Leeds Health Pathways

Management of Irritable Bowel Syndrome (IBS) - Adult Leeds

1. Background Information / Scope of Pathway

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This pathway has been developed jointly by LTHT gastroenterologists and LWCCG.

2. Information Resource for Patients and Carers

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Recommended resources for patients and carers, produced by organisations certified by The Information Standard:

'Irritable bowel syndrome' (URL) from Bupa at http://www.bupa.co.uk
'Irritable bowel syndrome' (URL) from Patient UK at http://www.patient.co.uk

For details on how these resources are identified, please see Map of Medicine's document on Information Resources for Patients and Carers (URL - http://www.mapofmedicine.com/solution/policy).

3. Development and Updates to this Pathway

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Pathway developed in June 2014
To be reviewed June 2016

4. Likely Diagnosis of Irritable Bowel Syndrome (IBS)

Quick info:
IBS is a chronic functional condition of the lower GI tract characterised by abdominal pain or discomfort and disordered bowel habit (diarrhoea, constipation or fluctuation between the two).

There is no known structural or biochemical explanaton for the symptoms.

Symptom based criteria (e.g. Manning criteria or Rome criteria) aid diagnosis, but their main use is recruiting patients for clinical trials.

The Rome III criteria (latest revision of Rome criteria) subcategorise IBS according to the predominant symptom (diarrhoea - D-IBS, constipation - C-IBS, or alternating bowel habit).

The Rome criteria can be reviewed by clicking on this link.

In practice the division between D-IBS and C-IBS may not be clear cut [1].

Reference:
[1] Ford, AC., Vandvik, PO. Irritable Bowel Syndrome. Clinical Evidence. 01:410. 2012.

5. Red Flag

Quick info:
Symptoms and signs of Ovarian Cancer:

Carry out tests in primary care if a woman (especially if 50 or over) reports having any of the following symptoms on a persistent or frequent basis – particularly more than 12 times per month:
- persistent abdominal distension (women often refer to this as ‘bloating’)
- feeling full (early satiety) and/or loss of appetite
- pelvic or abdominal pain
- increased urinary urgency and/or frequency.
Carry out appropriate tests for ovarian cancer in any woman of 50 or over who has experienced symptoms within the last 12 months that suggest irritable bowel syndrome (IBS), because IBS rarely presents for the first time in women of this age.
See NICE Guidelines for Ovarian Cancer detection (2011) ; tests include measurement of Ca125 +/- ultrasound scanning.

Patients should be referred urgently (within 2 weeks) if they have symptoms suggesting colorectal or anal cancer:

are age 40 years and older with rectal bleeding and change of bowel habit towards looser stools and/or increased stool frequency persisting for 6 weeks or mores
are age 60 years and older with a change in bowel habit to looser stools and/or more frequent stools persisting for 6 weeks or more without rectal bleeding
are any age presenting with right lower abdominal mass consistent with involvement of the large bowel
are any age presenting with a palpable rectal mass (intraluminal and not pelvic)
are men of any age with unexplained iron deficiency anaemia
are non-menstruating women with unexplained iron deficiency anaemia
wake at night due to bowel symptoms
have weight loss
tenesmus

6. Offer General Lifestyle Advice

Quick info:
Patient information Leaflet:
Maintaining a Healthy Bowel Booklet

Diet:

insoluble fibres e.g. wholegrains, high fibre flour and breads, cereals high in bran, have been discouraged.
Soluble fibres have been recommended if more fibre is needed e.g. ispaghula, or foods high in soluble fibre, eg oats [1].

Physical activity levels:

encourage patients with low physical activity levels to increase their level of activity [2]
adults should aim to do 30 minutes of moderate intensity physical activity on at least 5 days of the week, either by doing all the daily activity in one session, or by doing several sessions of at least 10 minutes [2]
the activity can be [2]:
- lifestyle-based, eg climbing stairs, walking, or cycling
- structured exercise, eg attending a dance class or fitness training session
- sport
- a combination
increased physical activity may not be appropriate for patients with diarrhoea-predominant IBS, and patients with certain medical conditions [1,2]

Probiotic use:

National Institute for Health and Clinical Excellence (NICE) guidelines recommend that people with IBS who choose to try probiotics should [3]:
- be advised to take the product for at least four weeks while monitoring the effect
- take the dose recommended by the manufacturer
expert opinion recommends to discontinue if there is no obvious benefit after 2 months [3]

References:

[1] Clinical Knowledge Summaries (CKS). Irritable bowel syndrome. Version 1.0. Newcastle upon Tyne: CKS; 2008.

[2] Contributors representing the Royal College of Physicians; 2011.

[3] National Institute for Health and Clinical Excellence (NICE). Irritable bowel syndrome in adults: Diagnosis and management of irritable bowel syndrome in primary care. Clinical guideline 61. London: NICE; 2008.

7. Define and Manage Irritable Bowel Syndrome (IBS) According to the Dominant Symptom

Quick info:
The definition and management of irritable bowel syndrome (IBS) should be based on the nature and severity of symptoms and individual or combinations of medication, with lifestyle advice, directed at the predominant symptom(s) [1].

Establish the patient's most dominant symptom(s) through open-ended questioning, eg asking which is the most important symptom to them [1]:

patients often have more than one symptom
patients are often able to define dominant symptom(s)
non-gastrointestinal (GI) symptoms are sometimes the most dominant
management is often complex and multimodal
both physical and psychological components of the disorder need to be addressed

Reference:

[1] National Institute for Health and Clinical Excellence (NICE). Irritable bowel syndrome in adults: Diagnosis and management of irritable bowel syndrome in primary care. Clinical guideline 61. London: NICE; 2008.

8. Constipation or Diarrhoea

Quick info:
Constipation:

consider treatment with a laxative [1]
bulk-forming laxatives are preferred, eg ispaghula [1]:
- for patients who cannot tolerate a bulk-forming laxative, or who need an additional laxative, offer a macrogol (polyethylene glycol) or a stimulant laxative (for short-term use only)
lactulose is not recommended

Diarrhoea [2]:

consider treatment with an antimotility drug:
- loperamide is the antimotility drug of choice
- amitriptyline in a low dose (10-30 mg at night) may be helpful. A trial for three months would be appropriate.

A systematic review in 2012 concluded that antidepressants (TCAs and SSRIs) may reduce global symptoms of IBS and abdominal pain compared with placebo. The same review concluded loperamide may reduce stool frequency in D-IBS, but it may not improve other symptoms compared with placebo [3].

References:

[2] Clinical Knowledge Summaries (CKS). Irritable bowel syndrome. Version 1.0. Newcastle upon Tyne: CKS; 2008. [3] Ford, AC., Vandvik, PO. Irritable Bowel Syndrome. Clinical Evidence. 01:410. 2012.

9. Pain

Quick info:
If an analgesic is required, paracetamol is preferred to non-steroidal anti-inflammatory drugs (NSAIDs) [1]

opiates are to be avoided at all costs, as dependence and addiction are a high risk in such a chronic condition.
NSAIDs and opiates also have undesirable side effects on the gastrointestinal (GI) tract. First-line treatments:

A systematic review in 2012 [2] concluded

Some antispasmodic drugs e.g. hyoscine butylbromide, dicycloverine, may be more effective than placebo at improving global symptoms or abdominal pain in IBS.
Peppermint oil may be more effective than placebo at improving global symptoms or abdominal pain in IBS.
Other anti-spasmodics including mebeverine and alverine may beno more effective than placebo at improving global symptoms or abdominal pain in IBS.

Second-line treatment:

low-dose tricyclic antidepressants (TCAs) e.g. amitriptyline [1,2] may be more effective than placebo at improving persistent symptoms, global symptoms or abdominal pain in IBS.
amitriptyline in a low dose (10-30 mg at night) thus may be helpful. A trial for three months would be appropriate.

References:

[1] Clinical Knowledge Summaries (CKS). Irritable bowel syndrome. Version 1.0. Newcastle upon Tyne: CKS; 2008. [2] Ford, AC., Vandvik, PO. Irritable Bowel Syndrome. Clinical Evidence. 01:410. 2012.

10. Bloating, Distension, and Flatulence

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Bloating, distension, and flatulence:

diets including foods containing substantial amounts of poorly absorbed polysaccharides such as in some brassica and root vegetables, such as artichokes, should be avoided where excessive flatus is a problem [1]
ingestion of probiotics:
- National Institute for Health and Clinical Excellence (NICE) guidelines recommend that people with IBS who choose to try probiotics should [1]:
  - be advised to take the product for at least four weeks while monitoring the effect
  - take the dose recommended by the manufacturer
- expert clinical opinion recommends the following [2]:
  - some specific strains, such as Bifidobacterium lactis DN-173 010 and the probiotic cocktail VSL#3, have clinical trial evidence of efficacy for bloating, distension, and flatulence
  - others, such as Bifidobacterium infantis 35624, reduce bloating as well as the other cardinal symptoms of IBS
there is no evidence to support the use of activated charcoal-containing products, antiflatulents, simethicone, and other agents in irritable bowel syndrome (IBS) [1]

References:

[2] Contributors representing the Royal College of Physicians; 2011.

11. Co-Morbidity With Other Disorders

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25-30% of irritable bowel syndrome (IBS) patients also have fibromyalgia conversely IBS is common in several other chronic pain disorders [1]:

chronic fatigue syndrome (CFS; 51%)
temporomandibular joint disorder (64%)
chronic pelvic pain (50%)

The lifetime rates of IBS in patients with these symptoms are higher [1]:

fibromyalgia (77%)
CFS (92%)
temporomandibular joint disorder (92%)

Those with overlap syndromes in general have severe IBS IBS patients in primary care with numerous other somatic complaints report higher levels of [4]:

mood disorder
hypochondriasis
neuroticism
adverse life events
reduced quality of life (QoL)
increased healthcare seeking

Systematic questioning to identify these comorbid disorders is helpful in identifying patients who are likely to have severe IBS and an associated psychiatric disorder [2].

References:

[1] World Gastroenterology Organisation (WGO). Irritable bowel syndrome: a global perspective. Philadelphia, PA: WGO; 2009.

[2] Spiller R, Aziz Q, Creed F et al. Guidelines on the irritable bowel syndrome: mechanisms and practical management. Gut 2007; 56: 1770-98.

12. Consider Referral to Community Dietitian if Appropriate

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Early referral to a Dietitian may lead to a reduction in future costs of care for people with IBS reduction in future costs of care for people with IBS[1]. These costings are based on 3 x one hour dietetic consultations [1].

If diet continues to be a major factor in a person’s symptoms and they are following general lifestyle/first line advice then they should be referred to a Dietitian for advice and treatment, including single food avoidance and exclusion diets [2]. NICE stipulates this should only be given by a Dietitian [2]. British Dietetic Association guidelines outlines evidence-based second and third line IBS dietary approaches for registered Dietitians [3].
New ‘second-line’ dietary approach for IBS is a diet low in FODMAPS (Fermentable, Olio-, Di-, Monosaccharide and Polyols), which are short-chained carbohydrates that are slowly or poorly absorbed in the small intestine and increase the luminal water content of the small and large intestine via their osmotic effects [4], rapidly ferment by intestinal bacteria, resulting in increased gas production [5]. The resultant luminal distension has been hypothesised to trigger abdominal symptoms in patients with IBS [6], because of the visceral hypersensitivity, altered motility and disturbance of the brain-gut axis. Efficacy of the diet low in FODMAPs, is that the intestinal bacteria will be reduced [7] and thus symptoms resolve.
Traditional dietary approaches to IBS have 54% success rates [8]. A new IBS dietary strategy from Australia provides symptom relief in 75% of patients [6]. Similar results using this new approach are now being demonstrated in UK [8]. Evidence base for this new dietary approach has only been demonstrated in Registered Dietitians expertly trained in this new approach [6,8]. Dietary adherence is crucial to the success of the diet and confirmed using a trained Dietitian is essential to maximise outcomes [9].
A low FODMAP diet is complex and requires expertly trained Dietitians to support patients on an eight week trial diet with supporting literature. Then a lengthy reintroduction period is required to complete all the food challenges and identify ‘culprit’ foods and/or ascertain acceptable thresholds of high FODMAP foods that could be consumed. Since the diet is very restrictive it is recommended that all patients complete the reintroduction period to widen the variety of foods consumed and aid the efficacy and sustainability of this new dietary approach in the long-term. Leeds Community Dietetic has invested in training some Dietitians to deliver this new strategy.

Inclusion criteria – patients with diagnosed IBS
Exclusion criteria – patients with red flags

References
[1]. NICE. (2008). Irritable bowel syndrome: Costing report – implementing NICE guidance. Accompanies the clinical guideline CG61.

[2]. NICE. (2008). Irritable bowel syndrome in adults: diagnosis and management of Irritable bowel syndrome in primary care. CG61.

[3]. McKenzie Y.A., et al. on behalf of Gastroenterology Specialist Group of the British Dietetic Association. (2012). British Dietetic Association evidence-based practice guidelines for the dietary management of irritable bowel syndrome in adults. J Hum Nutr Diet, 25: 260–274.

[4]. Barrett JS et al 2010. Dietary poorly absorbed, short-chain carbohydrates increase delivery of water and fermentable substrates to the proximal colon. Aliment Pharmacol Ther 31, 874-882.

[5]. Ong DK et al. 2010. Manipulation of dietary short chain carbohydrates alters the pattern of gas production and genesis of symptoms in irritable bowel syndrome. J Gastroenterol Hepatol, 25, 1366-1373.

[6]. Gibson, P. R. and Shepherd, S. J. (2010), Evidence-based dietary management of functional gastrointestinal symptoms: The FODMAP approach. J Gastroenterol Hepatol, 25: 252–258.

[7]. Staudacher, H. M., et al. (2012). Fermentable carbohydrate restriction reduces luminal bididobacteria and gastrointestinal symptoms in patientw with irritable bowel syndrome. J Nutr, 142(8): 1510-8.

[8]. Staudacher, H. M., et al. (2011). Comparison of symptom response following advice for a diet low in fermentable carbohydrates (FODMAPs) versus standard dietary advice in patients with Irritable bowel syndrome . J Hum Nutr Diet, 24: 487–495.

[9]. De Roest, R. et al. (2013). The low FODMAP diet improves gastrointestinal symptoms in patients with irritable bowel syndrome: a prospective study. International Journal of Clinical Practice, 67: 895-903.

Rachel Vine, Community Dietitian, Leeds Community Healthcare NHS Trust, 18.3.14

13. Follow-Up

Quick info:
Negotiate a follow-up timescale between the clinician and the patient to evaluate the patient's response to lifestyle changes and/or any medication therapies [1].

Reference:

14. Symptoms Improve - Continue to Manage Accordingly

Quick info:
If symptoms improve:

continue to manage accordingly [1]
be aware of eating disorders developing, especially in female patients with irritable bowel syndrome (IBS) [1]:
- most patients with IBS try some form of dietary manipulation
  - this can lead to nutritionally inadequate diets or ingestion of abnormal amounts of fruit, caffeine, dairy products, and dietary fibre

Reference:

[1] World Gastroenterology Organisation (WGO). Irritable bowel syndrome: a global perspective. Philadelphia, PA: WGO; 2009.

15. Symptoms Do Not Improve

Quick info:

If symptoms have not responded to lifestyle advice, first line treatments +/- dietician, and a trial of a TCA or SSRI has not already been instigated, consider this now as follows:
Trial of a low-dose tricyclic antidepressant (TCA) for pain relief [1]:

start treatment at a low dose
review 4 weeks after starting treatment and titrate the dose upwards if necessary
continue to review every 6-12 months
consider a selective serotonin reuptake inhibitor (SSRI) if a TCA has previously been shown to be ineffective
National Institute for Health and Clinical Excellence (NICE) does not encourage the use of acupuncture or reflexology for treatment of irritable bowel syndrome (IBS) evidence for any benefit of herbal medicines is weak and should not be encouraged in patients with IBS [2]

NB: TCAs are recommended in low doses to relieve pain and not as antidepressants. SSRIs do not specifically help pain but do produce global improvement in how the patient feels [3].

References:

[1] World Gastroenterology Organisation (WGO). Irritable bowel syndrome: a global perspective. Philadelphia, PA: WGO; 2009. [2] National Institute for Health and Clinical Excellence (NICE). Irritable bowel syndrome in adults: Diagnosis and management of irritable bowel syndrome in primary care. Clinical guideline 61. London: NICE; 2008.

[3] Clinical Knowledge Summaries (CKS). Irritable bowel syndrome. Version 1.0. Newcastle upon Tyne: CKS; 2008.

16. Refractory Symptoms

Quick info:
If symptoms persist, psychological factors should again be considered.
Psychological symptoms:

stress and psychological factors are common in patients with irritable bowel syndrome (IBS) in patients referred to secondary care, approximately half will have symptoms of anxiety and depression [1,2]:
- enquire about such factors, followed by treatment helpful in many cases [1]
- a clear model of how stress can make IBS worse, and vice versa, should be discussed with the patient [1]
- systematic reviews support the efficacy of antidepressants in the treatment of IBS, and antidepressants should always be considered if depressive symptoms are prominent (persistent low mood of moderate-to-severe severity) [1]

A systematic review in 2012 concluded that CBT may reduce IBS symptoms compared with control therapy or physician's usual care in the short term, though longer term benefit is unknown. The same review advised hypnotherapy may reduce IBS symptoms compared with control therapy or physician's usual care in the short term [3].

Currently in Leeds, psychological therapies for IBS are only accessible through gastroenterology consultant referral.

References:

[2] Spiller R, Aziz Q, Creed F et al. Guidelines on the irritable bowel syndrome: mechanisms and practical management. Gut 2007; 56: 1770-98.

[3] Ford, AC., Vandvik, PO. Irritable Bowel Syndrome. Clinical Evidence. 01:410. 2012.

17. Routine Gastroenterology Referral

Quick info:
Leeds Teaching Hospitals Trust (LTHT) are currently establishing a refractory IBS clinic.

Refer patients with possible irritable bowel syndrome (IBS) for further investigation if any of the following ‘red flag’ indicators are present:

unintentional and unexplained weight loss [2]
rectal bleeding [2]
a family history of bowel or ovarian cancer [2]
a change in bowel habit lasting more than 6 weeks with looser and/or more frequent stools in patients over age 50 years [1] Assess and clinically examine patients with possible IBS and refer if any of the following are found [2]:
anaemia
abdominal masses
rectal masses
raised inflammatory markers for inflammatory bowel disease (IBD)

If symptoms may suggest ovarian cancer, consider performing a pelvic examination [2].

References:

[1] Contributors representing the Royal College of Physicians; 2011.

[2] National Institute for Health and Clinical Excellence (NICE). Irritable bowel syndrome in adults: Diagnosis and management of irritable bowel syndrome in primary care. Clinical guideline 61. London: NICE; 2008.

Key Dates

Published: 19-Jun-2014, by Leeds
Valid until: 01-Jun-2016

References

This is a list of all the references that have passed critical appraisal for use in the care map Gastroenterology - Irritable bowel syndrome (IBS)

ID Reference

1 World Gastroenterology Organisation (WGO). Irritable bowel syndrome: a global perspective. Philadelphia, PA: WGO; 2009. http://www.worldgastroenterology.org/assets/downloads/en/pdf/guidelines/20_irritable_bowel_syndrome.pdf

2 Contributors representing the Royal College of Physicians (RCP). 2011.

3 National Institute for Health and Clinical Excellence (NICE). Irritable bowel syndrome in adults: diagnosis and management of irritable bowel syndrome in primary care. Clinical guideline 61. London: NICE; 2008. http://www.nice.org.uk/nicemedia/pdf/IBSFullGuideline.pdf

4 Spiller R, Aziz Q, Creed F. Guidelines on the irritable bowel syndrome: mechanisms and practical management. Gut 2007; 56: 1770-98. http://www.bsg.org.uk/pdf_word_docs/ibs.pdf

5 Clinical Knowledge Summaries (CKS). Irritable bowel syndrome. Version 1.0. Newcastle upon Tyne: CKS; 2008. http://www.cks.nhs.uk/irritable_bowel_syndrome/management/quick_answers/scenario_irritable_bo wel_syndrome#-324216

6 Gonsalkorale WM, Houghton LA, Whorwell PJ. Hypnotherapy in irritable bowel syndrome: a large-scale audit of clinical service with examination of factors influencing responsiveness. Am J Gastroenterol 2002; 97: 954-61. http://www.ncbi.nlm.nih.gov/pubmed/12003432

7 Ford AC, Marwaha A, Lim A et al. Systematic review and meta-analysis of the prevalence of irritable bowel syndrome in individuals with dyspepsia. Clin Gastroenterol Hepatol 2010; 8: 401-9. http://www.ncbi.nlm.nih.gov/pubmed/19631762

8 Chouinard LE. The role of psyllium fibre supplementation in treating irritable bowel syndrome. Can J Diet Pract Res 2011; 72: e107-14. http://www.ncbi.nlm.nih.gov/pubmed/21382232