1. IBS or IBD: a N.I.C.E. Way to Tell
Diagnosing GI symptoms can be challenging because the number of symptoms is limited, which can make it difficult to discriminate between conditions,1 and in-depth knowledge of GI conditions can be lacking among practitioners.2
Current treatment options for GI conditions are not always very effective, which can be frustrating for both patients and physicians.
Hammer J, Eslick GD, Howell SC, Altiparmak E, Talley NJ. Diagnostic yield of alarm features in irritable bowel syndrome and functional dyspepsia. Gut 2004; 53:
Dixon-Woods M, Critchley S. Medical and lay views of irritable bowel syndrome. Family Practice 2000; 17:
UKLIN1693, date of preparation: March 2013. 1

2. Dr Stephen Grainger
Honorary Consultant Gastroenterologist King George and Queen’s Hospitals
Diagnosing GI symptoms can be challenging because the number of symptoms is limited, which can make it difficult to discriminate between conditions,1 and in-depth knowledge of GI conditions can be lacking among practitioners.2
Current treatment options for GI conditions are not always very effective, which can be frustrating for both patients and physicians.
Hammer J, Eslick GD, Howell SC, Altiparmak E, Talley NJ. Diagnostic yield of alarm features in irritable bowel syndrome and functional dyspepsia. Gut 2004; 53:
Dixon-Woods M, Critchley S. Medical and lay views of irritable bowel syndrome. Family Practice 2000; 17:
UKLIN1693, date of preparation: March 2013. 2

3. Disclosures I have received payment from:
Almirall speaking at meetings
British Medical Journal reviewing Action Sets
AP&T reviewer
IBD Registry consultant adviser
McKesson UK consultant adviser
Diagnosing GI symptoms can be challenging because the number of symptoms is limited, which can make it difficult to discriminate between conditions,1 and in-depth knowledge of GI conditions can be lacking among practitioners.2
Current treatment options for GI conditions are not always very effective, which can be frustrating for both patients and physicians.
Hammer J, Eslick GD, Howell SC, Altiparmak E, Talley NJ. Diagnostic yield of alarm features in irritable bowel syndrome and functional dyspepsia. Gut 2004; 53:
Dixon-Woods M, Critchley S. Medical and lay views of irritable bowel syndrome. Family Practice 2000; 17:
UKLIN1693, date of preparation: March 2013. 3

4. Why is it difficult? Diagnosing GI symptoms can be challenging:
Few symptoms, many conditions
Lack of in-depth knowledge
Diagnosing GI symptoms can be challenging because the number of symptoms is limited, which can make it difficult to discriminate between conditions,1 and in-depth knowledge of GI conditions can be lacking among practitioners.2
Current treatment options for GI conditions are not always very effective, which can be frustrating for both patients and physicians.
Hammer J, Eslick GD, Howell SC, Altiparmak E, Talley NJ. Diagnostic yield of alarm features in irritable bowel syndrome and functional dyspepsia. Gut 2004; 53:
Dixon-Woods M, Critchley S. Medical and lay views of irritable bowel syndrome. Family Practice 2000; 17:
UKLIN1693, date of preparation: March 2013. 4

5. Prevalence of GI conditions in the UK
Incidence per CCG = national incidence/number of CCGs.
Incidence per GP = incidence per CCG/100.
Patients with gastrointestinal (GI) conditions make up a large proportion of the GP’s workload. This table summarizes the differences in prevalence and incidence among various GI conditions in England/UK.
The incidence per CCG has been calculated by dividing the national incidence by 212 (the number of CCGs). The incidence per GP has been caculated by dividing the CCG number by 100 (on the assumption that each CCG has ~200,000 patients and each GP has ~2000).
As can be seen, the prevalence and incidence of irritable bowel syndrome (IBS) are higher than those of other conditions such as Crohn’s disease and colorectal cancer.
By way of comparison, the UK prevalence of type 2 diabetes was estimated as 4.5% in Some UK studies have estimated the prevalence of IBS in women as up to 23%.12
*Data from England (all other data from UK).
NICE clinical guideline 152, Crohn’s disease: management in adults, children and young people. 
Bowel Disease Research Foundation: inflammatory bowel disease. (accessed January 2013).
Macmillan cancer support: family history of breast and/or ovarian cancer? Check your risk. (accessed January 2013).
NICE costing statement, Ovarian cancer: the recognition and initial management of ovarian cancer.
MIMS patient resources: ulcerative colitis. (accessed January 2013).
Royal Surrey County Hospital. Coeliac disease & a gluten-free diet: a patient information leaflet.
Bupa: bowel cancer information. (accessed January 2013).
NICE clinical guideline 131 costing report, Colorectal cancer: costing report, implementing NICE guidance.
Wilson S, Roberts L, Roalfe A, Bridge P, Singh S. Prevalence of irritable bowel syndrome: a community survey. British Journal of General Practice 2004; 54:
NICE clinical guideline 61 costing template, Irritable bowel syndrome: costing report.
Diabetes UK. Key statistics on diabetes, (accessed January 2013).
Kennedy TM, Jones RH. Epidemiology of cholecystectomy and irritable bowel syndrome in a UK population. British Journal of Surgery 2000; 87:
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6. Case study: Kate
Kate W* is 36 and works as a personal assistant in a busy office. Over the past 12 months, she has consulted five other GPs in your practice for symptoms of anxiety, headache, abdominal pain, and constipation.
*All patient names are fictional.
*All patient names are fictional
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7. Case study: Kate
When you see Kate, she explains that she has abdominal discomfort and frequent bloating.
She does not pass stools very frequently and usually finds that she has to strain.
She describes her stools as ‘hard,’ and finds that her symptoms are relieved by having a ‘good’ bowel movement.
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8. Case study: Kate
When asked how long she has been having symptoms, Kate explains that she has had them intermittently for 10 years, but has never received a satisfactory diagnosis or management plan.
Audience question: What is your gut feeling about her diagnosis?
In general, a gut feeling that the diagnosis may be serious can be clinically useful; a study of infections in young people showed that children were more likely to have a serious illness when their doctor had a ‘gut feeling’ that something was wrong despite a clinical assessment of non-severe disease.1
Van den Bruel A, Thompson M, Buntinx F, Mant D. Clinicians’ gut feeling about serious infections in children: observational study. British Medical Journal 2012; 345: e6144.
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9. An important part of GI diagnosis is eliminating organic disease
Need to eliminate the possibility of organic disease:
Check for alarm features
An important part of diagnosing a patient with GI symptoms is to eliminate the possibility of organic disease.1
This can be done by checking for the presence of certain ‘alarm features’, the next step in our GI routemap.2,3
Although most doctors are familiar with alarm features, the intention of this programme is to show how they can be used practically. In the alarm features module, we will discuss the significance of alarm features and introduce some new tools that can be useful when deciding how to respond to patients who present with alarm features.
Burbige EJ. Irritable bowel syndrome: diagnostic approaches in clinical practice. Clinical and Experimental Gastroenterology 2010; 3:
BSG guidelines: Spiller R, Aziz Q, Creed F, Emmanuel A, Houghton L, Hungin P, et al. Guidelines on the irritable bowel syndrome: mechanisms and practical management. Gut 2007; 56:
NICE clinical guideline 61, Irritable bowel syndrome in adults: diagnosis and management of irritable bowel syndrome in primary care.
UKLIN1693, date of preparation: March 2013. 9

10. Alarm features Alarm features from NICE and BSG guidelines
The alarm features listed here indicate that the cause of the symptoms may be organic rather than functional. Patients with these alarm features require onward referral.1,2
Broad spectrum antibiotics can lead to transient diarrhoea in about 10% of patients, but diarrhoea that is severe and persistent warrants referral for C. difficile toxin testing or sigmoidoscopy to exclude pseudomembranous colitis.1
Many people present with IBS-type symptoms after travel abroad.
In women over 50, persistent distension should be considered an alarm feature, as it may indicate ovarian cancer.2,3
BSG guidelines: Spiller R, Aziz Q, Creed F, Emmanuel A, Houghton L, Hungin P, et al. Guidelines on the irritable bowel syndrome: mechanisms and practical management. Gut 2007; 56:
NICE clinical guideline 61, Irritable bowel syndrome in adults: diagnosis and management of irritable bowel syndrome in primary care.
NICE clinical guideline 122, Ovarian cancer: the recognition and initial management of ovarian cancer.
Alarm features from NICE and BSG guidelines
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11. Differential diagnoses
The table lists possible alternative, organic diagnoses for GI symptoms.1
Lucak S. Diagnosing irritable bowel syndrome: what’s too much, what’s enough? Medscape General Medicine 2004; 6: 17.
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12. Case study: Kate
Questioning reveals that Kate does not have any alarm features. From her notes, you can see that the results of previous investigations have been unremarkable, and therefore her history does not indicate cause for concern.
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13. Case study: Kate
You can be fairly confident of a functional diagnosis for Kate.
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14. Case study: Janet
Janet S presented aged 30 with altered bowel habit: she used to open her bowels 2-3 times a day, but now goes up to 6 times a day with looser stools.
She has lost 3kg over the past three months and has abdominal pain on most days.
Janet’s previous weight was 72kg, it is now 69kg.
At a previous consultation, she complained of abdominal discomfort – this has now progressed to pain.
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15. Case study: Janet
On questioning, her doctor discovers that Janet’s father recently passed away.
Janet’s father died of pancreatic cancer.
Audience question:
What symptoms or factors in Janet’s history would need to be present in addition to her weight loss for you to be concerned?
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16. Case study: Janet UKLIN1693c, date of preparation: March 2013. 16
Janet currently has the slightly worrying features of unintentional weight loss associated with a change in bowel habits and a short symptom history; however, this could be because of the stress of recently losing her father.
Audience question:
What would you do next if Janet was your patient?
Since Janet did not have any of the other alarm features listed on the slide, her GP decided to order blood tests, as discussed on the next slide.
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17. Case study: Janet
Janet’s GP ordered a full set of blood tests, the results of which were:
Haemoglobin: 12.1
White blood count: 5.6
Platelet count: 414
Erythrocyte sedimentation rate: 12
Audience questions:
Are any of these blood results abnormal? How would you respond to the results?
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18. Case study: Janet
Janet’s only abnormality was a slightly elevated platelet count.
Janet’s GP thought that her symptoms could be an acute reaction to the stress of losing her father, and asked her to return for a follow-up appointment in a month's time to re-check her blood tests.
A raised platelet count could be indicative of inflammation.
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19. Case study: Janet Janet did not attend her appointment.
She returned a year later and explained that she had forgotten her last appointment as she was busy arranging her father’s funeral.
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20. Case study: Janet
She still had episodic loose stools and abdominal pain. So far, she had managed her symptoms with over the counter loperamide, but she was worried that they hadn’t disappeared with time.
Janet still has loose stools and abdominal pain, but has had no further weight loss or major life stresses.
Audience questions:
What are your thoughts on a potential diagnosis? What would you do next?
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21. Case study: Janet
Janet’s GP repeated her blood tests, and found that her platelet count was still elevated (420).
Janet’s GP decided to refer her to a gastroenterologist for further investigation.
Janet presented with alarm features, has had repeatedly abnormal blood tests, and has symptoms that have not resolved over time.
Janet’s GP was worried by this, and decided to refer her to a gastroenterologist for further investigation.
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22. Case study: Janet
In secondary care, Janet’s blood tests were repeated. It was found that her CRP level was now high (20), as well as her platelets.
Janet now has two slightly raised inflammatory markers: her platelet count and CRP levels.
CRP = C-reactive protein.
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23. Janet was diagnosed with Crohn’s disease
A colonoscopy was performed, which confirmed that Janet had Crohn’s disease.
This diagram visualizes how faecal calprotectin and lactoferrin can be used as inflammatory markers:
Calrpotectin and lactoferrin are found in neutrophils
In a non-inflamed gut, the neutrophils do not enter the gut lumen
In an inflamed gut, neutrophils enter the gut lumen and release calprotectin and lactoferrin, which can be detected in the stool
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24. Calprotectin and lactoferrin may help to distinguish IBS from IBD
Faecal calprotectin
Inflammatory marker
Useful to determine which patients require endoscopy for IBD
Faecal lactoferrin
Useful for discriminating IBD from IBS patients and healthy subjects
Patients with both inflammatory bowel disease (IBD) and IBS often present with symptoms such as diarrhoea and abdominal pain, thus discriminating between the two conditions can be challenging for clinicians. In addition, patients may find investigations invasive and uncomfortable.2 Two new non-invasive tests have been proposed as methods for distinguishing IBD from IBS: faecal calprotectin and lactoferrin.
Calprotectin is a protein found in neutrophils. Faecal calprotectin has been proposed as a non-invasive and simple test for intestinal inflammation; studies have shown that faecal calprotectin tests are useful in determining which patients require endoscopic investigation for inflammatory bowel disease (IBD).1 Faecal calprotectin testing is currently being reviewed by NICE as a method of differentiating IBD from IBS.3
Lactoferrin is an iron binding protein and a major constituent of a type of neutrophils. Faecal lactoferrin testing has been shown to have high sensitivity and specificity for discriminating patients with active or inactive IBD from patients with IBS and healthy subjects.2
van Rheenen PF, Van de Vijver E, Fidler V. Faecal calprotectin for screening of patients with suspected inflammatory bowel disease: diagnostic meta-analysis. British Medical Journal 2010; 341: c3369.
Sidhu R, Wilson P, Wright A, Yau CWH, D’Cruz FA, Foye L, et al. Faecal lactoferrin – a novel test to differentiate between the irritable and inflamed bowel? Alimentary Pharmacology and Therapeutics 2010; 31:
NICE diagnostics guidance. Faecal calprotectin diagnostic tests to differentiate inflammatory bowel disease from irritable bowel disease. (accessed February 2013).
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25. True positives True negatives
81/94
71/94
170/189
31/31
20/20
79/91
30/30
True positives
True negatives
BMJ July, 2010

26. Faecal Calprotectin

27. UKLIN1693, date of preparation: March 2013.
This diagram visualizes how faecal calprotectin and lactoferrin can be used as inflammatory markers:
Calrpotectin and lactoferrin are found in neutrophils
In a non-inflamed gut, the neutrophils do not enter the gut lumen
In an inflamed gut, neutrophils enter the gut lumen and release calprotectin and lactoferrin, which can be detected in the stool
UKLIN1693, date of preparation: March 2013. 27

28. Need for referral
Patients with alarm features need to be referred. It is important to have a lower referral threshold for people with colorectal cancer risk factors.
Patients who present with alarm features need to be referred to a gastroenterologist for further investigation, whereas patients without such features can normally be diagnosed and managed in primary care.1,2
However, it is important to have a lower threshold for referral in people with recognized risk factors for colorectal cancer, as shown on the next slide.3
BSG guidelines: Spiller R, Aziz Q, Creed F, Emmanuel A, Houghton L, Hungin P, et al. Guidelines on the irritable bowel syndrome: mechanisms and practical management. Gut 2007; 56:
NICE clinical guideline 61, Irritable bowel syndrome in adults: diagnosis and management of irritable bowel syndrome in primary care.
Watson M. Assessment of suspected cancer. InnovAiT: The RCGP Journal for Associates in Training 2008; 1: 
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29. Colorectal cancer risk factors
Age >65 years
Smoking
Diet
Family history
Obesity
Related conditions
Lack of exercise
Alcohol intake
The following are risk factors for colorectal cancer:
Age over 65 years
Diet low in fibre, high in red/processed meat and saturated fat
Obesity
Lack of exercise
High alcohol intake
Smoking
Family history of bowel cancer
Related conditions – Crohn’s disease, ulcerative colitis, familial adenomatous polyposis, hereditary non-polyposis colorectal cancer
NHS choices: bowel cancer, causes of bowel cancer. (accessed January 2013).
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30. Case study: Alan
Alan F is well known at his doctor’s surgery and presented at age 53 with intermittent diarrhoea (three months’ duration).
The doctor noted that his age and sex may indicate cause for concern, but since no other worrying features were present and his blood count was normal, he asked Alan to return in a month’s time to review his symptoms.
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31. Case study: Alan UKLIN1693, date of preparation: March 2013. 31
Although Alan has the concerning features of short symptom history, male sex, and age over 50 years, he has no other worrying features and his full blood count is normal. His doctor decided to keep a watchful eye on him by asking him to return for review in a month’s time.
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32. Case study: Alan
When Alan returned, he still had abdominal pain and diarrhoea.
Since Alan still did not have any worrying symptoms and his repeat full blood count was normal, he agreed with his GP to try pharmacological treatment (loperamide).
Alan’s symptoms have not progressed and his full blood count is still normal. His GP decided not to refer him, but, as shown on the next slide, he makes sure to ask Alan to return for follow-up to ensure his condition does not progress.
Some doctors may suggest performing faecal ova/parasite or occult blood tests. However, studies have found that only 1.7% of IBS patients had evidence of an intestinal pathogen on examination for faecal ova and parasites. It has also been found that faecal occult blood test fail to identify significantly more organic disease in patients with suspected IBS compared with historical prevalence rates for the general population.1
Cash BD, Schoenfeld P, Chey WD. The utility of diagnostic tests in irritable bowel syndrome patients: a systematic review. The American Journal of Gastroenterology 2002; 97:
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33. Case study: Alan
The doctor issued clear instructions for Alan to come back to the surgery for further investigation in six weeks if his symptoms persisted or if any other symptoms developed.
Alan’s symptoms do not indicate a need for referral, but he does need monitoring to ensure that his condition does not become more concerning.
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34. Case study: Alan
Six weeks later, Alan returned with painless rectal bleeding. A rectal exam revealed a haemorrhoid, but this did not sufficiently explain the bleeding and Alan’s GP referred him for urgent colonoscopy.
Alan was found to have Dukes’ stage A annular adenocarcinoma of the sigmoid colon.
This shows how important it is to monitor patients whose condition is not initially concerning – a process known as safety netting, explained further on the next slide.
In Alan’s case, his disease was caught at an early stage thanks to the explicit safety net advice and careful observation of his doctor for accumulating worrying features.
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35. Alan was diagnosed with early stage bowel cancer
Alan did not initially need referral, however, an alarm feature became apparent later. Due to the advice of his doctor to return if his symptoms changed, Alan was referred and his cancer diagnosed at an early stage. This is an example of safety netting.
Although Alan’s symptoms did not initially indicate a need for referral, a new alarm feature (rectal bleeding) became apparent at his follow-up appointment.
This demonstrates how important it is to remember that patients appear at different stages of disease evolution, and alarm features may not have developed when a patient first presents.1
Safety netting is a practice that ensures that serious diagnoses will not be missed if symptoms advance or change over time.1
Almond S, Mant D, Thompson M. Diagnostic safety-netting. British Journal of General Practice 2009; 59:
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36. NICE IBS Diagnostic Criteria1
4/15/2017
NICE IBS Diagnostic Criteria1
Patients exhibiting any of the following symptoms for at least six months in the absence of red flags:
Abdominal pain/discomfort
Bloating
Change in bowel habit
Firstly, it is important to define what we mean by IBS. Whilst there are differences of opinion as to what constitutes true IBS, NICE have the following definition which encourages the positive clinical diagnosis of IBS in the absence of red flag symptoms. We will touch upon the practical implications of this in the following slides, which will be focussing exclusively on the irritable bowel syndrome with constipation subtype.
1. NICE clinical guideline 61: irritable bowel syndrome in adults, 2008. 36

37. Specific examination findings:
To exclude organic diagnosis:
Abdominal masses/obstruction/enlarged liver2
Perianal/rectal examination
As reassurance of absence of organic diagnosis:
Carnett’s sign
Certain physical examinations are recommended to rule out organic disease.1
It should be explained to the patient that you expect the results of these tests to be negative, but are performing them to exclude the small chance of an alternative, organic diagnosis:1,2
Check for abdominal masses, obstruction, and an enlarged liver3
Perianal/rectal examination
Carnett’s sign can be checked for as a reassurance that the cause of pain is of visceral, rather than myofascial or abdominal wall, origin.1
Instructions on how to perform a perianal exam can be found in the following four hidden slides.
BSG guidelines: Spiller R, Aziz Q, Creed F, Emmanuel A, Houghton L, Hungin P, et al. Guidelines on the irritable bowel syndrome: mechanisms and practical management. Gut 2007; 56:
Valori R. Eight top tips for managing patients with medically unexplained symptoms. Frontline Gastroenterology 2011; 2:
Lucak S. Diagnosing irritable bowel syndrome: what’s too much, what’s enough? Medscape General Medicine 2004; 6: 17.
UKLIN1693, date of preparation: March 2013. 37

38. Certain tests are recommended
Non-invasive tests can also exclude the possibility of an organic diagnosis:
Full blood count
Erythrocyte sedimentation rate/C-reactive protein
Ca 125
Coeliac serology + serum IgA
Faecal calprotectin
Basic blood tests can also be performed to exclude the remote possibility of an organic diagnosis.1,2 As before, you should explain to the patient that you expect the results of these tests to be negative, but want to perform them to double check that you’re not missing anything.3
Full blood count (FBC), particularly for older patients presenting for the first time
Erythrocyte sedimentation rate (ESR), particularly for those with recent onset diarrhoea, to test for inflammation
C-reactive protein (CRP), particularly for those with recent onset diarrhoea, to test for inflammation
Endomysial/tissue transglutaminase antibody, particularly for those with diarrhoea to exclude coeliac disease
Unless alarm features are present or there is genuine uncertainty with the diagnosis, IBS patients do not require further investigations such as sigmoidoscopy, colonoscopy, ultrasound, hydrogen breath, faecal occult blood, thyroid function, or faecal ova/parasite tests.1,2
BSG guidelines: Spiller R, Aziz Q, Creed F, Emmanuel A, Houghton L, Hungin P, et al. Guidelines on the irritable bowel syndrome: mechanisms and practical management. Gut 2007; 56:
NICE clinical guideline 61, Irritable bowel syndrome in adults: diagnosis and management of irritable bowel syndrome in primary care.
Valori R. Eight top tips for managing patients with medically unexplained symptoms. Frontline Gastroenterology 2011; 2:
UKLIN1693, date of preparation: March 2013. 38

40. Which patients need to be referred?
Alarm features
Genuine uncertainty about diagnosis
Concerns are not allayed after multiple consultations
Of course, certain patients do still require referral to a gastroenterologist:1,2
Those with the alarm features listed on the next slide
Patients in whom there is a genuine uncertainty about the diagnosis
Patients who request referral and whose concerns are not allayed after multiple consultations in primary care
If patients are referred because they are still concerned despite your reassurances, it should be explained to them that you expect the test results to be negative, but performing them will exclude the small possibility of organic diagnosis.3
BSG guidelines: Spiller R, Aziz Q, Creed F, Emmanuel A, Houghton L, Hungin P, et al. Guidelines on the irritable bowel syndrome: mechanisms and practical management. Gut 2007; 56:
NICE clinical guideline 61, Irritable bowel syndrome in adults: diagnosis and management of irritable bowel syndrome in primary care.
Valori R. Eight top tips for managing patients with medically unexplained symptoms. Frontline Gastroenterology 2011; 2:
UKLIN1693, date of preparation: March 2013. 40

41. Secondary care investigations for IBS
This slide shows the rough cost of various secondary care tests for IBS, and the estimated prevalence of new patients with suspected IBS that receive them.
NICE and BSG guidance recommends that the diagnosis and management of IBS should be decommissioned from secondary to primary care.7,8 In primary care, the following measures could be implemented:7
Specially trained nurses/professionals as gatekeepers to secondary care
12-week-long IBS self management groups, supported by access to the trained nurse and IBS charity, The Gut Trust
Access to regional specialist services if required
Specialists could support this transition by helping to refine care pathways and train staff, as well as managing tertiary referral centres.7
Payment by results tariff information spreadsheet.
Thompson WG, Heaton KW, Smyth GT, Smyth C. Irritable bowel syndrome in general practice: prevalence, characteristics, and referral. Gut 2000; 46:
Salford Royal NHS Foundation Trust
Bellini M, Tosetti C, Costa F, et al. The general practitioner’s approach to irritable bowel syndrome: from intention to practice. Digestive and Liver Disease 2005; 37:
PenClarc. Thyroid function test priority briefing. (accessed April 2013).
University College Hospital
BSG commissioning report: IBS/functional symptoms. (accessed January 2013).
NICE clinical guideline 61 costing report, Irritable bowel syndrome costing report: implementing NICE guidance.
*Including biopsy.
UKLIN1693, date of preparation: March 2013. 41

42. Agreeing an IBS diagnosis:
Explanation Helps to relate symptoms to the underlying disorder and the approaches to treatment
Worries Reassurance can only come when the patient’s concerns are addressed
Goals Set realistic goals to avoid patient dissatisfaction
Ideas:
In the same way that each clinician has their own preferred consultation model, each patient will have a personal model of illness and health. When explaining a diagnosis to a patient, it can be useful to understand and refer to their ideas or perceptions of what is causing their symptoms.1
To elicit Kate’s ideas, you could ask questions such as the ones on the next slide.
Moulton L. The naked consultation: a practical guide to primary care consultation skills. Radcliffe Publishing Ltd. Oxon: 2007; pp70-74.
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43. Symptoms can be induced by stress
Patients with functional disorders such as IBS commonly have high levels of stress or anxiety.1
It has been proposed that patients with functional disease may have alterations in the hypothalamic-pituitary-adrenal axis, the central circuit that mediates stress responses.1
These alterations could predispose them to developing gut and extraintestinal symptoms in response to external stressors.1
BSG guidelines: Spiller R, Aziz Q, Creed F, Emmanuel A, Houghton L, Hungin P, et al. Guidelines on the irritable bowel syndrome: mechanisms and practical management. Gut 2007; 56:
UKLIN1693, date of preparation: March 2013. 43

44. Symptoms can be induced by diet
Intestinal function may be affected by specific types of food.
Although IgE-mediated food allergies are rarely seen in IBS food intolerances, particularly to wheat and lactose, may play a role in some patients. Intolerances can be identified by a dietitian.1
Most IBS patients will have tried some form of dietary manipulation, which may lead to the adoption of bizarre, nutritionally unbalanced diets.1
Asking about a patient’s diet may help you to understand their lifestyle and behaviours.
BSG guidelines: Spiller R, Aziz Q, Creed F, Emmanuel A, Houghton L, Hungin P, et al. Guidelines on the irritable bowel syndrome: mechanisms and practical management. Gut 2007; 56:
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45. The doctor may be the most important drug
This is particularly important in IBS:
Chronic and relapsing condition
Long-term consultation pattern
A well-known, general principle in primary care practice is that ‘the doctor is the most important drug.’1 This concept is particularly important in IBS, which is chronic and relapsing characterized by a long-term consultation pattern.2
A systematic review found that sustained continuity of care (continued care over time by the same healthcare professional) is associated with patient satisfaction, decreased hospitalizations, and improved receipt of preventive services, particularly for patients with chronic conditions such as asthma or diabetes.3
Throughout the management process, it is important to remember that patients appear at different stages of disease evolution and should therefore be reminded to alert their physician of any new symptoms (this is safety netting - more information can be found in the alarm features section).4
Stevens R. What Lord Darzi doesn't know: the role of psychodynamic factors in health. Journal of the Balint Society 2009; 37:
BSG guidelines: Spiller R, Aziz Q, Creed F, Emmanuel A, Houghton L, Hungin P, et al. Guidelines on the irritable bowel syndrome: mechanisms and practical management. Gut 2007; 56:
Cabana MD, Jee SH. Does continuity of care improve patient outcomes? The Journal of Family Practice 2004; 53:
Almond S, Mant D, Thompson M. Diagnostic safety-netting. British Journal of General Practice 2009; 59:
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46. Pharmacological management should be tailored to symptoms
Aim is symptomatic relief of the most troublesome symptom, rather than cure.
Different subtypes require different management strategies:
IBS with constipation
IBS with diarrhoea
IBS mixed
Initial management strategies such as explanation, reassurance, and dietary adjustments may be effective in some patients, but others may require further treatment with pharmacological agents. The aim of pharmacological treatment is to provide symptomatic relief, rather than a cure.
Initial treatment decisions should be based on the nature of the symptoms; hence the different subtypes of IBS require different management strategies, as shown in more detail in the management pathways on the following slides.1-3
While the objective of pharmacological treatment is usually relief of the most troublesome symptom, some symptom-targeted treatments also improve global assessment - a global measure that includes overall wellbeing, abdominal pain/discomfort, and bowel function.4
Hulisz D. The burden of illness of irritable bowel syndrome: current challenges and hope for the future. Journal of Managed Care Pharmacy 2004; 10:
BSG guidelines: Spiller R, Aziz Q, Creed F, Emmanuel A, Houghton L, Hungin P, et al. Guidelines on the irritable bowel syndrome: mechanisms and practical management. Gut 2007; 56:
NICE clinical guideline 61, Irritable bowel syndrome in adults: diagnosis and management of irritable bowel syndrome in primary care.
Ruepert L, Quartero AO, de Wit NJ, van der Heijden GJ, Rubin G, Muris JWM. Bulking agents, antispasmodics and antidepressants for the treatment of irritable bowel syndrome (review). Cochrane Database of Systematic Reviews 2011; 10: CD
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47. Summary of management options in IBS
PAIN
Antispasmodics
Linaclotide (IBS-C)
Antidepressants
TCAs
SSRIs
BLOATING
Probiotics
Linaclotide (IBS-C)
 BOWELS
Laxatives
osmotic
stimulant
fibre ?
Linaclotide (IBS-C)
 BOWELS
Antimotility agents
 FODMAPs
This slide summarizes the management options for IBS patients with different symptoms.
NB. Some probiotics may help symptoms other than bloating.
Antidepressants are not licensed for the treatment of IBS in the UK, but their use is recommended in the NICE and BSG IBS guidelines.1,2
NICE clinical guideline 61, Irritable bowel syndrome in adults: diagnosis and management of irritable bowel syndrome in primary care.
BSG guidelines: Spiller R, Aziz Q, Creed F, Emmanuel A, Houghton L, Hungin P, et al. Guidelines on the irritable bowel syndrome: mechanisms and practical management. Gut 2007; 56:
*Not licensed for IBS.
UKLIN1693, date of preparation: March 2013. 47