2. NICE guidelines february 2008
Irritable bowel syndrome in adults: diagnosis and management of irritable bowel syndrome in primary care
NICE guidelines february 2008

3. Why develop IBS guidelines ?
distinguish organic from functional disease
encourage early +ve diagnosis
minimize investigations
evidence based management
aid appropriate referral to GI clinics
limit referrals to non-GI specialists
reduce excess rates of surgery in IBS
raise awareness of existing IBS resources
better information and advice for patients
 improve patient care and reduce costs

4. Introduction
Irritable bowel syndrome (IBS) is one of the most common gastrointestinal disorders, with a prevalence estimated between 10 and 20%.
People present to primary care with a wide range of symptoms, some of which overlap with other gastrointestinal disorders
The key elements of management are:
establishing a positive diagnosis
identifying symptoms that require prompt referral
working in longterm partnership with the patient

6. Initial Presentation
a person reports having had any of the following symptoms for at least 6 months:
A bdominal pain or discomfort
B loating
C hange in bowel habit

8. Positive diagnostic criteria for IBS
consider diagnosing IBS only if the person has abdominal pain or discomfort that is:
relieved by defaecation, or
associated with altered bowel frequency or form
and at least 2 of the following:
altered stool passage
bloating, distension, tension or hardness
symptoms made worse by eating
passage of mucus
supportive non-gastrointestinal symptoms

9. Multiple non GI symptoms support a diagnosis of IBS
headache
low backache
fibromyalgia
thigh pain
lethargy
poor sleep
urinary frequency
dyspareunia
nausea
early satiety
 avoid referral to many different specialists

11. In people who meet the diagnostic criteria
carry out the following tests to exclude other
diagnoses:
full blood count (FBC)
ESR or plasma viscosity
c-reactive protein (CRP)
antibody test for coeliac disease (TTG)
(stool culture, faecal inflammatory markers)

13. In people who meet the diagnostic criteria
Do not do the following tests to confirm a diagnosis of IBS:
ultrasound
rigid/flexible sigmoidoscopy
colonoscopy or barium enema
thyroid function tests
stool ova/parasites
faecal occult blood
hydrogen breath test

15. Symptoms requiring referral to secondary care
If any of the following red flag symptoms:
unintentional/unexplained weight loss
rectal bleeding
family history of bowel or ovarian cancer
In people aged over 60, a change in bowel habit lasting more than 6 weeks with looser and/or more frequent stools.

17. Signs requiring referral to secondary care
assess and clinically examine people with
possible IBS symptoms and refer if any of the
following ‘red flags’ are found:
anaemia
abdominal masses
rectal masses
inflammatory markers for IBD
If symptoms suggest ovarian cancer consider performing a pelvic examination

19. Lifestyle: diet and physical activity
provide information about self-help
encourage time for leisure and relaxation
assess physical activity levels (GPPAQ)
assess diet and give general advice
review fibre intake and adjust accordingly
take probiotics according to the manufacturers instructions for a trial of at least 4 weeks
discourage the use of aloe vera

20. Randomised controlled trial of self-help interventions in patients with a primary care diagnosis of IBS
Self-help guidebook (diet, lifestyle, drugs & alternative therapies)
baseline
1 year 1 2 3 4 5
GP visits per year
usual care (n=141)
usual care plus guidebook (n=140)
average reduction in GP visits over the trial year = 1.56 ( ), p = 0.001
improves coping with rather than symptom severity
first line treatment for patients with functional bowel symptoms in primary care ?
Robinson et al, Gut 2006

21. The Gut Trust is a UK national charity offering
advice information and support @
members benefits include:
online self-help management programme.
fact sheets on all aspects of IBS
IBS telephone helpline staffed by trained nurses
support from others with IBS
practical advice and hints on living with IBS
Gut Reaction quarterly magazine

24. General dietary advice
have regular meals and take time to eat
avoid missing meals or long gaps between eating
drink at least 8 cups of fluid per day
restrict tea and coffee
reduce intake of alcohol and fizzy drinks
consider limiting intake of high fibre food
reduce intake of resistant starch
for diarrhoea avoid sorbitol
for wind and bloating consider oats

25. Probiotics and IBS B. infantis 35624 (1x108 cfu) vs placebo
Whorwell et al Am J Gastroenterol 2006
B. infantis (1x108 cfu) vs placebo
362 females with IBS (Rome II)
improved abdo pain/discomfort after 4 weeks (p=0.2)
improved other IBS symptoms and global relief
available as Align™ capsules (Proctor & Gamble)
VSL#3 (Ferring)
sachets containing live lactobacilli and bifidobacteria
can be ordered by local pharmacy (£13.95/pack of 10)

27. First line pharmacological treatment
choose single or combination medication based
on the predominant symptom(s)
consider antispasmodics - these should be taken PRN alongside dietary and lifestyle measures
offer laxatives for constipation but discourage use of lactulose
offer loperamide as the first choice anti-motility agent for diarrhoea
adjust he dose of laxative or anti-motility agent according to stool consistency (bristol type 4)

29. Second line pharmacological treatment
consider tricyclics for their analgesic effect
start at a low dose (5-10mg equivalent of amitriptyline) taken once at night and review regularly - the dose may be increased but should not usually exceed 30mg.
consider SSRI’s only if tricyclics are ineffective
take into account the possible side-effects of tricyclics and SSRI’s.
if prescribing for the first time follow up at 4 weeks and then every 6-12 months

31. Follow-up
agree follow-up with the person based on symptom responses to interventions.
this should form part of the annual patient review
investigate or refer to secondary care if ‘red flag’ symptoms appear during management or follow-up.

33. Referral for psychological interventions
for people with refractory IBS who do not respond to pharmacological treatments after 12 months, consider referring for:
cognitive behavioural therapy (CBT)
hypnotherapy
psychological therapy
do not encourage the use of acupuncture
or reflexology for the treatment of IBS

34. GUIDELINES FOR THE MANAGEMENT OF FUNCTIONAL LOWER GI DISORDERS IN PRIMARY CARE1.
Investigation of colorectal symptoms:
If anaemic check ferritin/folate/B12 to confirm cause. Screen for coeliac disease in patients with diarrhoea using transglutaminse antibody (TTG). Stool cultures if acute diarrhoea (<6 weeks) particularly if there are risk factors. 1 in 10 people with bacterial gastroenteritis develop post-infectious IBS. Exclude clostridium difficile if recent antibiotic use
Alarm features – always refer to the colorectal cancer guidelines as first priority
New colorectal symptoms in patients  45 years, rectal bleeding, iron deficiency anaemia, abdominal or rectal mass, significant unintended weight loss, family history of colorectal cancer. Also refer to alarm features in the IBD guidelines
ROME III criteria
Abdominal pain or discomfort for at least 3 days per month in the past 3 months associated with at least two of the following: (1) relieved by defaecation (2) onset associated with change in stool frequency (3) onset associated with change in stool consistency
The presence of multiple non-gastrointestinal symptoms increases the likelihood of a functional diagnosis
headaches, poor sleep, chronic fatigue, fibromyalgia, low back pain, thigh pain, gynaecological or urinary symptoms, nausea and dyspepsia. Avoid referring to multiple specialists if these are present.
Presentation to GP with colorectal symptoms 2.
history
abdominal and rectal examination 3.
full blood count in all patients
If diarrhoea consider
CRP , coeliac antibodies and stool culture 1
patients aged years with NO alarm features 2 4.
pain
bloating
diarrhoea
constipation
diverticular disease
drug-induced
bowel obstruction/adhesions
functional dyspepsia
gallstones
lactose intolerance
microscopic colitis
bile salt malabsorption
slow transit constipation
pelvic floor dysfunction
gynaecological disorders
small bowel bacterial overgrowth
pancreatitis
assess ROME 3 criteria 3
POSITIVE
make a positive diagnosis of IBS
NEGATIVE
functional disorder still highly likely but consider other diagnosis 4 5.
General therapeutic approach
Positive diagnosis, simple explanation, reassurance, lifestyle and dietary advice are the cornerstones of management. Refer all patients to for information and online self-help. 6.
Recommendations for symptomatic treatment - use standard drug doses in the BNF unless specified below
reassurance & explanation
diet and lifestyle changes 5
magnesium hydroxide
drugs
diet
step 1
step 2
step 3
pain
bloating
diarrhoea
constipation
antispasmodic(s)
tricyclic
SSRI
trial of probiotics
loperamide
codeine phosphate
cholestyramine
fybogel
lactose exclusion
slowly  wheat fibre intake up to 30g/day
 wheat fibre and  soluble fibre intake
 fibre intake to 10g/day
 intake of fibre and gassy foods
symptomatic treatment 6
review response
movicol
All of the antispasmodics can be tried, combining an anticholinergic + smooth muscle relaxant if necessary. Best used PRN as efficacy may wear off when used regularly
Use loperamide daily at the lowest dose required - using the liquid preparation makes it easier titrate a low dose to avoid constipation. Loperamide increases anal tone and has no CNS effects unlike codeine which causes dependence and should be avoided longterm. Cholestyramine is useful for bile salt malabsorption but needs slow and careful titration.
Osmotic laxatives are best taken in small regular doses. They do not damage the bowel and longterm use is acceptable.
Start tricyclics at low doses (5-10mg) nocte and increase in weekly increments of 10mg up to 30mg. Initial side-effects such as dry mouth, nausea, constipation and sedation usually settle so encourage patients to persist with the drug if they occur. Nortriptyline is the best tolerated. SSRI’s are less effective for IBS but may be better in depressed patients and do not cause constipation. They can be used alone or in combination with a tricyclic. Continue for at least 12 months before weaning off.
new alarm features since initial presentation
good response to treatment in guidelines
abnormal inflammatory markers or TTG
refractory to all treatments including antidepressants
urgent referral according to guidelines
observe in primary care
referral to gastroenterology outpatient clinic or direct access OGD with duodenal biopsy

36. Anti-spasmodics dicycloverine hyoscine anti-cholinergics mebeverine
alverine
colpermin
anti-cholinergics
smooth muscle relaxants
improve global symptoms (NNT 5.5)
relieve pain (NNT 8.3)
try them all – can be used in combination
can be used PRN
often given before food

37. Anti-diarrhoeals loperamide best used regularly
titrate lowest dose that slows the gut
no effect on abdominal pain
improves anal tone
non-addictive
safe for longterm use
codeine phosphate
cholestyramine

38. Laxatives soluble fibre fybogel osmotic laxatives magnesium hydroxide
movicol
no evidence of longterm gut damage
best used regularly at a low dose
lactulose – wind and bloating
senna – abdominal cramps

39. Tricyclic drugs most effective agents for pain in IBS (NNT 5)
affect motility, visceral sensitivity and central processing
may alter pain perception during acute stress
need to sell them – resistance common
start at low dose 5-10mg and titrate slowly
taper after 6-12 months
adverse effects in 1 in 3 patients (NNH 22)
help with sleep
nortriptyline has fewer side-effects

40. Serotonin re-uptake inhibitors
Rx anxiety, depression & somatisation
serotonin modulates gut sensory & motor function
Creed 2003
n = 257
randomised
placebo-c
paroxetine
12 weeks
global improvement
health related QoL
p<0.001
Kuiken 2003
n = 40
fluoxetine
6 weeks
abdominal pain NS
Tabas 2004
n = 110
p<0.01
Tack 2006
n = 23
crossover
placebo -c
citalopram
pain
bloating
impact of symptoms on QoL
overall wellbeing
p<0.05

41. CBT in addition to antispasmodics for IBS in primary care: randomised controlled trial
IBS patients aged in primary care
nurse delivered CBT (6 sessions) + mebeverine (n=72)
controls on mebeverine alone (n=77)
follow up at 3, 6 and 12 months using IBS-SSS
symptom benefit at 3 months waned at 6, 12 months
improved coping behaviours up to 6 months
less effective in males who believed in a physical cause
treatment and social costs not reduced
Kennedy et al Health Technol Assess, Jun 2006

42. Gut-directed hypnotherapy for IBS: piloting a primary care based RCT
IBS patients aged failing standard Rx
intervention (n=41): gut-directed hypnotherapy (5 sessions) + usual management
controls (n=40): usual management
reduced symptom scores at 3 months
less likely to require medication
no effect on QoL
Roberts et al Br J General Practice, Feb 2006