Treatment
Treatment of IBS can be difficult because symptoms often are recurrent and resistant to therapy.
Three steps approach:
- Patients’ concerns
- Explanation
- Treatment approaches
Patients’ Concerns
- Usually very concerned about a serious cause for their symptoms.
- Take time to explore the patients’ agenda.
- Remember that investigations may heighten anxiety.
Explanation
- Must offer a plausible reason for symptoms.
- Even if the cause is unknown, patients require some explanation.
- Drawing a parallel with baby colic may help.
- Stress is currently a socially acceptable explanation for many symptoms in life.
Treatment Approaches
- Placebo effect of up to 70% in all IBS treatments.
- Treatment should depend on symptom sub-type.
- Often considerable overlap between sub-groups.
Antidepressants
- Poor evidence for efficacy.
- Better evidence for tricyclics.
- Very little evidence for SSRIs.
Diarrhoea Predominant
- Increasing dietary fibre is sensible advice.
- Fibre varies; 55% of patients will get worse with bran.
- “Medical fibre” adds to placebo effect.
- Loperamide may help.
Constipation Predominant
- Increased fibre.
- Osmotic laxatives helpful. Ispaghula husk is one.
- Stimulant laxatives make symptoms worse.
- Lactulose may aggravate distension and flatulence.
Pain Predominant
- Antispasmodics will help 66%.
- Mebeverine is probably first choice.
- Hyoscine 10mg qid can be added.
- Bloating may be helped by peppermint oil.
- Nausea may require metoclopramide.
Diet
- Dietary manipulation may help.
- Food intolerance is common; food allergy is rare.
- Relaxation therapies may be useful adjunct.
Psychological Thoughts
- Should a mental health assessment always be done?
- Should all therapy be directed at psychological causes?
- Is IBS a physical or a somatisation disorder?
IBS Red Flags:
Evaluated for:
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Anaemia
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Abdominal masses
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Rectal masses
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Inflammatory bowel disease.
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Measure serum CA125 in primary care in women with symptoms that suggest ovarian cancer.
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Unintentional/unexplained weight loss
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Rectal bleeding
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Family history of bowel or ovarian cancer
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In people aged >60, change in bowel habit lasting more than 6 weeks
Diet Advice:
- A. Having regular meals
- B. Avoid leaving long gaps
- C. Drink at least 8 cups of fluid a day (non-caffeinated)
- D. Limit the intake of high fiber food
- E. Limit fresh fruit to 3 portions per day
- F. Reduce the intake of resistant starch**
IBS Management (First Line)Z
- Antispasmodic agents
- Laxatives for constipation
- Loperamide as antimotility agent for diarrhoea
IBS Management (Second Line)
- Laxatives
- TCA’s and SSRI’s
Prognosis of IBS:
- IBS does not increase the mortality or the risk of inflammatory bowel cancer
- Patients with IBS may carry an increased risk of ectopic pregnancy and miscarriage
Referral
- About 15% of patients seen by GPs with IBS are referred.
- Gastroenterology – Mainly upper GI symptoms.
- General Surgical – Lower GI symptoms.
Reasons to Refer
- Age > 50 years at onset.
- Family history of bowel cancer.
- Failure of primary care management.
- Uncertainty of diagnosis.
- Abnormality on examination or investigation.
Urgent Referral
- Constant abdominal pain.
- Constant diarrhoea.
- Constant distension.
- Rectal bleeding.
- Weight loss or malaise.
Importance of Good Explanation for IBS
- Drug of choice for IBS pain & diarrhea
- Complications of long-standing GERD
- Celiac disease should be considered in patients with diarrhea-predominant or mixed presentation IBS.
- H-pylori - Link/ Diagnosis/ Eradication
- See (Assessment of dyspepsia) in The BMJ Best Practice –PDF – Page 11.