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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

Irritable Bowel Syndrome

Dr Bruce Davies

www.bradfordvts.co.uk

introduction
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

what is ibs
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

diagnostic criteria
Diagnostic Criteria
  • Rome 11 Diagnostic criteria.
  • Manning’s Criteria.

Bruce Davies

rome 11 diagnostic criteria
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

rome 11 diagnostic criteria6
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

rome 11 diagnostic criteria7
Rome 11 Diagnostic Criteria.
  • General:
    • Feeling of incomplete evacuation.
    • Passing mucus per rectum.
    • Abdominal fullness, bloating or swelling.

Bruce Davies

manning s criteria
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

associated symptoms
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

associated symptoms10
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

reasons to refer
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

urgent referral
Urgent Referral
  • Constant abdominal pain.
  • Constant diarrhoea.
  • Constant distension.
  • Rectal bleeding.
  • Weight loss or malaise.

Bruce Davies

subtypes
Subtypes
  • Diarrhoea predominant.
  • Constipation predominant.
  • Pain predominant.

Bruce Davies

differential diagnosis
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

examination
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

treatment
Treatment
  • Patients’ concerns.
  • Explanation.
  • Treatment approaches.

Bruce Davies

patients concerns
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

explanation
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

treatment approaches
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

antidepressants
Antidepressants
  • Poor evidence for efficacy.
  • Better evidence for tricyclics.
  • Very little evidence for SSRIs.

Bruce Davies

diarrhoea predominant
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

constipation predominant
Constipation Predominant.
  • Increased fibre.
  • Osmotic laxatives helpful. Ispaghula husk is one.
  • Stimulant laxatives make symptoms worse.
  • Lactulose may aggravate distension and flatulence.

Bruce Davies

pain predominant
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

slide24
Diet
  • Dietary manipulation may help.
  • Food intolerance is common food allergy is rare.
  • Relaxation therapies may be useful adjunct.

Bruce Davies

referral
Referral
  • About 15% of patients seen by GPs with IBS are referred.
  • Gastroenterology – Mainly upper GI symptoms.
  • General Surgical – Lower GI symptoms.

Bruce Davies

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

Bruce Davies

audit
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

psychological thoughts
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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