1. Irritable bowel syndrome in adults
Implementing NICE guidance
ABOUT THIS PRESENTATION: This presentation has been written to help you raise awareness of the NICE clinical guideline on Irritable bowel syndrome in adults (available at available at This guideline has been written for GPs and other staff in primary care who care for people with irritable bowel syndrome.
You can add your own organisation’s logo alongside the NICE logo. We have included notes for presenters broken down into ‘key points to raise’ for you to highlight these in your presentation and ‘additional information’ that you may want to draw on. Where necessary the recommendation will be given in full.
DISCLAIMER
This slide set is an implementation tool and should be used alongside the published guidance. This information does not supersede or replace the guidance itself.
2008
NICE clinical guideline 61

2. What this presentation covers
Background
Key priorities for implementation
Costs and savings
Discussion
Find out more
NOTES FOR PRESENTERS:
In this presentation we will start by providing a definition of the guideline scope and why it is important.
The NICE guideline contains 10 key priorities for implementation, which you can find in your quick reference guide.
The key priorities for implementation cover the following areas:
Initial assessment, including ‘red flag’ indicators
Diagnostic tests
Clinical management: dietary and lifestyle advice
Clinical management: pharmacological therapy
Costs and savings that are likely to be incurred in implementing the guideline are summarised, followed by a suggested list of questions to help prompt discussion.
Information on how to find out more about the support provided by NICE is given at the end of this presentation.

3. Background
Irritable bowel syndrome (IBS) has a prevalence of % in the general population
It is a chronic, relapsing and often life-long disorder
The people most commonly affected are those aged 20–30 years
It is twice as common in women as in men
NOTES FOR PRESENTERS:
Key points to raise:
This guideline aims to:
provide positive diagnostic criteria for people presenting with symptoms suggestive of IBS
provide guidance on clinical and cost-effective management of IBS in primary care
determine clinical indications for referral to IBS services, taking into account cost effectiveness.
Recent trends indicate there is a significant prevalence of IBS in older people.
Diagnosis and management of IBS can be frustrating, both for people presenting with IBS symptoms and for clinicians. Both parties need to understand the limitations of current knowledge about IBS and to recognise the chronic nature of the condition.
Additional information:
Key aspects of this guideline include establishing a diagnosis; referral to secondary care only after identification of ‘red flags’ (symptoms and/or features that may be caused by another condition that needs investigation); providing lifestyle advice; drug and psychological interventions; and referral and follow-up.
It may be helpful to refer to this guidance within the following health policy context:
‘National service framework for long term conditions’ (DH 2005).
‘The Expert Patient: A New Approach to Chronic Disease Management in the 21st Century’ (DH 2001).
‘Our health, our care, our say: a new direction for community services’ (DH 2006).
‘Supporting people with long term conditions to self care – a guide to developing local strategies and good practice’ (DH 2006).
‘Improving chronic disease management’ (DH 2004).

4. Initial assessment
Consider assessment for IBS if any of these symptoms have been present for at least 6 months
Abdominal pain or discomfort
Bloating
Change in bowel habit
NOTES FOR PRESENTERS:
Key points to raise:
People with IBS present to primary care with a wide range of symptoms, some of which they may be reluctant to disclose without sensitive questioning. The most common symptom profiles are ‘diarrhoea predominant’, ‘constipation predominant’ or alternating symptom profiles.
IBS symptoms may include disordered defaecation (constipation or diarrhoea or both) and abdominal distension, usually referred to as bloating.
Symptoms sometimes overlap with other gastrointestinal disorders such as non-ulcer dyspepsia or coeliac disease.
Recommendation in full:
Healthcare professionals should consider assessment for IBS if the person reports having had any of the following symptoms for at least 6 months: abdominal pain or discomfort; bloating; change in bowel habit.

5. Initial assessment: ‘red flag’ indicators
Refer to secondary care if any of these indicators present
Ask
Unintentional and unexplained weight loss
Rectal bleeding
A family history of bowel or ovarian cancer
Bowel habit change for > 6 weeks in person over 60 years
Assess/examine
Anaemia
Abdominal masses
Rectal masses
Inflammatory markers for inflammatory bowel disease
NOTES FOR PRESENTERS:
Recommendations in full:
All people presenting with possible IBS symptoms should be asked if they have any of the following ‘red flag’ indicators and should be referred to secondary care for further investigation if any are present: unintentional and unexplained weight loss; rectal bleeding; a family history of bowel or ovarian cancer; a change in bowel habit to looser and/or more frequent stools persisting for more than 6 weeks in a person aged over 60 years.
All people presenting with possible IBS symptoms should be assessed and clinically examined for the following ‘red flag’ indicators and should be referred to secondary care for further investigation if any are present: anaemia; abdominal masses; rectal masses; inflammatory markers for inflammatory bowel disease.
Measure serum CA125 in primary care in women with symptoms that suggest ovarian cancer in line with ‘Ovarian cancer’ (NICE clinical guideline 122).
See ‘Referral guidelines for suspected cancer’, NICE clinical guideline 27, for detailed referral criteria where cancer is suspected.

6. Initial assessment: establishing the diagnosis
Consider IBS diagnosis only if the person has abdominal pain that is relieved by defaecation or associated with altered bowel frequency or stool form, and at least two symptoms from:
altered stool passage
abdominal bloating, distension, tension or hardness
symptoms made worse by eating
passage of mucus
NOTES FOR PRESENTERS:
Key points to raise:
Confirming a diagnosis of IBS is a crucial part of this guideline and can normally be accomplished within primary care.
The primary aim of diagnosis should be to establish the symptom profile, with abdominal pain or discomfort being a key symptom along with the quantity, quality and site of the pain/discomfort (which can be anywhere in the abdomen) and whether this varies. This distinguishes IBS from cancer-related pain, which typically has a fixed site.
Altered stool passage could include straining, urgency or incomplete evacuation.
Abdominal bloating is more common in women than men.
Other features such as lethargy, nausea, backache and bladder symptoms are common in people with IBS, and may be used to support the diagnosis.
When establishing bowel habit, showing people the Bristol Stool Form Scale (see slide 8) may help them with description, particularly in determining quality and quantity of stool.
Recommendation in full:
A diagnosis of IBS should be considered only if the person has abdominal pain or discomfort that is either relieved by defaecation or associated with altered bowel frequency or stool form. This should be accompanied by at least two of the following four symptoms: altered stool passage (straining, urgency, incomplete evacuation); abdominal bloating (more common in women than men), distension, tension or hardness; symptoms made worse by eating; passage of mucus. Other features such as lethargy, nausea, backache and bladder symptoms are common in people with IBS, and may be used to support the diagnosis.

7. Initial assessment: establishing the diagnosis
Take the following factors into account to facilitate effective consultation
People should be asked open questions to establish symptoms, for example, ‘tell me about how your symptoms affect aspects of your daily life, such as leaving the house’
Healthcare professionals should be sensitive to the cultural, ethnic and communication needs of people for whom English is not a first language or who may have cognitive and/or behavioural problems or disabilities
NOTES FOR PRESENTERS:
Key points to raise:
Treatment and care should take into account patients’ needs and preferences.
People with IBS should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals.
If patients do not have the capacity to make decisions, healthcare professionals should follow the Department of Health guidelines – ‘Reference guide to consent for examination or treatment’ (2001) (available from Healthcare professionals also need to follow a code of practice accompanying the Mental Capacity Act (summary available from

8. Bristol Stool Form Scale
Reproduced by kind permission of Dr K W Heaton, Reader in Medicine at the University of Bristol Norgine Ltd.
NOTES FOR PRESENTERS:
Key points to raise:
A copy of the Bristol Stool Form Scale may help in determining the quality and quantity of stool, and assist in the diagnostic process during a consultation with a person with IBS.

9. Diagnostic tests
In people who meet the IBS diagnostic criteria, the following tests should be undertaken to exclude other diagnoses:
full blood count (FBC)
erythrocyte sedimentation rate (ESR) or plasma viscosity
c-reactive protein (CRP)
antibody testing for coeliac disease (endomysial antibodies [EMA] or tissue transglutaminase [TTG])
NOTES FOR PRESENTERS:
This slide features the recommendation in full.
Additional information: The low-cost tests recommended within the guideline (listed above) have been established as clinically useful in supporting a positive diagnosis of IBS.

10. Diagnostic tests
The following tests are not necessary to confirm a diagnosis where IBS diagnostic criteria are met:
ultrasound
rigid/flexible sigmoidoscopy
colonoscopy; barium enema
thyroid function test
faecal ova and parasite test
faecal occult blood test
hydrogen breath test (for lactose intolerance and bacterial overgrowth).
NOTES FOR PRESENTERS:
This slide features the recommendation in full.
Additional information:
This guideline provides an evidence-based diagnostic process for IBS, allowing primary healthcare professionals to make a positive diagnosis with confidence. This provides the potential to change the current approach to IBS diagnosis, avoiding unnecessary diagnostic tests which have limited or, in many cases, no value.

11. Clinical management of IBS: dietary and lifestyle advice
People with IBS should be given information that explains the importance of self-help in effectively managing their IBS
NOTES FOR PRESENTERS:
Recommendation in full:
People with IBS should be given information that explains the importance of self-help in effectively managing their IBS. This should include information on general lifestyle, physical activity, diet and symptom-targeted medication.
Additional information:
The NICE/British Dietetic Association IBS dietary information resource and the NICE UNG document may support healthcare professionals in implementing this recommendation.
The Gut Trust (formerly the IBS Network) has revised its IBS self-help factsheet, which now includes the dietary and lifestyle advice recommended in this guideline.
Other recommendations in full within the NICE guideline include:
Healthcare professionals should encourage people with IBS to identify and make the most of their available leisure time and to create relaxation time.[ ]
Healthcare professionals should assess the physical activity levels of people with IBS, ideally using the General Practice Physical Activity Questionnaire. People with low activity levels should be given brief advice and counselling to encourage them to increase their activity levels. [ ]

12. Clinical management of IBS: dietary and lifestyle advice
Healthcare professionals should review the fibre intake of people with IBS, adjusting (usually reducing) it while monitoring the effect on symptoms
If symptoms persist after following lifestyle/dietary advice, consider referral to a dietitian
PRESENTERS NOTES:
Key points to raise:
People with IBS should be advised to consume at least eight cups of fluid per day, especially water or other non-caffeinated drinks such as herbal teas.
People with diarrhoea should avoid sorbitol, an artificial sweetener found in sugar-free sweets (including chewing gum) and drinks, and in some diabetic and slimming products. [ ]
Recommendation in full:
Healthcare professionals should review the fibre intake of people with IBS, adjusting (usually reducing) it while monitoring the effect on symptoms. People with IBS should be discouraged from eating insoluble fibre (for example, bran). If an increase in dietary fibre is advised, it should be soluble fibre such as ispaghula powder or foods high in soluble fibre (for example, oats).
If diet continues to be considered a major factor in a person’s symptoms and they are following general lifestyle/dietary advice, they should be referred to a dietitian for advice and treatment, including single food avoidance and exclusion diets. Such advice should only be given by a dietitian.
Other recommendations in full within the NICE guideline include:
People with IBS who choose to try probiotics should be advised to take the product for at least 4 weeks while monitoring the effect. Probiotics should be taken at the dose recommended by the manufacturer. [ ]
Healthcare professionals should discourage the use of aloe vera in the treatment of IBS.[ ]

13. Clinical management of IBS: pharmacological therapy
Advise people with IBS how to adjust their doses of laxative or antimotility agent
Healthcare professionals should consider low-dose tricyclic antidepressants (TCAs) as second-line treatment, recommended only for their analgesic effect
NOTES FOR PRESENTERS:
Key points to raise:
Pharmacological management decisions should be based on the nature and severity of symptoms. Recommendations in this guideline assume that the choice of single or combination medication is determined by the predominant symptom(s).
Recommendation in full:
People with IBS should be advised how to adjust their doses of laxative or antimotility agent according to the clinical response. The dose should be titrated according to stool consistency, with the aim of achieving a soft, well-formed stool (corresponding to Bristol Stool Form Scale type 4).
Healthcare professionals should consider tricyclic antidepressants (TCAs) as second-line treatment for people with IBS if laxatives, loperamide or antispasmodics have not helped. TCAs are primarily used for treatment of depression but are only recommended here for their analgesic effect. Treatment should be started at a low dose (5–10 mg equivalent of amitriptyline), which should be taken once at night and reviewed regularly. The dose may be increased, but does not usually need to exceed 30 mg. (At the time of publication [February 2008] TCAs did not have UK marketing authorisation for the indication described. Informed consent should be obtained and documented.)
Additional information:
The Bristol Stool Form Scale is reproduced on slide 8 of this presentation.
Other recommendations in full within the NICE guideline include:
Selective serotonin reuptake inhibitors (SSRIs) should be considered for people with IBS only if TCAs have been shown to be ineffective.[ ]
Healthcare professionals should take into account the possible side effects when prescribing TCAs or SSRIs. After prescribing either of these drugs for the first time at low doses for the treatment of pain or discomfort in IBS, the person should be followed up after 4 weeks and then at 6–12 monthly intervals thereafter. [ ]
(At the time of publication [February 2008] SSRIs did not have UK marketing authorisation for the indication described. Informed consent should be obtained and documented.)

14. Costs per 100,000 population Recommendations with significant costs
Costs (£ per year)
Reduction in unnecessary diagnostic tests
– 17,200
Increased referral to dietitian
2,600
Increased prescribing of low-dose antidepressants
31,600
Increased referral to psychological interventions
3,500
Estimated net cost of implementation
20,500
ADAPTING THIS SLIDE FOR LOCAL USE: We are aware that local factors such as incidence and baseline can vary considerably when compared with the national average. NICE has provided a costing template for you to calculate the financial impact this guideline will have locally. We encourage you to calculate the local impact of this guideline by amending the local variations in the template such as incidence, baseline and uptake. You can then remove the national figures from the table and replace them with your local figures to present to your colleagues.
NOTES FOR PRESENTERS: The information on this slide has been extracted from the NICE costing report which has been provided by NICE to support implementation of this guidance. It was developed after careful consideration of the available data and by working closely with the guideline developers and other people in the NHS. It is not NICE guidance. Assumptions used in this report are based on assessment of the national average and it is recognised that local practice or circumstances may differ from this. The costs published in this report are estimates only and are not to be taken as the Institute's view of desirable, or maximum or minimum figures.
NICE has also provided a costing template to help calculate the local costs associated with implementing this guideline. The costs per 100,000 population are summarised in the table.
NICE has worked closely with the guideline developers and other people in the NHS to look at the major costs and savings related to implementing this guideline. The estimated national annual net cost arising from implementing the Irritable bowel syndrome guideline is £20,500 per 100,000 population.
It is recognised that implementation of the recommendations may take place over a number of years.
In addition, compliance with NICE guidance is one of the criteria indicating good risk reduction strategies, and in combination with meeting other criteria could lead to a discount on contributions to the NHS Litigation Authority schemes, including CNST.

15. Discussion What does our primary care IBS pathway look like?
Where do our local protocols need updating to reflect all the recommendations in the guideline?
How can we manage the expectations of clinicians and patients about the use of tests to diagnose IBS?
When should psychological interventions be considered?
Are we offering ineffective treatments for IBS? For example, reflexology, acupuncture.
NOTES FOR PRESENTERS:
These questions are suggestions that we have developed to help provide a prompt for a discussion at the end of your presentation – please edit and adapt these to suit your local situation.
With reference to question 1 (above) the emphasis within the guidance is for patients to be diagnosed and treated within primary care. It is therefore likely that existing care pathways will require review and amendment.

16. Find out more Visit www.nice.org.uk/cg061 for: Other guideline formats
Costing report and template
Audit support
Algorithm for diagnosis and management of IBS within primary care
IBS dietary information resource
NOTES FOR PRESENTERS:
The guideline is available in a number of formats.
The pathway – a digital version of the guidance.
The NICE guideline – which includes all of the recommendations in full.
The full guideline – which includes all of the evidence and rationale.
‘Understanding NICE guidance’ – a version for patients and carers.
NICE has developed tools to help organisations implement this guideline, which can be found on the NICE website.
Costing tools – a costing report gives the background to the national savings and costs associated with implementation, and a costing template allows you to estimate the local costs and savings involved.
Audit support – assists NHS trusts to determine how well they meet NICE recommendations.
An algorithm of the diagnostic and treatment pathway contained in the guidance, for awareness raising and reference within primary care settings.
An IBS dietary information resource for patients, which can be downloaded and printed from the NICE website.