1. IBS VTS teaching 1/2/12 Leena Patel

2. Overview StatisticsStatistics PathophysiologyPathophysiology SymptomsSymptoms Red flagsRed flags DiagnosisDiagnosis InvestigationInvestigation ManagementManagement

3. Statistics PrevalencePrevalence Europe – 11.5% America – 10-15% Female: Male ratio of 2:1Female: Male ratio of 2:1 Can affect any age group but commonly young people Can affect any age group but commonly young people Only 15% seek help!Only 15% seek help! Make up upto 30% of secondary care referralsMake up upto 30% of secondary care referrals

4. Pathophysiology Gastrointestinal motilityGastrointestinal motility Visceral hypersensitivityVisceral hypersensitivity Intestinal inflammationIntestinal inflammation Post-infectiousPost-infectious Food sensitivitiesFood sensitivities Bacterial overgrowthBacterial overgrowth Psychosocial dysfunctionPsychosocial dysfunction

5. ABC NICE suggests consider diagnosis of IBS if presents with:NICE suggests consider diagnosis of IBS if presents with: A bdominal pain/discomfort B loating C hange in bowel habit

6. Symptoms- Gastrointestinal Abdominal pain/discomfortAbdominal pain/discomfort Bloating/distensionBloating/distension Increased flatulence/belchingIncreased flatulence/belching Change in bowel habit – diarrhoea, constipation, alternating diarrhoea & constipationChange in bowel habit – diarrhoea, constipation, alternating diarrhoea & constipation Change in stool passage - urgency, occasional incontinence, straining, incomplete bowel emptyingChange in stool passage - urgency, occasional incontinence, straining, incomplete bowel emptying Mucus in stoolMucus in stool NauseaNausea

7. Extra-gastrointestinal symptoms LethargyLethargy Back/ thigh painBack/ thigh pain Urinary frequency and urgencyUrinary frequency and urgency MennorhagiaMennorhagia DysmenorrhoeaDysmenorrhoea DyspareuniaDyspareunia HeadacheHeadache Low moodLow mood Fibromyalgia symptomsFibromyalgia symptoms

8. Red flags Rectal bleedingRectal bleeding Unintentional or unexplained weight lossUnintentional or unexplained weight loss Anorexia/malnutritionAnorexia/malnutrition >60 years old with >6weeks of change in bowel habit to loose stool/increased frequency>60 years old with >6weeks of change in bowel habit to loose stool/increased frequency FH of bowel/ovarian cancerFH of bowel/ovarian cancer AnaemiaAnaemia Abdominal/rectal massAbdominal/rectal mass Pain affecting sleepPain affecting sleep Progressive and worseningProgressive and worsening Raised inflammatory markersRaised inflammatory markers

9. Diagnostic criteria Abdominal pain/discomfort that isAbdominal pain/discomfort that is -Relieved by defecation OR -Associated with altered bowel frequency/stool form AND at least 2 of the following:- Altered stool passage (straining, urgency, incomplete evacuation) Altered stool passage (straining, urgency, incomplete evacuation) Abdominal bloating, distension, tension, hardness Abdominal bloating, distension, tension, hardness Symptoms made worse by eating Symptoms made worse by eating Passage of mucus Passage of mucus

10. investigations DO’S FBCFBC ESR or CRPESR or CRP Coeliac serology (TTG/EMA)Coeliac serology (TTG/EMA) May consider stool culture (giardia)May consider stool culture (giardia)Don'ts Ultrasound Ultrasound TSH TSH H2 breath test for H- pylori/lactose intolerance H2 breath test for H- pylori/lactose intolerance Barium enema/endoscopic investigations Barium enema/endoscopic investigations

11. management Diet and lifestyle changesDiet and lifestyle changes MedicationMedication Psychological therapiesPsychological therapies

12. Diet & lifestyle Regular meals Regular meals Avoid missing/delaying meals Avoid missing/delaying meals 8 glasses of fluid/day 8 glasses of fluid/day Minimize caffeine to <3 cups/day Minimize caffeine to <3 cups/day Reduce alcohol and fizzy drinks Reduce alcohol and fizzy drinks Increase physical activity Increase physical activity Limit fresh fruit to 3 portions/day Limit fresh fruit to 3 portions/day Can try probiotics or 4 weeks, discontinue if not effective Can try probiotics or 4 weeks, discontinue if not effective

13. Diet Limit amounts of high fibre foods (e.g. Bran) Limit amounts of high fibre foods (e.g. Bran) Reduce intake of resistant starch (e.g. Grains, seeds, tubers, reheated potatoes) Reduce intake of resistant starch (e.g. Grains, seeds, tubers, reheated potatoes) Reduce gas producing foods (e.g. Onion, bananas, celery, carrots) Reduce gas producing foods (e.g. Onion, bananas, celery, carrots) For wind/bloating – increase soluble fibre (e.g. Oats, isphagula) and linseeds (1 tbsp/day) For wind/bloating – increase soluble fibre (e.g. Oats, isphagula) and linseeds (1 tbsp/day) For diarrhoea, try limiting artificial sweetener use and sorbitol For diarrhoea, try limiting artificial sweetener use and sorbitol If particular foods thought to be associated, can try one exclusion at a time for a period of 4 weeks If particular foods thought to be associated, can try one exclusion at a time for a period of 4 weeks Dietitian referral if appropriate Dietitian referral if appropriate

14. drugs ANTISPASMODICS ANTISPASMODICS  Anticholinergic e.g. hyoscine  Smooth muscle relaxants e.g. Mebeverine, peppermint oil Good for symptoms of bloating, wind and pain Try different ones, combination of both sometimes beneficial Tachyphylaxis can occur, prn use to reduce this

15. Drugs LAXATIVESLAXATIVES Avoid lactulose as causes bloating and wind Regular use recommended rather than intermittent use ANTIDIARRHOEALS ANTIDIARRHOEALS Can titrate dose up and down to control motions, also increases anal tone which will help reduce incontinence

16. Drugs ANTIDEPRESSANTSANTIDEPRESSANTS  Tricyclic antidepressants (e.g.. Amitriptyline) - low dose usually sufficient - Can cause constipation so may be help if diarrhoea predominant IBS  SSRI

17. Drugs Possible treatment options ( some evidence, ongoing research)Possible treatment options ( some evidence, ongoing research) -Antibiotics -5-HT3 antagonists (e.g.. ondansetron) -5-HT4 agonists

18. Psychological therapies CBT (individual or group CBT)CBT (individual or group CBT) HypnotherapyHypnotherapy Combination of antidepressant and psychological therapies found to more effective.

19. Summary Think about IBS if present with ABCThink about IBS if present with ABC Ask about GI and non-GI symptomsAsk about GI and non-GI symptoms Exclude red flagsExclude red flags Tests to exclude other possible diagnosisTests to exclude other possible diagnosis Diet and lifestyle changesDiet and lifestyle changes Medication choices depending on predominant symptoms, trial for at least 4-6 weeks.Medication choices depending on predominant symptoms, trial for at least 4-6 weeks. Psychological therapies shown to work but ?available locallyPsychological therapies shown to work but ?available locally