1. COMMON OPD PATIENT

2. 29 y.o. lady 18 month history loose stool  2-3 per day  Begins just soft, then looser –”explosive”  Night ok  No blood, occasional mucus  Can have a week or 2 when all is ok

3. Abdominal discomfort Occasional pain relief needed Generally across lower abdomen Relieved in part by going to the toilet Weight stable No significant family history Abdominal exam and rigid sigmoidoscopy normal

4. What next?

5. Rome 3 Criteria for IBS Recurrent abdominal pain or discomfort at least 3 days/month in the last 3 months associated with 2 or more of:  Improvement with defaecation  Onset associated with change in frequency of stool  Onset associated with change in form (appearance) of stool  Diarrhoea/constipation predominant subtypes

6. Historical advice Increase fibre Adequate fluid intake Regular physical activity Avoid triggers e.g. spicy/fatty foods, “windy vegetables, caffine

7. What are FODMAPS? Poorly absorbed, short chain carbohydrates F ermentable O ligo-saccharides D i-saccharides M ono-saccharides A nd P olyols

8. Indications- why? IBS – unresponsive to traditional advice IBD with IBS symptoms during controlled periods (33% UC and 57% Crohn’s report functional symptoms) Coeliac disease without complete resolution of symptoms on strict GF diet

9. Indications – when? Waking without symptoms but develop over the day Symptoms improved with poor intake Gluten avoidance with partial improvement Already trialling self imposed food exclusion

10. Contraindications IBS associated with eating disorders Uncontrolled IBD Caution with low body weight (unless symptoms cause of this) Other symptoms such as headache, rash, asthma, eczema, allergies

11. How do FODMAPS work? When malabsorbed ↑water secretion into bowel leading to diarrhoea Sugars reach large intestine → fermented by bacteria = ↑gas Gas in small / large intestine = wind, bloating, discomfort, nausea, abdo cramps Can slow movement through bowel = constipation Other factors = bacterial overgrowth in small intestine and gut hypersensitivity to gas

12. Sources Fructose -Apple -Pear -Mango -Honey -High fructose syrup -Tinned fruit in juice - Concentrated sources: wine/ dried fruit/ excess juice/tomato paste Fructans - Wheat - Rye - Onion - Spring onion - Shallots - Leek - Artichokes - Asparagus - Inulin

13. Sources Galactans - Broccoli - Brussel sprouts - Cabbage - Legumes: - Baked beans - Red kidney beans - Chickpeas - Lentils - Soy lentils Polyols - Apricots - Plums - Cherries - Watermelon - Avocado - Mushrooms - Cauliflower - Articial sweeteners: mannitol, sorbitol, xylitol, isomalt

14. Sources Lactose - Cow’s milk - Yoghurt (2tblspns tolerated) - Soft cheese - Ice cream - Condensed milk - Custard - Evaporated milk

15. Fructose Malabsorption Those who incompletely absorb fructose leading to GI symptoms 30-40% of population malabsorb excess fructose - ? Reason > 1/3 adults with IBS unable to absorb fructose load of 25-50g FM causes symptoms due to delivery to colonic lumen where fermented to produce H2, CO2 and short chain FAs → luminal distention

16. Fructose Malabsorption Increased fructose malabsorption when taken without other food Foods problematic if have high fructose load or more fructose than glucose Prescence of glucose = improved tolerance Sucrose well tolerated Should have breath test to diagnose fructose and lactose intolerance

17. Nutritional management Prior to referral check for coeliac disease, other pathology 2-6 week low FODMAP diet + food and symptom diary 45-60 minute appointment If improvement Challenge fructose and lactose Liberalisation and maintenance: establish tolerance to FODMAPS

18. Nutritional Management Education needed Gluten vs low FODMAP Appropriate substitutes Allergy vs intolerance Avoiding constipation

19. Summary Low FODMAP diet worth trialling under dietetic supervsion Many patients will attempt to manipulate their own diet, therefore need structure and sound advice Clear explanation needed: reduced load not total avoidance

20. Questions?