NOTES FOR PRESENTERS: Key points to raise: This guideline aims to: provide positive diagnostic criteria for people presenting with symptoms suggestive of IBS provide guidance on clinical and cost-effective management of IBS in primary care determine clinical indications for referral to IBS services, taking into account cost effectiveness. Recent trends indicate there is a significant prevalence of IBS in older people. Diagnosis and management of IBS can be frustrating, both for people presenting with IBS symptoms and for clinicians. Both parties need to understand the limitations of current knowledge about IBS and to recognise the chronic nature of the condition. Additional information: Key aspects of this guideline include establishing a diagnosis; referral to secondary care only after identification of ‘red flags’ (symptoms and/or features that may be caused by another condition that needs investigation); providing lifestyle advice; drug and psychological interventions; and referral and follow-up. It may be helpful to refer to this guidance within the following health policy context: ‘ National service framework for long term conditions’ (DH 2005). ‘ The Expert Patient: A New Approach to Chronic Disease Management in the 21st Century’ (DH 2001). ‘ Our health, our care, our say: a new direction for community services’ (DH 2006). ‘ Supporting people with long term conditions to self care – a guide to developing local strategies and good practice’ (DH 2006). ‘ Improving chronic disease management’ (DH 2004).
NOTES FOR PRESENTERS: Key points to raise: People with IBS present to primary care with a wide range of symptoms, some of which they may be reluctant to disclose without sensitive questioning. The most common symptom profiles are ‘diarrhoea predominant’, ‘constipation predominant’ or alternating symptom profiles. IBS symptoms may include disordered defaecation (constipation or diarrhoea or both) and abdominal distension, usually referred to as bloating. Symptoms sometimes overlap with other gastrointestinal disorders such as non-ulcer dyspepsia or coeliac disease. Recommendation in full: Healthcare professionals should consider assessment for IBS if the person reports having had any of the following symptoms for at least 6 months: a bdominal pain or discomfort; bloating; change in bowel habit.
NOTES FOR PRESENTERS: Recommendations in full: All people presenting with possible IBS symptoms should be asked if they have any of the following ‘red flag’ indicators and should be referred to secondary care for further investigation if any are present: unintentional and unexplained weight loss; rectal bleeding; a family history of bowel or ovarian cancer; a change in bowel habit to looser and/or more frequent stools persisting for more than 6 weeks in a person aged over 60 years. All people presenting with possible IBS symptoms should be assessed and clinically examined for the following ‘red flag’ indicators and should be referred to secondary care for further investigation if any are present: anaemia; abdominal masses; rectal masses; inflammatory markers for inflammatory bowel disease. If there is significant concern that symptoms may suggest ovarian cancer, a pelvic examination should also be considered. S ee ‘Referral guidelines for suspected cancer’, NICE clinical guideline 27, for detailed referral criteria where cancer is suspected.
NOTES FOR PRESENTERS: Key points to raise: Confirming a diagnosis of IBS is a crucial part of this guideline and can normally be accomplished within primary care. The primary aim of diagnosis should be to establish the symptom profile, with abdominal pain or discomfort being a key symptom along with the quantity, quality and site of the pain/discomfort (which can be anywhere in the abdomen) and whether this varies. This distinguishes IBS from cancer-related pain, which typically has a fixed site. Altered stool passage could include straining, urgency or incomplete evacuation. Abdominal bloating is more common in women than men. Other features such as lethargy, nausea, backache and bladder symptoms are common in people with IBS, and may be used to support the diagnosis. When establishing bowel habit, showing people the Bristol Stool Form Scale (see slide 8) may help them with description, particularly in determining quality and quantity of stool. Recommendation in full: A diagnosis of IBS should be considered only if the person has abdominal pain or discomfort that is either relieved by defaecation or associated with altered bowel frequency or stool form. This should be accompanied by at least two of the following four symptoms: altered stool passage (straining, urgency, incomplete evacuation); abdominal bloating (more common in women than men), distension, tension or hardness; symptoms made worse by eating; passage of mucus. Other features such as lethargy, nausea, backache and bladder symptoms are common in people with IBS, and may be used to support the diagnosis.
NOTES FOR PRESENTERS: Key points to raise: A copy of the Bristol Stool Form Scale may help in determining the quality and quantity of stool, and assist in the diagnostic process during a consultation with a person with IBS.
NOTES FOR PRESENTERS: This slide features the recommendation in full. Additional information: The low-cost tests recommended within the guideline (listed above) have been established as clinically useful in supporting a positive diagnosis of IBS.
NOTES FOR PRESENTERS: This slide features the recommendation in full. Additional information: This guideline provides an evidence-based diagnostic process for IBS, allowing primary healthcare professionals to make a positive diagnosis with confidence. This provides the potential to change the current approach to IBS diagnosis, avoiding unnecessary diagnostic tests which have limited or, in many cases, no value.
NOTES FOR PRESENTERS: Recommendation in full: 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. Additional information: The NICE/British Dietetic Association IBS dietary information resource and the NICE UNG document may support healthcare professionals in implementing this recommendation. The Gut Trust (formerly the IBS Network) has revised its IBS self-help factsheet, which now includes the dietary and lifestyle advice recommended in this guideline. Other recommendations in full within the NICE guideline include: Healthcare professionals should encourage people with IBS to identify and make the most of their available leisure time and to create relaxation time.[220.127.116.11] Healthcare professionals should assess the physical activity levels of people with IBS, ideally using the General Practice Physical Activity Questionnaire. People with low activity levels should be given brief advice and counselling to encourage them to increase their activity levels. [18.104.22.168]
PRESENTERS NOTES: Key points to raise: People with IBS should be advised to consume at least eight cups of fluid per day, especially water or other non-caffeinated drinks such as herbal teas. 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. [22.214.171.124] Recommendation in full: Healthcare professionals should 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). If diet continues to be considered a major factor in a person’s symptoms and they are following general lifestyle/dietary advice, they should be referred to a dietitian for advice and treatment, including single food avoidance and exclusion diets. Such advice should only be given by a dietitian. Other recommendations in full within the NICE guideline include: 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. [126.96.36.199] Healthcare professionals should discourage the use of aloe vera in the treatment of IBS.[188.8.131.52]
NOTES FOR PRESENTERS: Key points to raise: Pharmacological management decisions should be based on the nature and severity of symptoms. Recommendations in this guideline assume that the choice of single or combination medication is determined by the predominant symptom(s). Recommendation in full: People with IBS should be advised how to adjust their doses of laxative or antimotility agent according to the clinical response. The dose should be titrated according to stool consistency, with the aim of achieving a soft, well-formed stool (corresponding to Bristol Stool Form Scale type 4). Healthcare professionals should consider tricyclic antidepressants (TCAs) as second-line treatment for people with IBS if laxatives, loperamide or antispasmodics have not helped. TCAs are primarily used for treatment of depression but are only recommended here for their analgesic effect. Treatment should be started at a low dose (5–10 mg equivalent of amitriptyline), which should be taken once at night and reviewed regularly. The dose may be increased, but does not usually need to exceed 30 mg. (At the time of publication [February 2008] TCAs did not have UK marketing authorisation for the indication described. Informed consent should be obtained and documented.) Additional information: The Bristol Stool Form Scale is reproduced on slide 8 of this presentation. Other recommendations in full within the NICE guideline include: Selective serotonin reuptake inhibitors (SSRIs) should be considered for people with IBS only if TCAs have been shown to be ineffective.[184.108.40.206] Healthcare professionals should take into account the possible side effects when prescribing TCAs or SSRIs. After prescribing either of these drugs for the first time at low doses for the treatment of pain or discomfort in IBS, the person should be followed up after 4 weeks and then at 6–12 monthly intervals thereafter. [220.127.116.11] (At the time of publication [February 2008] SSRIs did not have UK marketing authorisation for the indication described. Informed consent should be obtained and documented.)
Geprikkeld door de darmen
Geprikkeld door mijn darmen J. Schmidt MDL arts Westfries Gasthuis
Casus• Mw M. B. 26 jr; sinds 12e bij vlagen zeurende/krampende pijn onderbuik, niet gerelateerd aan menstruatie,• Geen bewegingsdrang• Opgezette buik, veel windjes; geen duidelijk verbd met levensmiddelen• Def: f 2a3x/wk, cons. 2a3 op Bristol schaal• Lozen van ontlasting geeft wat verlichting
Background• Irritable bowel syndrome (IBS) has a prevalence of 10-20% in the general population• It is a chronic, relapsing and often life-long disorder• The people most commonly affected are those aged 20–30 years• It is twice as common in women as in men
IBS: How to relate COMORBIDITY• Headache >25% • Fibromyalgia >30%• Back Pain >30% • Chronic pelvic• Fatigue >40% pain >35%• Myalgia >30% • GER >50%• Urinary Freq >20% • Functional• Dyspareunia >10% dyspepsia >30%
Initial assessment• Consider assessment for IBS if any of these symptoms have been present for at least 6 months • Abdominal pain or discomfort • Bloating • Change in bowel habit
Initial assessment: ‘red flag’ indicators• Refer to secondary care if any of these indicators present Ask • Unintentional and unexplained weight loss • Rectal bleeding • A family history of bowel or ovarian cancer • Bowel habit change for > 6 weeks in person over 60 years Assess/examine • Anaemia • Abdominal masses • Rectal masses • Inflammatory markers for inflammatory bowel disease
Initial assessment: establishing the diagnosis• Consider IBS diagnosis only if the person has abdominal pain that is relieved by defaecation or associated with altered bowel frequency or stool form, and at least two symptoms from: • altered stool passage • abdominal bloating, distension, tension or hardness • symptoms made worse by eating • passage of mucus
Bristol Stool FormScale Reproduced by kind permission of Dr K W Heaton, Reader in Medicine at the University of Bristol. 2000 Norgine Ltd.
Diagnostic tests• In people who meet the IBS diagnostic criteria, the following tests should be undertaken to exclude other diagnoses: • 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])
Diagnostic testsThe following tests are not necessary to confirm a diagnosiswhere IBS diagnostic criteria are met: • ultrasound • rigid/flexible sigmoidoscopy • colonoscopy; barium enema/ct colonography • thyroid function test • faecal ova and parasite test • faecal occult blood test • hydrogen breath test (for lactose intolerance and bacterial overgrowth).
Clinical management of IBS: dietary and lifestyle advice• People with IBS should be given information that explains the importance of self-help in effectively managing their IBS
Clinical management of IBS: dietary and lifestyle advice• Healthcare professionals should review the fibre intake of people with IBS, adjusting (usually reducing) it while monitoring the effect on symptoms• If symptoms persist after following lifestyle/dietary advice, consider referral to a dietitian
Diet• Dietary manipulation may help.• Food intolerance is common - food allergy is rare.• Relaxation therapies may be useful adjunct [e.g. hypnosis]
Diarrhoea Predominant.• Increasing dietary fibre is sensible advice• Fibre varies, 55% of patients will get worse with bran [tarwe zemelen].• “Medical fibre” adds to placebo effect.• Loperamide may help. 15
Constipation Predominant.• Increased fibre.• Osmotic laxatives helpful [PEG]• Stimulant laxatives make symptoms worse [bisacodyl]• Lactulose may aggravate distension and flatulence.
Pain Predominant.• Antispasmodics will help 66%.• Mebeverine is probably first choice.• Bloating may be helped by peppermint oil.• Nausea may require metoclopramide.
Clinical management of IBS: pharmacological therapy• Advise people with IBS how to adjust their doses of laxative or antimotility agent• Healthcare professionals should consider low- dose tricyclic antidepressants (TCAs) as second-line treatment, recommended only for their analgesic effect