAIDs for 6 weeks prior to test (false positive)
Rome III criteria
Referral via ICE (prospectively monitored)

22. In summary Aim for non invasive diagnosis of IBS where possible
Sub-classification of IBS will help tailor treatments
The use of faecal calprotectin will help to differentiate difficult to manage IBS from inflammatory disease
The direct access IBS service will help stream line referral process and give patients quicker access to treatments that work
Dietary manipulation is an effective approach to the treatment of IBS

23. Thank you for listening…..
Any questions?

24. A closer look at the LOW FODMAP diet

25. FODMAP Fermentable Oligo- Di- Monosaccharides A P nd olyols
Fructans, GOS
Di-
Lactose
Monosaccharides
Fructose A P nd
olyols
Sorbitol, Mannitol

26. Fructose
Fermentable O D M
onosaccharides A P

27. Fructose Monosaccharide Often absorbed well
30% of population malabsorb it when:
in excess of glucose or
if taken in large loads
Found in honey, corn syrups, apples, sugar snaps.

28. Lactose F O D
isaccharides M A P

29. Lactose
Lactose
Galactose
Glucose

30. Lactose
Lactase enzyme
Lactose
Galactose
Glucose

31. …. Lactose is malabsorbed
Lactase deficiency
…. Lactose is malabsorbed
and becomes a FODMAP
Wide prevalence from 2%-90% in some asian countries

32. Oligosaccharides F O
ligosaccharides D M A P

33. Fructans Naturally in foods – wheat, onions, garlic, leek, rye
Chains of fructose units with a glucose terminal end
Lack of enzyme to break bonds
<5% absorption
Naturally in foods – wheat, onions, garlic, leek, rye
Added to food in form of inulin, oligofructose, fructo-oligosaccharides F G
Most dietary sources of fructans are FOS
-are being added for its putative health benefits

34. Galacto-oligosaccharides
Various types e.g.
Raffinose (1 F + 1G + 1 Gal)
Stachyose (1R + 1 Gal)
Humans lack α-galactosidase enzyme
Found in wheat, pulses, beans and some nuts F G Ga F G Ga
These are oligo-saccharides with a beta-fructosidic linkage and an alpha-galactosidic linkage.
Rapidly fermented and induce gas formation

35. Polyols F O D M
And
Polyols

36. Polyols Sugar alcohols
sorbitol, xylitol, mannitol, maltitol isomalt, erythritol
Poorly absorbed in the small intestine (<20%)
passive absorption only
Naturally occurring in fruits and vegetables
Mushrooms, cauliflower, stone fruits, pears
Also added as a sweetener
Chewing gum, sugar-free mints, diabetic foods.
Used as a non stimulant laxative

37. The low FODMAP diet Regular balanced diets are moderate to high FODMAP
Healthy individuals don’t feel the effects
IBS patients suffer the effects of poor absorption due to gut hypersensitivity

38. The low FODMAP diet Restriction of all FODMAPs for up to 8 weeks
Comprehensive resources and advice about suitable alternative products is imperative to prevent nutritional / calorie deficits
Structured reintroduction of FODMAPs to tolerance
increases dietary variety while maintaining symptom improvement
enables long-term symptom management on a modified FODMAP diet

39. Conclusion
The low FODMAP diet offers an exciting future for the management of IBS patients
Implementation by a specialist trained dietitian is required for clinical effectiveness

40. FODMAP Research – further details

41. Shepherd and Gibson (2006)
Fructose malabsorption and symptoms of irritable bowel syndrome: guidelines for effective dietary management .J Am Diet Assoc 106:
Retrospective study of 64 IBS patients on the low FODMAP diet
77% adhered
3/4 had marked improvement of all IBS abdominal symptoms

42. Staudacher et al (2010)
UK service evaluation assessed response to the low FODMAP diet compared to those given NICE guideline advice
Dietitians completed questionnaires for each IBS review patient seen
Symptom and satisfaction questions
Total n=82 (n=39 standard; low FODMAP n=43)

43. n/N (%) of patients reporting symptom improvement
Standard
advice
Low FODMAP advice P
Bloating
17/35 (49)
32/39 (82)
0.002
Abdominal pain
20/33 (61)
29/34 (85)
0.02
Diarrhoea
18/29 (62)
30/36 (83)
0.052
Flatulence
14/28 (50)
33/38 (87)
0.001
Constipation
10/22 (45)
14/21 (67)
0.2
Global satisfaction
20/37 (54)
32/42 (76)
0.04

44. Shepherd et al (2008) 25 IBS patients
Dietary triggers of abdominal symptoms in patients with irritable bowel syndrome: randomized placebo-controlled evidence. Clin Gastroenterol and Hepatol 6:
25 IBS patients
Already had symptomatic improvement on low FODMAP diet
Blind challenges with fructose and fructans: induced symptoms
Improvement not a placebo effect or due to change in other dietary components e.g. gluten