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IBS Summary IBS denotes a mixed group of abdominal disorders for which no organic cause can be found.

Aetiology and Epidemiology - Prevalence: 10-20 %; age at onset ≲40 y; ♀:♂ ≳2:1 Pathogenesis - Most IBS probably arises from disorders of intestinal motility or enhanced visceral perception; research is underway into possible modulation of the brain-gut axis by neurotransmitter manipulation (see Rx) - Several diagnostic criteria exist to evaluate Sx and their duration (Manning, Rome I/II/III), but complex interactions between IBS and chronic pain syndromes may complicate their use Clinical Presentation - Diagnosis: only Δx IBS if abdominal pain (or discomfort) is either relieved by defaecation or associated with altered stool form or bowel frequency and ≥2 of urgency; incomplete evacuation; abdominal bloating/distention; mucous PR; worsening of Sx after food - Other Sx: nausea, urinary Sx, backache; Sx are chronic (>6/12), exacerbated by stress, menstruation or gastroenteritis - Signs: examination often normal, but general abdominal tenderness common; insufflation of air on sigmoidoscopy (not usually indicated) may reproduce pain - Reconsider IBS Δx if >40 y (esp. ♂), Hx <6/12, anorexia, ↓weight, night waking with pain/ diarrhoea, mouth ulcers, abnormal bloods, PR bleeding (Ix urgently) Ix - Bloods: FBC, ESR, CRP, LFTs, coeliac serology 1 - Stool: MC+S (esp. if diarrhoea prominent), giardia tests (often triggers IBS) - Colonoscopy ± rectal biopsy: if ≳60 y or any marker of organic disease (↑temp., blood on PR, ↓weight) - Refer: if Δx unsure; if changing Sx in ‘known’ IBS; to surgeon if rectal mucosal prolapse; to dietician if food intolerance; to counsellor if marked stress/depression (seen in ≳50 %); to gynaecologist if cyclical pain, dyspareunia, dysmenorrhoea (endometriosis often mimics IBS); to dermatologist if co-existing atopy; to chronic pain team if overlapping chronic pain syndromes; (FH of ovarian or bowel ca.) Rx - General principles: pragmatism; focus on a attempting to achieve a strong therapeutic alliance with the pt.; explanation and reassurance - Food intolerance: exclusion diets may be tried (risk of obsessions); try limiting high-bran cereals and whole grains ± fructose; drink++ (limit caffeine, EtOH, carbonated beverages); probiotics may help (OD Bacillus coagulans GBI-30, B. infantis 35624, E. coli DSM17252, L. acidophilusSDC 2012, 2013 may help pain and bloating) - Constipation: ↑fibre intake slowly (avoiding insoluble fibre, e.g. bran); ispaghula or methylcellulose are non-fermentable ∴ >lactulose

If diarrhoea prominent, add on B12/folate, TFTs

Sx are still troublesome in the rest at 5 y).Colic/bloating: antispasmodics (e. sexual) exacerbate Sx . try a bulking agent ± loperamide 2 mg after each loose stool (max 16 mg. dicycloverine 10-20 mg/8 h PO) . CBT and gut-focused hypnotherapy all have roles. mebeverine 135 mg/8 h PO.g. amitriptyline* 10-50 mg ON)/SSRIs may improve visceral hypersensitivity.. bismuth 120 mg/8 h has been tried (S/E: dark stools) . available OTC.d–1).Ψ therapy: emphasise positive aspects and prognosis (in 50 % some Sx improve or resolve after 1 y. <5 % worsen.Diarrhoea: avoid sorbitol.g. TCAs (e. alverine citrate 60-120 mg/8 h PO. verbal. explain that all forms of stress (physical.

Rx: difficult and often unsatisfactory. some evidence for Rx with PPIs or psychotherapy. eradication of H. pylori.Present similarly to DUs/GUs .Other functional disorders of the GI tract → see Rome III Diagnostic Criteria for FGIDs Functional/‘non-ulcer’ dyspepsia . may be helpful. if present. evidence for metoclopramide (sometimes used) uncertain .