This document summarizes common mistakes made in managing irritable bowel syndrome (IBS) patients. It discusses 11 potential mistakes, including failing to test for bile acid malabsorption, not recognizing somatization, and not clearly explaining the likelihood of IBS being the diagnosis early in evaluation. It emphasizes the importance of considering IBS as a heterogeneous condition requiring an individualized approach, and avoiding unnecessary or potentially harmful tests and treatments.

1. Kurdistan Board GEH/GIT Surgery weekly J Club:
Supervised by:
Professor Dr.Mohamed Alshekhani
MBChB-CABM,FRCP,EBGH.

2. Introduction:
• Around 11% of population experience IBS, one of the most
frequent GE diagnoses.
• Symptoms: abd pain associated with unpredictable bowel habits
& variable changes in the form & frequency of stool.
• While all patients with IBS suffer from recurrent bouts of abd
pain, their bowel habits are varied: 1/3 predominantly with
diarrhoea (IBS-D), 1/5 predominantly constipation (IBS-C) & ½
mixed pattern of both diarrhoea / constipation (IBS-M).
• This very heterogeneous condition undoubtedly has multiple
causes & an individualized approach to management& treatment
is required.

3. M1:Failing to detect bile salt malabsorption.
• If excess bile acids enter the colon, colonic secretion is stimulated
& more water incorporated in the stool causing frequent loose
stools &urgency, often with nocturnal diarrhoea.
• 10% of patients with IBS-D-like symptoms may have severe bile
acid malabsorption, retaining <5% of bile acids at 7 days.
• Almost ¼ IBS patients referred to secondary care with diarrhoea
have bile acid diarrhoea.
• The most sensitive/specific test is 7-day retention of Selenium-75-
labelled homocholic acid taurine (75SeHCAT) not available WW.
• If retention at 7 days is <5%, it predicts 100% response to
colestyramine, while 5–10% retention predicts a response of 37%.
• Alternatives include serum 7-alpha-hydroxy-4-cholesten-3-one
(C4), faecal bile acids and serum FGF19, also not available WW.
• A therapeutic trial of colestyramine; less reliable as influenced by
many other uncontrolled factors like diet & emotion.

4. M2:Failing to recognize somatization.
• Multiple medically unexplained symptoms are a common feature
in IBS.
• This can easily be assessed using the Patient Health
Questionnaire-12 somatic symptom (PHQ-12SS) scale, which asks
about non-GI symptoms as bodily pains &symptoms.
• <5% of healthy controls score >6 while 67% of IBS patients do.
• High scores predict more visits to the primary care physician &
are clinically useful.
• Low scores suggest alternative diagnosis to be excluded.
• Ignoring this results in multiple referrals to non-GI specialists
&cause of the excess of hysterectomies&cholecystectomies seen in
IBS patients.

5. M3:Failing to tell that IBS is the most likely diagnosis at
the onset of investigation.
• Meeting IBS criteria in the absence of any alarm features is
associated with a very high probability that investigations will
yield normal results, so it is important to make this clear to the
patient at the onset& normal test results confirms the soundness
of the diagnosis.
• By contrast, if no prior diagnosis has been made then a negative
test may simply lead to the demand for more tests, an all too
common feature of many IBS patients’ medical ‘careers’.

6. M4:Failing to recognize bloating as a key IBS feature.
• Bloating may be mysterious to many patients7physicians, often
leads to unnecessary investigations & considerable irradiation.
• Two types of bloating:
• 1. sensation of distension without any obvious change in girth
,reflect increased visceral sensitivity.
• 2. Visible distension that requires loosening of clothes &increase
in abdominal girth, something that usually worsens during the
day & remits overnight.
• Even small amount of food can induce a sudden distension of the
abdomen , a very characteristic & diagnostically helpful feature,
due to a combination of relaxation of abdominal wall&lowering of
the diaphragm,can occur within seconds.
• The day-to-day variability characteristic of IBS bloating is
different from slow progressive nature of obesity & ovarian can.

7. M5:Using opiates to control pain.
• Although the pain often is extremely severe&opiates are
undoubtedly effective, most clinicians strongly advise against
their use because receptor desensitization occurs rapidly leading
to rapid dose escalation.
• High doses of opiates are associated with troublesome side effects,
including nausea / vomiting,profound constipation& dependence.
• While IBS symptoms are usually intermittent, opiate use is
constant.
• In a subgroup of susceptible patients who often have
psychological comorbidities, opiate use may result in ‘narcotic
bowel syndrome’, in which the opiates appear to actually
aggravate the pain.
• Opiate withdrawal is difficult owing to psychological dependence,
but can result in marked remission of pain.

8. M6:misdiagnosing Chrons as IBS-D.
• All new cases of IBS-D should have, CBP, serological for coeliac
disease & faecal calprotectin to exclude IBD.
• An ileocolonoscopy should be performed for those with abnormal
results or, family history of IBD or weight loss.
• If symptoms are chronic&unchanged since a previous normal
colonoscopy this need not be repeated unless there is evidence of
systemic inflammation (raised CRP s or platelet count) or
elevated faecal calprotectin.
• Referred patients have a greater risk of having Crohn’s (8.6%).
• Colonic Crohn’s can have symptoms for many years prior to
diagnosis&often labelled as IBS as lack the key alarm features of
rectal bleeding & weight loss.
• Faecal calprotectin ,elevated platelet or microcytosis have high
sensitivity & specificity for IBD.

9. Using best practice to create a pathway to improve IBS
management: aiming for timely diagnosis, effective treatment &care
• The proportion of new patient slots used reduced from 14.3% to
8.7% over 10 months while overall costs reduced by 25% for
patients with no alarm symptoms & likely IBS aged 16–45 years.
• FC results confirmed research findings with no inflammatory
pathology, if FC≤50 μg/g over 2 years.
• 63% of patients had satisfactory control of their IBS after
specialist dietetic input with 74% reporting improved QOL.
• The combination of GP education, providing diagnosis &
management pathways, using FC to exclude IBD& providing an
effective treatment for patients with likely IBS appeared
successful,cost-effective, reduced secondary care&improved
patient care.
• Williams M, et al. Frontline Gastroenterology 2016;7:323–330.

10. M7:Performing lapchole for RUQ pain without GSs.
• The pain in patients with IBS is poorly localized, but may in some
cases be RUQt pain, which can lead to confusion with biliary pain.
• Relief on defaecation may help distinguish the two.
• The pattern of pain is also helpful: biliary pain is typically very
episodic with weeks of freedom, whereas IBS pain is associated
with only a few days free from pain before the next flare occurs.
• Postcholecystectomy pain may reflect the presence of pre-existing,
unrecognized IBS.

11. M8: Performing hysterectomy/laparoscopy& division of adhesions
for IBS pain.
• IBS patients have an increased risk of undergoing gynaecological
procedures, most likely due to the attribution of IBS symptoms to
gynaecological disease.
• Paying careful attention to the Rome criteria, especially relief on
defaecation or association of pain with changes in bowel habit,
should help distinguish IBS from other causes of lower abdominal
pain.
• Multiple somatic complaints should also point towards a diagnosis
of IBS rather than a specific gynaecological cause.
• Once surgery has been performed there is a very real risk of
developing adhesions, further confusing the diagnosis &
hindering management.

12. M9: Testing for lactose intolerance when consuming<240 ml of milk
or its equivalent/day.
• Taking a careful dietary history is important before any dietary
recommendations.
• Many patients already restrict their consumption of dairy
products & there is little point in doing a lactose tolerance test on
someone who consume <240ml of milk or its equivalent / day.

13. M10: Encouraging food exclusion without re-chalange, causing more
restricted diets & malnutrition.
.
• Some patients develop an eating disorder& lose weight because
they exclude more&more foods.
• It is vital to explain to patients that flares should only be
attributed to foods if the response can be reproduced on more
than one occasion& test these foods again after an interval &
supervision of such exclusion diets by a dietician is helpful to
avoid patients developing a nutritionally inadequate diet.

14. M11: my comments.
.
• Stool calprotectin is not sensitive for small bowel Crohn's
• Stool calpo should be quantitative & not qualitative.
• Even Performing lapchole for RUQ pain wit GSs when there is no
clear history of biliary pain.
• Even performing appendicetomy for IBS pain assuming the non-
existant chronic appendicitis as a cause.
• Giardiasis in developing countries also should be addressed.