NICE guidelinesfebruary 2008

Irritable bowel syndrome in adults: diagnosis and management of irritable bowel

syndrome in primary care

Why develop IBS guidelines ?• distinguish organic from functional disease• encourage early +ve diagnosis • minimize investigations• evidence based management• aid appropriate referral to GI clinics• limit referrals to non-GI specialists• reduce excess rates of surgery in IBS• raise awareness of existing IBS resources• better information and advice for patients

improve patient care and reduce costs

IntroductionIrritable bowel syndrome (IBS) is one of the most common gastrointestinal disorders, with a prevalence estimated between 10 and 20%.

People present to primary care with a wide range of symptoms, some of which overlap with other gastrointestinal disorders

The key elements of management are:• establishing a positive diagnosis• identifying symptoms that require prompt referral• working in longterm partnership with the patient

Initial Presentation

a person reports having had any of the following symptoms for at least 6 months:

• A bdominal pain or discomfort• B loating• C hange in bowel habit

Positive diagnostic criteria for IBSconsider diagnosing IBS only if the person has abdominal pain or discomfort that is:• relieved by defaecation, or• associated with altered bowel frequency or form

and at least 2 of the following:• altered stool passage• bloating, distension, tension or hardness• symptoms made worse by eating• passage of mucus• supportive non-gastrointestinal symptoms

• headache

• low backache

• fibromyalgia

• thigh pain

• lethargy

• poor sleep

• urinary frequency

• dyspareunia

• nausea

• early satiety

avoid referral to many different specialists

Multiple non GI symptoms support a diagnosis of IBS

In people who meet the diagnostic criteria

carry out the following tests to exclude otherdiagnoses:

• full blood count (FBC)• ESR or plasma viscosity• c-reactive protein (CRP)• antibody test for coeliac disease (TTG)

• (stool culture, faecal inflammatory markers)

In people who meet the diagnostic criteria

• Do not do the following tests to confirm a diagnosis of IBS:

• ultrasound• rigid/flexible sigmoidoscopy• colonoscopy or barium enema• thyroid function tests• stool ova/parasites• faecal occult blood• hydrogen breath test

Symptoms requiring referral to secondary care

If any of the following red flag symptoms:

• unintentional/unexplained weight loss• rectal bleeding• family history of bowel or ovarian cancer• In people aged over 60, a change in bowel

habit lasting more than 6 weeks with looser and/or more frequent stools.

Signs requiring referral to secondary care

assess and clinically examine people with possible IBS symptoms and refer if any of thefollowing ‘red flags’ are found:• anaemia• abdominal masses• rectal masses• inflammatory markers for IBD

• If symptoms suggest ovarian cancer consider performing a pelvic examination

Lifestyle: diet and physical activity• provide information about self-help• encourage time for leisure and relaxation• assess physical activity levels (GPPAQ)• assess diet and give general advice• review fibre intake and adjust accordingly• take probiotics according to the

manufacturers instructions for a trial of at least 4 weeks

• discourage the use of aloe vera

Randomised controlled trial of self-help interventions in patients with a primary care diagnosis of IBS

usual care (n=141)

usual care plus guidebook (n=140)

improves coping with rather than symptom severity

first line treatment for patients with functional bowel symptoms in primary care ?

baseline 1 year

1

2

3

4

5

GP

vis

its p

er y

ear

average reduction in GP visits over the trial year = 1.56 (1.98-1.15), p = 0.001

Self-help guidebook (diet, lifestyle, drugs & alternative therapies)

Robinson et al, Gut 2006

The Gut Trust is a UK national charity offering advice information and support @ www.theguttrust.org

members benefits include:• online self-help management programme.• fact sheets on all aspects of IBS• IBS telephone helpline staffed by trained nurses• support from others with IBS• practical advice and hints on living with IBS• Gut Reaction quarterly magazine

General dietary advice• have regular meals and take time to eat• avoid missing meals or long gaps between eating• drink at least 8 cups of fluid per day• restrict tea and coffee• reduce intake of alcohol and fizzy drinks• consider limiting intake of high fibre food• reduce intake of resistant starch• for diarrhoea avoid sorbitol• for wind and bloating consider oats

Probiotics and IBS

Whorwell et al Am J Gastroenterol 2006

• B. infantis 35624 (1x108 cfu) vs placebo• 362 females with IBS (Rome II)• improved abdo pain/discomfort after 4 weeks (p=0.2)• improved other IBS symptoms and global relief• available as Align™ capsules (Proctor & Gamble)

• VSL#3 (Ferring) • sachets containing live lactobacilli and bifidobacteria• can be ordered by local pharmacy (£13.95/pack of 10)

First line pharmacological treatment

choose single or combination medication basedon the predominant symptom(s)

• consider antispasmodics - these should be taken PRN alongside dietary and lifestyle measures

• offer laxatives for constipation but discourage use of lactulose

• offer loperamide as the first choice anti-motility agent for diarrhoea

• adjust he dose of laxative or anti-motility agent according to stool consistency (bristol type 4)

Second line pharmacological treatment

• consider tricyclics for their analgesic effect• start at a low dose (5-10mg equivalent of

amitriptyline) taken once at night and review regularly - the dose may be increased but should not usually exceed 30mg.

• consider SSRI’s only if tricyclics are ineffective• take into account the possible side-effects of

tricyclics and SSRI’s.• if prescribing for the first time follow up at 4

weeks and then every 6-12 months

Follow-up• agree follow-up with the person based on

symptom responses to interventions. • this should form part of the annual patient

review• investigate or refer to secondary care if ‘red

flag’ symptoms appear during management or follow-up.

Referral for psychological interventions

for people with refractory IBS who do not respond to pharmacological treatments after 12 months, consider referring for:

•cognitive behavioural therapy (CBT)•hypnotherapy•psychological therapy

do not encourage the use of acupuncture or reflexology for the treatment of IBS

Investigation of colorectal symptoms:If anaemic check ferritin/folate/B12 to confirm cause. Screen for coeliac disease in patients with diarrhoea using transglutaminse antibody (TTG). Stool cultures if acute diarrhoea (<6 weeks) particularly if there are risk factors. 1 in 10 people with bacterial gastroenteritis develop post-infectious IBS. Exclude clostridium difficile if recent antibiotic use

Alarm features – always refer to the colorectal cancer guidelines as first priorityNew colorectal symptoms in patients 45 years, rectal bleeding, iron deficiency anaemia, abdominal or rectal mass, significant unintended weight loss, family history of colorectal cancer. Also refer to alarm features in the IBD guidelines

ROME III criteriaAbdominal pain or discomfort for at least 3 days per month in the past 3 months associated with at least two of the following: (1) relieved by defaecation (2) onset associated with change in stool frequency (3) onset associated with change in stool consistencyThe presence of multiple non-gastrointestinal symptoms increases the likelihood of a functional diagnosisheadaches, poor sleep, chronic fatigue, fibromyalgia, low back pain, thigh pain, gynaecological or urinary symptoms, nausea and dyspepsia. Avoid referring to multiple specialists if these are present.

Recommendations for symptomatic treatment - use standard drug doses in the BNF unless specified below

magnesium hydroxide

drugs

diet step 1

step 2

step 1

step 2

step 3

pain bloating diarrhoea constipation

antispasmodic(s)

tricyclic

SSRI

antispasmodic(s)

trial of probiotics

loperamide

codeine phosphate

cholestyramine

fybogel

lactose exclusion slowly wheat fibre intake up to 30g/day wheat fibre and soluble fibre intake

lactose exclusion

fibre intake to 10g/day

intake of fibre and gassy foods

pain bloating diarrhoea constipation

diverticular disease

drug-induced

bowel obstruction/adhesions

functional dyspepsia

gallstones

lactose intolerance

microscopic colitis

bile salt malabsorption

slow transit constipation

pelvic floor dysfunction

gynaecological disorders

small bowel bacterial overgrowth

pancreatitis

General therapeutic approachPositive diagnosis, simple explanation, reassurance, lifestyle and dietary advice are the cornerstones of management. Refer all patients to www.theguttrust.org for information and online self-help.

All of the antispasmodics can be tried, combining an anticholinergic + smooth muscle relaxant if necessary. Best used PRN as efficacy may wear off when used regularly

Use loperamide daily at the lowest dose required - using the liquid preparation makes it easier titrate a low dose to avoid constipation. Loperamide increases anal tone and has no CNS effects unlike codeine which causes dependence and should be avoided longterm. Cholestyramine is useful for bile salt malabsorption but needs slow and careful titration.

Osmotic laxatives are best taken in small regular doses. They do not damage the bowel and longterm use is acceptable.

Start tricyclics at low doses (5-10mg) nocte and increase in weekly increments of 10mg up to 30mg. Initial side-effects such as dry mouth, nausea, constipation and sedation usually settle so encourage patients to persist with the drug if they occur. Nortriptyline is the best tolerated. SSRI’s are less effective for IBS but may be better in depressed patients and do not cause constipation. They can be used alone or in combination with a tricyclic. Continue for at least 12 months before weaning off.

full blood count in all patients If diarrhoea consider

CRP , coeliac antibodies and stool culture

NEGATIVEfunctional disorder still

highly likely but consider other

diagnosis

assess ROME 3 criteria

review response

new alarm features since

initial presentation

refractory to all treatments including

antidepressants

good response to treatment in

guidelines

observe in primary care

history

abdominal and rectal examination

symptomatic treatment

Presentation to GP with colorectal symptoms

abnormal inflammatory markers or

TTG

POSITIVEmake a positive diagnosis of IBS

urgent referral

according to guidelines

referral to gastroenterology outpatient clinic or direct access

OGD with duodenal biopsy

1

patients aged 18-45 years with NO alarm features

2

reassurance & explanationdiet and lifestyle changes

5

4

6

1.

2.

3.

4.

5.

6.

GUIDELINES FOR THE MANAGEMENT OF FUNCTIONAL LOWER GI DISORDERS IN PRIMARY CARE

3

movicol

Anti-spasmodics

dicycloverinehyoscinemebeverinealverinecolpermin

anti-cholinergics

smooth muscle relaxants

• improve global symptoms (NNT 5.5)• relieve pain (NNT 8.3)• try them all – can be used in combination• can be used PRN• often given before food

Anti-diarrhoeals

loperamide• best used regularly • titrate lowest dose that slows the gut• no effect on abdominal pain• improves anal tone• non-addictive• safe for longterm use

codeine phosphatecholestyramine

Laxativessoluble fibre• fybogelosmotic laxatives• magnesium hydroxide• movicol

• no evidence of longterm gut damage• best used regularly at a low dose • lactulose – wind and bloating• senna – abdominal cramps

Tricyclic drugs• most effective agents for pain in IBS (NNT 5)• affect motility, visceral sensitivity and central

processing • may alter pain perception during acute stress• need to sell them – resistance common• start at low dose 5-10mg and titrate slowly• taper after 6-12 months• adverse effects in 1 in 3 patients (NNH 22)• help with sleep• nortriptyline has fewer side-effects

Serotonin re-uptake inhibitors

Creed 2003

n = 257 randomisedplacebo-c

paroxetine

12 weeks

global improvement health related QoL

p<0.001p<0.001

Kuiken 2003

n = 40 randomisedplacebo-c

fluoxetine

6 weeks

global improvement abdominal pain

NSNS

Tabas 2004

n = 110 randomisedplacebo-c

paroxetine

12 weeks

global improvement p<0.01

Tack 2006

n = 23 crossoverplacebo -c

citalopram

6 weeks

painbloatingimpact of symptoms on QoLoverall wellbeing

p<0.05p<0.05p<0.05p<0.05

• Rx anxiety, depression & somatisation• serotonin modulates gut sensory & motor function

CBT in addition to antispasmodics for IBS in primary care: randomised controlled trial

• IBS patients aged 17-54 in primary care• nurse delivered CBT (6 sessions) + mebeverine (n=72)• controls on mebeverine alone (n=77)• follow up at 3, 6 and 12 months using IBS-SSS

• symptom benefit at 3 months waned at 6, 12 months• improved coping behaviours up to 6 months• less effective in males who believed in a physical cause• treatment and social costs not reduced

Kennedy et al Health Technol Assess, Jun 2006

Gut-directed hypnotherapy for IBS: piloting a primary care based RCT

• IBS patients aged 18-65 failing standard Rx• intervention (n=41): gut-directed hypnotherapy

(5 sessions) + usual management• controls (n=40): usual management

• reduced symptom scores at 3 months• less likely to require medication• no effect on QoL

Roberts Roberts et al et al Br J General Practice, Feb 2006Br J General Practice, Feb 2006