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Irritable Bowel Syndrome. Dr Bruce Davies www.bradfordvts.co.uk. Introduction. First described in 1771. 50% of patients present <35 years old. 70% of sufferers are symptom free after 5 years. GPs will diagnose one new case per week. GPs will see 4-5 patients a week with IBS.

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Irritable bowel syndrome l.jpg

Irritable Bowel Syndrome

Dr Bruce Davies

www.bradfordvts.co.uk


Introduction l.jpg
Introduction

  • First described in 1771.

  • 50% of patients present <35 years old.

  • 70% of sufferers are symptom free after 5 years.

  • GPs will diagnose one new case per week.

  • GPs will see 4-5 patients a week with IBS.

  • Point prevalence of 40-50 patients per 2000 patients.

Bruce Davies


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What Is IBS?

  • A syndrome.

  • One man’s constipation is another man’s normality.

  • Cause unknown.

  • 20% seem to start after an episode of gastroenteritis.

Bruce Davies


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Diagnostic Criteria

  • Rome 11 Diagnostic criteria.

  • Manning’s Criteria.

Bruce Davies


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Rome 11 Diagnostic Criteria.

  • At least 12 weeks history, which need not be consecutive in the last 12 months of abdominal discomfort or pain that has 2 or more of the following:

    • Relieved by defecation.

    • Onset associated with change in stool frequency.

    • Onset associated with change in form of the stool.

Bruce Davies


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Rome 11 Diagnostic Criteria.

  • Supportive symptoms.

    • Constipation predominant: one or more of:

      • BO less than 3 times a week.

      • Hard or lumpy stools.

      • Straining during a bowel movement.

    • Diarrhoea predominant: one or more of:

      • More than 3 bowel movements per day.

      • Loose [mushy] or watery stools.

      • Urgency.

Bruce Davies


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Rome 11 Diagnostic Criteria.

  • General:

    • Feeling of incomplete evacuation.

    • Passing mucus per rectum.

    • Abdominal fullness, bloating or swelling.

Bruce Davies


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Manning’s Criteria.

  • Three or more features should have been present for at least 6 months:

    • Pain relieved by defecation.

    • Pain onset associated with more frequent stools.

    • Looser stools with pain onset.

    • Abdominal distension.

    • Mucus in the stool.

    • A feeling of incomplete evacuation after defecation.

Bruce Davies


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Associated Symptoms

  • In people with IBS in hospital OPD.

    • 25% have depression.

    • 25% have anxiety.

  • Patients with IBS symptoms who do not consult doctors [population surveys] have identical psychological health to general population.

  • In one study 70% of women IBS sufferers have dyspareunia.

Bruce Davies


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Associated Symptoms

  • Stressful life events are associated.

  • Compared with controls people with IBS are less well educated and have poorer general health.

  • Women:Men = 3:1.

Bruce Davies


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Reasons to Refer

  • Age > 45 years at onset.

  • Family history of bowel cancer.

  • Failure of primary care management.

  • Uncertainty of diagnosis.

  • Abnormality on examination or investigation.

Bruce Davies


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Urgent Referral

  • Constant abdominal pain.

  • Constant diarrhoea.

  • Constant distension.

  • Rectal bleeding.

  • Weight loss or malaise.

Bruce Davies


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Subtypes

  • Diarrhoea predominant.

  • Constipation predominant.

  • Pain predominant.

Bruce Davies


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Differential Diagnosis

  • Inflammatory bowel disease.

  • Cancer.

  • Diverticulosis.

  • Endometriosis.

  • A positive diagnosis, based on Manning’s criteria may provoke less anxiety than extensive tests.

Bruce Davies


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Examination

  • Results should be normal or non-specific.

  • Abdomen and rectal examination.

  • FBC, CRP.

  • No consensus as to whether FOBs or sigmoidoscopy is needed.

Bruce Davies


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Treatment

  • Patients’ concerns.

  • Explanation.

  • Treatment approaches.

Bruce Davies


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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.

Bruce Davies


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Explanation.

  • Must offer a plausible reason for symptoms.

  • Even if 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.

Bruce Davies


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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.

Bruce Davies


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Antidepressants

  • Poor evidence for efficacy.

  • Better evidence for tricyclics.

  • Very little evidence for SSRIs.

Bruce Davies


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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.

Bruce Davies


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Constipation Predominant.

  • Increased fibre.

  • Osmotic laxatives helpful. Ispaghula husk is one.

  • Stimulant laxatives make symptoms worse.

  • Lactulose may aggravate distension and flatulence.

Bruce Davies


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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.

Bruce Davies


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Diet

  • Dietary manipulation may help.

  • Food intolerance is common food allergy is rare.

  • Relaxation therapies may be useful adjunct.

Bruce Davies


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Referral

  • About 15% of patients seen by GPs with IBS are referred.

  • Gastroenterology – Mainly upper GI symptoms.

  • General Surgical – Lower GI symptoms.

Bruce Davies


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Self-help

  • IBS network, St John’s House, Hither Green Hospital, Hither Green Lane, London SE13 6RU

Bruce Davies


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Audit?

  • Numbers on repeat prescription for anti-spasmodics.

  • Do they use their drugs as prescribed?

  • What other medications do they use?

  • Referral rates?

  • What investigations are done?

  • Protocol?

  • Formulary?

Bruce Davies


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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?

Bruce Davies


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