Irritable Bowel

Syndrome

Dr Bruce Davies

www.bradfordvts.co.uk
 Introduction
 First described in 1771.
 50% of patients present <35 years old.
 70% of sufferers are symptom free after 5
years.
 GPs will diagnose one new case per week.
 GPs will see 4-5 patients a week with IBS.
 Point prevalence of 40-50 patients per 2000
patients.
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 What Is IBS?
 A syndrome.
 One man’s
constipation is
another man’s
normality.
 Cause unknown.

 20% seem to start

after an episode of
gastroenteritis.

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 Diagnostic Criteria
 Rome 11 Diagnostic criteria.

 Manning’s Criteria.

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Rome 11 Diagnostic Criteria.

 At least 12 weeks history, which need not

be consecutive in the last 12 months of
abdominal discomfort or pain that has 2
or more of the following:
– Relieved by defecation.
– Onset associated with change in stool
frequency.
– Onset associated with change in form of the
stool.

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 Rome 11 Diagnostic Criteria.
 Supportive symptoms.
– Constipation predominant: one or more of:
 BO less than 3 times a week.
 Hard or lumpy stools.

 Straining during a bowel movement.

– Diarrhoea predominant: one or more of:

 More than 3 bowel movements per day.
 Loose [mushy] or watery stools.

 Urgency.

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Rome 11 Diagnostic Criteria.

– General:
 Feeling of incomplete evacuation.
 Passing mucus per rectum.

 Abdominal fullness, bloating or

swelling.

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 Manning’s Criteria.
 Three or more features should have been
present for at least 6 months:
– Pain relieved by defecation.
– Pain onset associated with more frequent
stools.
– Looser stools with pain onset.
– Abdominal distension.
– Mucus in the stool.
– A feeling of incomplete evacuation after
defecation.

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 Associated Symptoms
 In people with IBS in hospital OPD.
– 25% have depression.
– 25% have anxiety.
 Patients with IBS symptoms who do not
consult doctors [population surveys]
have identical psychological health to
general population.
 In one study 70% of women IBS sufferers
have dyspareunia.

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 Associated Symptoms
 Stressful life events are associated.
 Compared with controls people with

IBS are less well educated and have

poorer general health.
 Women:Men = 3:1.

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 Reasons to Refer
 Age > 45 years at
onset.
 Family history of
bowel cancer.
 Failure of primary
care management.
 Uncertainty of
diagnosis.
 Abnormality on
examination or
investigation.

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 Urgent Referral
 Constant
abdominal pain.
 Constant
diarrhoea.
 Constant
distension.
 Rectal bleeding.
 Weight loss or
malaise.

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 Subtypes

 Diarrhoea predominant.
 Constipation predominant.

 Pain predominant.

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 Differential Diagnosis
 Inflammatory bowel disease.
 Cancer.

 Diverticulosis.

 Endometriosis.

 A positive diagnosis, based on

Manning’s criteria may provoke less
anxiety than extensive tests.

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 Examination
 Results should be
normal or non-specific.
 Abdomen and rectal
examination.
 FBC, CRP.
 No consensus as to
whether FOBs or
sigmoidoscopy is
needed.

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 Treatment
 Patients’
concerns.
 Explanation.

 Treatment

approaches.

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 Patients’ Concerns.
 Usually very concerned about a
serious cause for their symptoms.
 Take time to explore the patients

agenda.
 Remember that investigations may

heighten anxiety.

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 Explanation.
 Must offer a plausible reason for
symptoms.
 Even if cause is unknown, patients

require some explanation.

 Drawing a parallel with baby colic may

help.
 Stress is currently a socially acceptable

explanation for many symptoms in life.

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 Treatment Approaches.
 Placebo effect of up to 70% in all
IBS treatments.
 Treatment should depend on

symptom sub-type.
 Often considerable overlap between

sub-groups.

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 Antidepressants

 Poor evidence for efficacy.

 Better evidence for tricyclics.

 Very little evidence for SSRIs.

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 Diarrhoea Predominant.

 Increasing dietary fibre is sensible

advice.
 Fibre varies, 55% of patients will get

worse with bran.

 “Medical fibre” adds to placebo

effect.
 Loperamide may help.

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 Constipation Predominant.
 Increased fibre.
 Osmotic laxatives helpful. Ispaghula

husk is one.
 Stimulant laxatives make symptoms

worse.
 Lactulose may aggravate distension

and flatulence.

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 Pain Predominant.
 Antispasmodics will help 66%.
 Mebeverine is probably first choice.

 Hyoscine 10mg qid can be added.

 Bloating may be helped by

peppermint oil.
 Nausea may require

metoclopramide.

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 Diet
 Dietary manipulation may help.
 Food intolerance is common food

allergy is rare.
 Relaxation therapies may be useful

adjunct.

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 Referral
 About 15% of patients seen by GPs
with IBS are referred.
 Gastroenterology – Mainly upper GI

symptoms.
 General Surgical – Lower GI

symptoms.


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 Self-help
 IBS network, St
John’s House,
Hither Green
Hospital, Hither
Green Lane,
London SE13
6RU

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 Audit?
 Numbers on repeat prescription for anti-
spasmodics.
 Do they use their drugs as prescribed?

 What other medications do they use?

 Referral rates?

 What investigations are done?

 Protocol?

 Formulary?

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 Psychological
Thoughts
 Should a mental health assessment
always be done?
 Should all therapy be directed at

psychological causes?
 Is IBS a physical or a somatisation

disorder?

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