NICE - Revised Irritable Bowel Syndrome guidelines. Dr Simon Smale Gastroenterologist, York

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1 NICE - Revised Irritable Bowel Syndrome guidelines Dr Simon Smale Gastroenterologist, York

2 Overview Diagnostic criteria History and examination Tests Clinical Management Effective intervention often requires patient empowerment Lifestyle Pharmaceuticals Psychological interventions

3 Diagnosis of IBS Consider IBS assessment in a patient with any of the following Symptoms for more than 6 months Abdominal pain or discomfort Bloating Change in bowel habit

4 Red flags All people with potential IBS should be asked about red flags; Unintentional or unexplained weight loss Rectal bleeding A family history of bowel or ovarian cancer Change in bowel habit/looser stools for more than 6 weeks in a person over 60 years old.

5 Examination Abdominal masses Rectal masses Anaemia

6 Diagnostic Tests FBC ESR/CRP Coeliac serology The following tests are not necessary to confirm diagnosis in people who meet the IBS diagnostic criteria: ultrasound rigid/flexible sigmoidoscopy colonoscopy; barium enema thyroid function test faecal ova and parasite test faecal occult blood hydrogen breath test (for lactose intolerance and bacterial overgrowth). [2008]

7 Clinical Management 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. Healthcare professionals should encourage people with IBS to identify and make the most of their available leisure time and to create relaxation time. General Practice Physical Activity Questionnaire (GPPAQ)

8 Clinical Management - Physical Activity Healthcare professionals should assess the physical activity levels of people with IBS, ideally using the General Practice Physical Activity Questionnaire (GPPAQ; see appendix J of the full guideline). People with low activity levels should be given brief advice and counselling to encourage them to increase their activity levels.

9 Clinical Management - Diet and nutrition Assess and give the following general advice; Have regular meals and take time to eat. Avoid missing meals or leaving long gaps between eating. Drink at least 8 cups of fluid per day, especially water or other non-caffeinated drinks Restrict tea and coffee to 3 cups per day. Reduce intake of alcohol and fizzy drinks. It may be helpful to limit intake of high-fibre food (such as wholemeal or high-fibre flour and breads, cereals high in bran, and whole grains such as brown rice). Reduce intake of 'resistant starch' (starch that resists digestion in the small intestine and reaches the colon intact), which is often found in processed or re-cooked foods. Limit fresh fruit to 3 portions per day (a portion should be approximately 80 g). 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. People with wind and bloating may find it helpful to eat oats (such as oat-based breakfast cereal or porridge) and linseeds (up to 1 tablespoon per day).

10 Clinical Management Diet and nutrition 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). 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. discourage the use of aloe vera in the treatment of IBS

11 Clinical Management Diet and nutrition If a person's IBS symptoms persist while following general lifestyle and dietary advice, offer advice on further dietary management. Such advice should: include single food avoidance and exclusion diets (for example, a low FODMAP [fermentable oligosaccharides, disaccharides, monosaccharides and polyols] diet) only be given by a healthcare professional with expertise in dietary management.

12 Clinical Management - Pharmacological therapy Consider prescribing antispasmodic agents Loperamide should be the first choice of antimotility agent for diarrhoea Laxatives should be considered for the treatment of constipation Lactulose use should be discouraged People with IBS should be advised how to adjust their doses of laxative or antimotility agent according to the clinical response. (BSS type 4- soft but well formed)

13 Clinical Management - Pharmacological therapy Consider linaclotide for people with IBS only if: optimal or maximum tolerated doses of previous laxatives from different classes have not helped and they have had constipation for at least 12 months. Follow up people taking linaclotide after 3 months.

14 Clinical Management - Pharmacological therapy Consider tricyclic antidepressants (TCAs) as second-line treatment (remember SEs) Start treatment at a low dose (5 10 mg equivalent of amitriptyline), nocte, and review regularly. Increase the dose if needed, but not usually beyond 30 mg Consider selective serotonin reuptake inhibitors (SSRIs) for people with IBS only if TCAs are ineffective 4 weeks and then every 6 12 months

15 Clinical Management Psycholgical therapies Referral for psychological interventions (cognitive behavioural therapy [CBT], hypnotherapy and/or psychological therapy) should be considered for people with IBS who do not respond to lifestyle and pharmacological treatments.

16 Case 1 45 year old married lady Presenting complaint Alternating bowel habit; BO 5x a day then not at all for 2-3 days Colicky abdominal pain Early satiety, weight stable (2kg increase since 2012) No Red Flags PMH Hypothyroidism DH thyroxine Lactulose PRN

17 Case 1 Social History Eating erratic don t have time Etoh 7 units a week usually at weekend Caffiene rarely Husband works away (forensic accountant) Two children 8 & 11 Mother in law unwell Family business recently gone bust brother Systemic Enquiry Tiredness and fatigue Nil focal

18 Case 1 Comfortable/ Articulate No significant abnormality Investigation normal FBC, CRP, Coeliac serology What shall we do?

19 Case 1 Tried Diet, really diffcult. Made some changes, struggling to sustain. Eating Breakfast A bit better, BO 3-4x on bad days, less constipation What now?

20 Case 1 No clear right answer Spend more time on motivational interviewing/coaching Dietician Antispasmodics? Referred to dietician and initiated mebverine tds.

21 Case1 Wait for dietician 6 weeks. Mebeverine makes me feel sick stopped What Now?

22 Case 1 TCA? Psychology referral? Hypnotherapy? Back to lifestyle change/ coaching? Wait for the dietician.. TCA

23 Case1 No better.. What will we do now?

24 Case 2 30 year old soldier returned from 3 rd tour in Middle East 12 months ago. Presenting Complaint Profuse watery loose stools, 10x a day Crampy abdominal pain, worst pre BO and after food No red flags

25 Case 2 PMH - nil DH - not tried any medication SH Single, ex partner in Edinburgh I did not expect to spend my time in the army picking up children s body parts High levels of activity inhibited by symptoms and fear of incontinence Prior excess alcohol episodically, nil now Coffee; 200g jar lasts a week

26 Case 2 Examination - unremarkable Investigation FBC, CRP, ESR, Coeliac serology normal, Faecal calprotectin 76mcg/g (<50mcg/g)

27 Faecal Calprotectin Calprotectin is a stable neutrophil granule protein detectable in stools Raised calprotectin is a marker of significant GI disease (Neoplasia, infection or IBD) Whilst normal is usually <50mcg/g significant inflammation inflammation usually results in clprotectins of >600mcg/g

28 Case 2 What now? Repeat Calprotectin Refer for colonoscopy (no!) Lifestyle and dietary review Anti-spasmodics/anti diarrhoeals Dietetic referral

29 Case 2 No response to diet and loperamide TCA - amitriptyline 10mg nocte Continue dietetic management Avoid caffiene (strategies discussed)

30 Case 2 Telephone review at 8 weeks (not 4 as no appointments!) Much better Decided to leave the army for the fire brigade New boyfriend in York

31 Case 3 68 year old Consultant s wife, attending OPA with Consultant and her best friend PC Prior IBS, investigated extensively 2 years ago (colonoscopy etc) Terrible crampy abdominal pain, bloating and variable bowel habit. At worst BO 7 x a day. No red flags

32 Case 3 PMH IBS, fibromyalgia, cholecystectomy(1980s) DH Prior antispasmodics (marginal benefit), TCA (no benefit) and trial of questran (for bile salt malabsorption no benefit)

33 Case 3 SH EtoH; 4 units nightly, non smoker Keen golfer Should be very happy SE unremarkable Examination and investigation all normal What now?

34 Case 3 Dietetic review Already doing sensible things Adequate fluids and avoiding caffiene, should reduce alcohol Try Low FODMAP diet

35 Case 3 Marginal benefit. What now? Hypnotherapy Psychological referral

36 Case 3 Husband leaves her for best friend. Psychology referral Much happier Some symptoms persist, but more bearable

37 Any Questions? Thank You