Irritable bowel syndrome (IBS) - suspected (PLCV)

Transcription

1 Care map information Information resources for patients and carers Updates to this care map Irritable bowel syndrome (IBS) - clinical presentation History Examination RED FLAG! - underlying malignancy or inflammatory bowel disease Consider differential diagnoses Consider colorectal cancer Consider upper gastrointestinal cancer Refer urgently to specialist or for further investigations R Diagnostic criteria Investigations Consider investigation for ovarian cancer Go to IBS - management Page 1 of 9

2 1 Care map information Scope: diagnosis and management of irritable bowel syndrome (IBS) symptoms in adults over age 18 years, including: diagnostic criteria alarm features alternative diagnosis investigations in primary and secondary care management of IBS including pharmacological interventions, diet, lifestyle, other interventions (eg counselling) Out of scope: diagnosis and management of IBS in children under age 18 years Definitions: IBS is a functional bowel disorder characterised by recurrent abdominal pain and/or discomfort which may be relieved by defecation and/or associated with an alteration in stool form or frequency [1] Incidence and prevalence: estimated prevalence in the UK is between 10-20% [3] is more common in people with dyspepsia compared to those without 8-fold increase [7] Associations: abdominal pain [3] diarrhoea [3] see 'Diarrhoea' care map for more details constipation [3] see 'Constipation' care map for more details chronic pain syndromes [1,4]: fibromyalgia chronic fatigue syndrome temporomandibular joint disorder chronic pelvic pain Prognosis: for most patients with IBS, symptoms are likely to persist, but not worsen [1] a smaller proportion will deteriorate, and some will recover completely [1]: a recent study found that while 18% of a random sample of 1021 patients in the general US population had IBS, 38% had no complaints months later approaches by the physician that positively affect the treatment outcome are [1]: acknowledging the disease educating the patient about IBS reassuring the patient 2 Information resources for patients and carers Recommended resources for patients and carers, produced by organisations certified by The Information Standard: 'Irritable bowel syndrome' (PDF) from Patient UK at 'Irritable bowel syndrome diet sheet' (PDF) from Patient UK at For details on how these resources are identified, please see Map of Medicine's document on Information Resources for Patients and Carers (URL). Page 2 of 9

3 3 Updates to this care map Local pathway enhanced by wording from international map: Date of publication: 31-Aug Irritable bowel syndrome (IBS) - clinical presentation Irritable bowel syndrome (IBS) is a chronic, relapsing, and often life-long disorder [3]. Consider assessment for IBS if the patient reports any of the following symptoms for at least 6 months [3]: abdominal pain or discomfort bloating change in bowel habit Clinical features: key features of IBS are chronic, recurring abdominal pain, and/or discomfort [4]: associated with disturbed bowel habit improved with defecation in the absence of structural abnormalities likely to account for these symptoms other common symptoms include [4]: bloating hard and/or loose stools abnormal stool frequency: less than 3 times per week or more than 3 times per day straining at defecation urgency feeling of incomplete evacuation passage of mucus per rectum symptoms are often intermittent with flares lasting 2-4 days followed by periods of remission NB: symptoms should be present for at least 6 months to distinguish them from those caused by other conditions, eg infection NB: Symptoms of IBS may overlap with other gastrointestinal disorders, eg non-ulcer dyspepsia, or coeliac disease [3]. 5 History History ask about: pattern of abdominal pain or discomfort: chronic, intermittent pain with previous episodes [1]: nocturnal pain is unusual and is considered a warning sign continuous pain [1] location varies [1] relief with defecation or passing flatus [1] pain associated with, and worsened by menses [10] other abdominal symptoms bloating, distension, borborygmi, flatulence [1] associated bowel disturbance and abnormal defecation [1]: diarrhoea for more than 2 weeks mucus in faeces Page 3 of 9

4 urgency feeling of incomplete defecation unintended weight loss [1] blood in stool [1] family history of: bowel [1,3] or ovarian cancer [3] coeliac disease [1] inflammatory bowel disease (IBD) [1] irritable bowel syndrome (IBS) [1] fever with lower abdominal pain [1] relation to [1]: menstruation drug therapy consumption of foods milk, artificial sweeteners, dieting products, or alcohol travel dietary habits [1]: irregular or inadequate meals insufficient fluid intake excessive fibre intake obsession with dietary hygiene precipitating factors: postinfective IBS patients may relate onset of symptoms to previous infectious gastroenteritis [4] associated factors [7]: patients with dyspepsia have been shown to have a higher prevalence of IBS compared to those without 8-fold increase: suggests common pathogenic mechanisms 6 Examination Examination usually reveals no relevant abnormality [4] Examination: abdominal examination [4]: ask patient to demonstrate any areas of pain pain which is well localised is atypical and suggests a possible alternative diagnosis perianal region examination [4] digital rectal examination (DRE) [4] examining for signs of systemic disease [4] Refer patients to secondary care for further investigation if any of the following are present [3]: anaemia abdominal masses rectal masses inflammatory markers for inflammatory bowel disease (IBD) Page 4 of 9

5 7 RED FLAG! - underlying malignancy or inflammatory bowel disease Refer patients to secondary care for further investigation if any of the following red flag indicators are present: unintentional and unexplained weight loss [3] rectal bleeding [3] a family history of bowel or ovarian cancer [3] a change in bowel habit in patients age 60 years or older [16]: however, expert opinion is that all adults over age 40 years presenting for the first time with persistent bowel disturbance for longer than 6 weeks merit referral to secondary care and further investigation [2] anaemia [3] abdominal masses [3] rectal masses [3] inflammatory markers for inflammatory bowel disease (IBD) [3] Referral criteria for suspected gastrointestingal malignancy recommended by the National Institute for Health and Care Excellence (NICE) for specific cancer sites are detailed in the care points below. 8 Consider differential diagnoses Other causes of constipation [5]: functional constipation drug-induced constipation Other causes of diarrhoea [5]: coeliac disease see 'Coeliac disease' care map for more details inflammatory bowel disease (IBD) see 'Ulcerative colitis' and 'Crohn's disease' care map for more details gastrointestinal (GI) infection laxative abuse antibiotic-associated diarrhoea, eg Clostridium difficile colitis Other causes of abdominal pain or discomfort: diverticular disease [5] chronic pancreatitis [5] gallstones [5] see 'Gallstones and associated symptoms' care map peptic ulcer disease [5] gastro-oesophageal reflux disease (GORD) [5] chronic mesenteric ischaemia [11] gynaecologic causes [10]: endometriosis dysfunctional uterine bleeding pelvic inflammatory disease (PID) ovarian cancer rupture ovarian cyst ectopic pregnancy Other causes of multiple chronic symptoms [5]: premenstrual syndrome see 'Premenstrual syndrome' care map endometriosis see 'Endometriosis' care map Page 5 of 9

6 anxiety see 'Anxiety' care map depression see 'Depression' care map 9 Consider colorectal cancer Refer patients urgently to a specialist suspected cancer clinic, to be seen within 2 weeks if [16]: aged 40 years and older with unexplained weight loss and abdominal pain aged 50 years and older with unexplained rectal bleeding aged 60 years and older with: iron deficiency anaemia; or changes in bowel habit tests show occult blood in their faeces: see 'Investigations' care point for further details on who should receive this test rectal or abdominal mass aged 50 years and younger with rectal bleeding, and any of the following unexplained symptoms or findings: abdominal pain change in bowel habit weight loss iron-deficiency anaemia unexplained anal mass or ulceration 10 Consider upper gastrointestinal cancer Patients with an upper abdominal mass [16]: consider an urgent suspected cancer pathway referral, to be seen within 2 weeks, if the mass is consistent with stomach cancer consider referring for an urgent direct access ultrasound scan, to be performed within 2 weeks, if the mass is consistent with: an enlarged gall bladder, to assess for gall bladder cancer an enlarged liver, to assess for liver cancer Refer for urgent direct access upper gastrointestinal endoscopy to be performed within 2 weeks in patients [16]: with dysphagia; or age 55 years and older with weight loss and any of the following: upper abdominal pain reflux dyspepsia Consider referral for non-urgent direct access upper gastrointestinal endoscopy in patients [16]: with haematemesis age 55 years and older with any of the following: treatment-resistant dyspepsia upper abdominal pain with low haemoglobin levels raised platelet count with any of the following: nausea vomiting Page 6 of 9

7 weight loss reflux dyspepsia upper abdominal pain nausea or vomiting with any of the following: weight loss reflux dyspepsia upper abdominal pain Consider the possibility of pancreatic cancer and [16]: refer patients urgently to a specialist to be seen within 2 weeks if they are aged 40 years and older and have jaundice consider an urgent direct access CT scan to be carried out within 2 weeks, or an urgent ultrasound scan if CT isn't available, in people aged 60 years and older with weight loss and any of the following: diarrhoea back pain abdominal pain nausea vomiting constipation new-onset diabetes 12 Diagnostic criteria Consider a diagnosis of irritable bowel syndrome (IBS) if all of the following are present: patient complains of abdominal discomfort or pain which is either [3]: relieved by defecation or passing of flatus; or associated with altered bowel frequency or stool form the patient has at least two of the following symptoms [3]: altered stool passage: straining urgency incomplete evacuation abdominal bloating (more common in women than men): distension tension hardness symptoms made worse by eating passage of mucus other conditions with similar features have been excluded [5] Other features which may support the diagnosis include: lethargy [1,3] nausea [1,3] backache [1,3] bladder symptoms [1,3] Page 7 of 9

8 13 Investigations The National Institute for Health and Care Excellence (NICE) recommend the following tests for patients who meet the irritable bowel syndrome (IBS) diagnostic criteria to exclude other diagnoses [3]: 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) If symptoms are suggestive of ovarian cancer, measure CA125 see 'Consider investigation for ovarian cancer' care point. Faecal calprotectin testing: is recommended as an option when inflammatory bowel disease (IBD) is a possibility and for whom specialist assessment is being considered, if [9]: cancer is not suspected; and appropriate quality assurance processes and locally agreed care pathways are in place for testing correlates with the level of bowel inflammation [9] must be interpreted in the context of a cut-off value [9]: below is negative and supports a diagnosis of IBS cut-off values vary depending on the type of test used, and local cut-offs may also be applied one study has shown CalDetect to perform well using a cut-off value of 15micrograms/g sensitivity 100% and specificity 95% is now routine in many primary care settings in the UK [10] in most cases a negative calprotectin rules out IBD [11] may spare most people with IBS from having invasive investigations [11] For patients who meet the diagnostic criteria for IBS, NICE recommend that the following are not necessary to confirm the diagnosis [3]: ultrasound colonoscopy barium enema thyroid function test (TFT) faecal ova and parasite test faecal occult blood see below hydrogen glucose breath test, eg for lactose intolerance and bacterial overgrowth NB: Clinical Knowledge Summaries (CKS) suggest that the use of some of these tests will be appropriate in patients who also have 'Red Flag' symptoms or symptoms suggestive of organic disease [5] Faecal occult blood testing [16]: may be offered to assess for colorectal cancer in patients without rectal bleeding with any of the following: are aged 50 years and older with unexplained: abdominal pain; or weight loss are aged 60 years or younger with: changes in bowel habit; or iron-deficiency anaemia are aged 60 years and older with anaemia, even in the absence of iron deficiency Ensure routine IBS assessment in patients with dyspepsia [2]. Page 8 of 9

9 14 Consider investigation for ovarian cancer Irritable bowel syndrome (IBS) rarely presents for the first time in women aged 50 years and older [16]. Tests for ovarian cancer are recommended [16]: in all women aged 50 years and older with symptoms suggestive of IBS within the last 12 months in woman (especially if age 50 years or older) reporting any of the following symptoms on a persistent or frequent basis particularly more than 12 times a month: persistent abdominal distention often described as bloating feeling dull (early satiety) and/or loss of appetite pelvic or abdominal pain increased urinary urgency and/or frequency in women with unexplained weight loss, fatigue, or changes in bowel habit The National Institute of Health and Care Excellence (NICE) recommend the following approach to investigation for possible ovarian cancer [16]: check CA125 if CA125 is 35 IU/mL or greater, carry out an ultrasound scan of the abdomen and pelvis further assessment/management is needed if: CA125 is normal; or CA125 is 35 IU/mL or greater, but ultrasound is normal NB: For a full, detailed account of assessment for suspected ovarian cancer, see the 'Ovarian cancer' care map. Page 9 of 9

10 Irritable bowel syndrome (IBS) Medicine / Gastroenterology Provenance certificate Provenance certificate for this International Map of Medicine pathway for Irritable bowel syndrome (IBS) published on 31 August 2015.