evidence & practice / CPD / long-term conditions

IRRITABLE BOWEL SYNDROME

Irritable bowel syndrome in adults:

symptoms, treatment and management
NS882 Sunderland R (2017) Irritable bowel syndrome in adults: symptoms, treatment and management. Nursing Standard.
31, 26, 52-62. Date of submission: 5 August 2016; date of acceptance: 13 October 2016. doi: 10.7748/ns.2017.e10654

Rhian Sunderland Abstract

Clinical specialist Irritable bowel syndrome (IBS) is a complex functional bowel disorder. It can be difficult
physiotherapist to treat because of its presentation with multiple symptoms and aggravating factors.
(biofeedback), St Marks GPs and gastroenterologists regularly see patients return for advice on symptom
Hospital, London, England management. IBS is often misdiagnosed, and is not always managed effectively, despite
the guidance available to clinicians. This article aims to inform readers about the
Correspondence symptoms and sub-classifications of IBS and the range of pharmacological and non-
rhian.sunderland@nhs.net pharmacological treatments available, to enable nurses to understand and manage
symptoms of the condition in this group of patients.
Conflict of interest
None declared Keywords
abdominal pain, biofeedback, bowel disorders, constipation, diarrhoea, gastrointestinal
Peer review system and disorders, irritable bowel syndrome, IBS
This article has been
subject to external
double-blind peer
review and checked Aims and intended learning Relevance to The Code
for plagiarism using outcomes Nurses are encouraged to apply the
automated software The aim of this article is to ensure four themes of The Code: Professional
healthcare professionals understand the Standards of Practice and Behaviour for
Revalidation symptoms and risk factors associated Nurses and Midwives to their professional
Prepare for revalidation: with irritable bowel syndrome (IBS) in practice (Nursing and Midwifery Council
read this CPD article, adults, and to inform them about the (NMC) 2015). The themes are: Prioritise
answer the questionnaire treatment and management options people, Practise effectively, Preserve safety,
and write a reflective available. After reading this article and and Promote professionalism and trust.
account: rcni.com/ completing the time out activities you This article relates to The Code in the
revalidation should be able to: following ways:
Describe the different sub-classifications It informs nurses about pharmacological
Online of IBS. and non-pharmacological treatments
For related articles visit List the signs and symptoms of IBS in for patients with IBS. The Code states
the archive and search adults. that nurses must practise effectively by
using the keywords Outline the risk factors that contribute ensuring that any information or advice
to the development of IBS. given is evidence based.
To write a CPD article Explain your role in the treatment and Nurses must prioritise people by
Please email gwen. management of IBS in adults. encouraging and empowering patients
clarke@rcni.com. Assess and treat patients who present with IBS to take an active role in making
Guidelines on writing for with IBS in your practice setting. decisions about their treatment and care.
publication are available Discuss pharmacological and non- The Code states that nurses must act in
at: journals.rcni.com/r/ pharmacological treatment interventions partnership with those receiving care,
author-guidelines for adults with IBS. assisting them to access relevant health
Describe the use of biofeedback therapy and social care, information and support
in the treatment of IBS. when they need it.

52 / 22 February 2017 / volume 31 number 26 nursingstandard.com

 Nurses must recognise and respect the
contribution people can make to their
own health and wellbeing. This article
indicates how nurses can enable patients
to manage diet, lifestyle, stress and
anxiety, which are common aggravating
factors in IBS.
Nurses must work within their
competence when assessing and treating
patients with IBS, requesting support
to carry out any action or procedure
beyond the limits of their competence,
for example a digital rectal examination.
Introduction
IBS is a chronic, relapsing functional
bowel disorder. Most adults with the
condition experience episodes of symptom
exacerbation, followed by periods when
symptoms remain dormant (Emmanuel and
Quigley 2013). The term IBS is used to define
the presence of various abdominal symptoms
with no organic cause (Travis et al 2005). IBS
is characterised by the presence of abdominal
pain and discomfort, and is associated with
disordered defaecation or a change in bowel
habit (National Institute for Health and Care
Excellence (NICE) 2015).
Symptoms and their effect vary between
individuals. Women are two to four times
more likely to have IBS symptoms than men
(Travis et al 2005). Prevalence studies in
2015, indicated that 10-15% of people in the
UK had IBS and that the condition accounted
for 2% of GP appointments (Quigley et al
2015). IBS accounted for 40-60% of referrals
made to gastroenterologists in 2014
(Jones et al 2000). In 2012/13 in the UK, the
cost to the NHS for laxatives was
44,977,959 and 25,582,752 for
antispasmodic medications (Soubieres et al
2015). These medications are commonly
used to treat patients with IBS.
IBS is a significant health issue that
affects many individuals. It is most
prevalent in people aged 15-65 years.
Many cases develop in early childhood, yet
often individuals do not present with the
problem until they are in their late 20s
to 40s (NICE 2015).
Patients commonly present with
symptoms that may include (NICE 2015):
Constipation, diarrhoea or both (mixed).
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Abdominal distension and/or bloating. KEY POINT
Abdominal pain. IBS is a chronic, relapsing
functional bowel disorder.
Diagnosing IBS Most adults with the
Diagnosis of IBS can be challenging and the condition experience
condition is not always formally diagnosed episodes of symptom
by healthcare professionals. Research exacerbation, followed by
indicates that many primary care providers periods when symptoms
are unaware of the diagnostic criteria remain dormant
for IBS (Hungin et al 2014). Suboptimal (Emmanuel and Quigley
diagnosis is likely, because of the multiple 2013). The term IBS is used
and variable presentation of symptoms and to define the presence
the lack of biological disease markers for of various abdominal
the condition (Soubieres et al 2015). Many symptoms with no organic
primary care physicians have shown a cause (Travis et al 2005).
preference for referring patients to specialist IBS is characterised by the
gastroenterologists for further diagnostic presence of abdominal
testing (Hungin et al 2014), although NICE pain and discomfort, and is
(2015) guidelines and the British Society of associated with disordered
Gastroenterology (BSG) (2014) state that defaecation or a change
diagnosis and management can be carried in bowel habit (National
out effectively in the primary care setting, Institute for Health and Care
at a lower cost (Soubieres et al 2015). Excellence 2015)
Uncertainty in diagnosis and persistent
symptoms are responsible for many of the
referrals to secondary care (Soubieres et al
2015). Around half of the patients diagnosed
with IBS in primary care are referred to
secondary care for endoscopic testing
(BSG 2014).
Classification systems, including the
Manning criteria and the Rome criteria, have
been developed to assist in standardising
the diagnosis of IBS. The Manning
criteria, developed in 1978, were the first
diagnostic criteria established to define IBS
(Manning et al 1978, Spiller et al 2007).
They compare the symptoms of patients
with abdominal pain against six criteria, to
determine who should be diagnosed with
organic disease, rather than IBS (Table 1).
The Rome I criteria were published in 1990
(Drossman 2007). The Rome criteria have
evolved over the past 20 years, to provide
a detailed, accurate and useful definition of
IBS. The most recent are the Rome IV criteria
(Table 1), released for use in June 2016
(Drossman 2016).
Research to validate the Manning criteria
and the Rome IV criteria has indicated
there is little difference in accuracy between
the two systems; both have been criticised
for their lack of accuracy and specificity
volume 31 number 26 / 22 February 2017 / 53
evidence & practice / CPD / long-term conditions
(Spiller et al 2010, Ford et al 2013).
Further work is required to develop a more
explicit method of diagnosis (Ford et al
2013). The Rome IV criteria are the most
widely used criteria for diagnosing
IBS; they provide a standard definition
and diagnosis of IBS as a functional
gastrointestinal disorder of brain-gut
interaction, and are easier to apply than
the Manning criteria (BSG 2014). The
development of the Rome IV criteria took
place over a six-year period involving
input from 117 experts worldwide
(Lacy et al 2016). The Rome IV criteria
form a comprehensive tool, which clarifies
that functional bowel disorders comprise
a spectrum of symptoms, requiring a
biopsychosocial approach (Drossman 2016).
One priority in diagnosing patients
with IBS is to establish their symptom
profile, and whether abdominal pain or
discomfort is among their main symptoms.
It is important to ask the patient to clarify
the severity, timing and location of their
pain or discomfort, and whether this is
localised to a specific site or is generalised
abdominal pain (NICE 2015). This helps
to distinguish IBS-related pain from cancer-
related pain, which typically has a specific,
fixed position (NICE 2015).
Red flag symptoms (Box 1) should be
identified in primary care, ideally at the
initial assessment, and patients should
be referred to secondary care for further
investigative studies (BSG 2014, NICE
2015, Quigley et al 2015). Establishing the
patients bowel habits helps to determine
TABLE 1. Criteria for diagnosing irritable bowel syndrome
Manning criteria Rome IV criteria
Diagnose irritable bowel syndrome if three or Recurrent abdominal pain, on average for
more of the following are present: at least one day per week in the last three
Abdominal pain months, associated with two or more of the
Relief of pain on defaecation following:
Increased stool frequency with pain Related to defaecation
Looser stools with pain Onset associated with a change in
Mucus in stools frequency of stool
Feeling of incomplete evacuation Onset associated with a change in form
(appearance) of stool
Diagnostic criteria fulfilled for the last three
months, with symptom onset at least six
months before diagnosis
(Manning et al 1978, British Society of Gastroenterology 2014, Drossman 2016)
54 / 22 February 2017 / volume 31 number 26
the sub-classification of IBS, which will
be discussed in detail in the next section.
The Bristol Stool Form Scale (Lewis and
Heaton 1997) is a valuable visual tool
(Figure 1), to enable patients to objectively
describe the quality and frequency of stool.
The NICE (2015) guidelines recommend
diagnostic testing for IBS in adults who
meet the IBS diagnostic criteria. The
following clinical investigations help to
exclude other diagnoses:
Full blood count.
Erythrocyte sedimentation rate or plasma
viscosity.
C-reactive protein test.
Antibody testing for coeliac disease
(endomysial antibodies or tissue
transglutaminase antibodies).
Sub-classifications of IBS
IBS may be classified as pain-predominant
IBS, IBS-diarrhoea (IBS-D), IBS-
constipation (IBS-C) or, IBS-mixed
(IBS-M), or IBS-unclassified (IBS-U).
Criteria for diagnosing these
sub-classifications are listed in Table 2.
An individual is defined as IBS-M, if they
report greater than 25% of their stools
being loose or watery and 25% of their
stools being hard or lumpy, when not
using a laxative or antidiarrhoeal
medication. Patients with IBS-M are often
misclassified because of variations
attributable to the medications they use to
treat their symptoms (Su et al 2014).
Symptoms of IBS-M resemble more closely
the symptoms of IBS-C than those of
IBS-D (Table 2). Although some estimates
BOX 1. Red flags symptoms
suggesting organic disease is more
likely than irritable bowel syndrome
A change in bowel habit to looser and/or more
frequent stools persisting for more than six weeks in
an individual aged <60 years
Rectal bleeding
Unintentional and unexplained weight loss
Family history of bowel or ovarian cancer
Rectal masses
Abdominal masses
Anaemia
Raised inflammatory markers
(National Institute for Health and Care Excellence 2015)
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suggest the prevalence of IBS-C, IBS-D
and IBS-M are approximately equal,
Su et al (2014) estimated that 44% of
patients with IBS have IBS-M, suggesting
that many patients are misclassified. This
group of patients was relatively
unrecognised until the Rome III criteria
were established (Travis et al 2005).
Patients with IBS-U present with a variety
of symptoms which do not fit into either
of the more predominant sub-
classifications of IBS.
It is important to note that daily pain
for six months rarely results from organic
causes, and is indicative of IBS alongside
other symptoms, in the absence of red flags
(Box 1).
TIME OUT 2
Identify and familiarise yourself with the most recent
guidelines available for the management of IBS in adults.
Are you implementing this guidance in your practice? List
four improvements that could be made to your practice
as a result of reading the guidance and share this
information with your colleagues.
Obtaining a thorough history of the patients
symptoms and performing a physical
examination, in conjunction with any
relevant clinical investigations, enables the
healthcare professional to form a definitive
diagnosis. An accurate assessment of the
patient is important for diagnosis, and for
developing an effective, patient-centred and
individualised treatment programme. The
healthcare professional should conduct

TIME OUT 1 Figure 1. Bristol Stool Form Scale

Research and collate a list of possible differential
diagnoses for IBS-C, IBS-D and IBS-M. Write short notes
on how could you use this information to ensure that
patients receive an accurate diagnosis, as well as tailored
treatment and management plans.

Patient assessment
Informed consent should be obtained
before undertaking an assessment of
the patient (NICE 2007, Ness 2009).
Patients with bowel dysfunction may
feel anxious before being assessed,
because of the sensitivity of the topic.
Patients may benefit from having a
friend or relative present during the
assessment, to support them and reduce
anxiety (Ness 2009).
It is important for healthcare
professionals to have knowledge of
female and male anatomy and physiology
in relation to the lower gastrointestinal
system (Skills for Health 2010) to ensure
a thorough examination of the patients
presenting symptoms. The healthcare
professional should also be familiar
with local and national protocols that
affect their practice in relation to bowel
dysfunction (Skills for Health 2010).
Inadequate knowledge limits assessment
of the patients condition. This can
result in management that might impede
the patients progress, resulting in
unsatisfactory health outcomes and poor (Reproduced with kind permission of Dr KW Heaton, formerly reader in medicine at the University of Bristol.
patient satisfaction. 2000 produced by Norgine Pharmaceuticals Limited.)

nursingstandard.com volume 31 number 26 / 22 February 2017 / 55

evidence & practice / CPD / long-term conditions
assessments of patients with IBS or bowel
dysfunction in a clean, well-equipped and
confidential environment that enables
patients to share their experience openly
(Skills for Health 2010, Royal College of
Nursing (RCN) 2012). To obtain a patient
history for IBS, the healthcare professional
should ask questions, such as those listed
in Box 2, and adapt these according to the
sub-classification of IBS associated with the
patients presenting symptoms.
Pre-assessment questionnaires are
useful to support overall patient
assessment. They can be used to prepare
patients for the type of language and
TABLE 2. Irritable bowel syndrome (IBS) sub-classifications
IBS sub-classification Description
IBS-diarrhoea (IBS-D) >25% loose or watery stools; <25% hard or lumpy stools
Morning frequency, often with urgency
Usually accompanied by pain that is often relieved by
defaecation
IBS-constipation (IBS-C) >25% hard or lumpy stools; <25% loose or watery stools
Most common in women
Sensation of incomplete evacuation
Associated with the passage of mucus
IBS-mixed (IBS-M) >25% loose or watery stools; >25% hard or lumpy stools
Symptoms alternate between constipation and diarrhoea
Symptoms often involve the passage of hard stools in the
morning, followed by increasingly loose or watery stools
throughout the day
IBS-unclassified (IBS-U) <25% loose or watery stools; <25% hard or lumpy stools
Insufficient abnormality of stool consistency to meet the
criteria for IBS-C or IBS-M
(National Institute for Health and Care Excellence 2015, Quigley et al 2015)
BOX 2. Example questions for obtaining a patient history of
irritable bowel syndrome
What is your main bowel problem and when did it start? Is there anything that might have
initiated your bowel problem?
How frequently do your bowels open?
What is the consistency of your stool? Use of the Bristol Stool Form Scale (Lewis and Heaton
1997) is helpful to assess this.
Have you ever noticed any blood or mucus in your stool?
Do you strain to open your bowels? How often do you spend each day on the toilet trying to
open your bowels?
Do you feel you empty your bowels fully each time? Do you ever feel evacuation is incomplete?
Do you take any medications to help regulate your bowels, such as laxatives, enemas,
suppositories or antidiarrhoeal medications?
How many meals do you eat each day? Are there any particular foods that you avoid eating?
What do you tend to eat on a regular basis for breakfast, lunch and dinner?
How does your bowel problem affect your daily life, relationships and emotions?
56 / 22 February 2017 / volume 31 number 26
questions that they will be asked
during the assessment. Frequently used
questionnaires include:
Patient Assessment of Constipation
Quality of Life (PAC-QOL)
(Marquis et al 2005).
International Consultation on
Incontinence Questionnaire-Bowels
(ICIQ-B) (Cotteril et al 2011).
Hospital Anxiety and Depression Scale
(HADS) (Zigmoid and Snaith 1983).
An objective physical assessment enables
healthcare professionals to develop a
complete overview of the patients presenting
symptoms. This should include palpating the
abdomen, and a digital rectal examination
that should only be undertaken by a trained
clinician (RCN 2012). Digital examination
enables the healthcare professional to (RCN
2012, Collins and OBrien 2015):
Establish if faecal matter is present in the
rectum, and its consistency and volume.
Assess the condition of the rectum,
before offering any rectal medication
or interventions, such as an enema,
suppositories or rectal irrigation.
Ascertain if faecal matter requires digital
removal from the anus.
Assess the function of the sphincter
complex.
TIME OUT 3
You should have a good understanding of the anatomy
and physiology of the lower gastrointestinal tract to
assess and manage patients with bowel dysfunction,
including IBS. Familiarise yourself with, and make brief
notes on, the following topics and processes and their
association with bowel function:
Reflexes.
The nervous system.
The pelvic floor and sphincter complex.
The usual process of stool production and factors that
influence this.
The usual process of defaecation.
Management
The symptoms of IBS are diverse.
Management of the condition varies
depending on the patients predominant
symptoms and bowel pattern (Anastasi et al
2013). Not all patients require the same
support. Some patients respond well to non-
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pharmacological treatment, while others also
require pharmacological treatment. Response
to treatment interventions can depend on
various physiological and psychological
factors. Treatment should be individualised.
Special consideration should be given to diet,
stress and psychological factors, because
these are the most common aggravating
factors in IBS (Quigley et al 2015).
Diet, physical activity and psychological
factors
Healthcare professionals should establish an
effective therapeutic relationship with the
patient. They should dedicate time to explain
to the patient the nature of IBS, treatment
options, and the effects of diet, lifestyle,
stress and anxiety on the condition. This can
improve the patients symptoms and reduce
the number of times they return for advice
and support. Patients do not all present with
the same exacerbating factors. Therefore, it
is important that the healthcare professional
obtains a thorough patient history to ensure
a relevant and effective management plan is
implemented.
Treatment of IBS should focus on symptom
management using lifestyle and dietary
modifications, because there is no known
cure for the condition. Regular exercise and
stress or anxiety management can be useful
in reducing symptoms of IBS. A study of 666
patients with IBS demonstrated that dietary
modifications, exercise and patient education
were the most frequently used interventions,
with satisfactory relief achieved in 57% of
patients (Whitehead et al 2004).
TIME OUT 4
Speak to a dietitian in your team or practice area, or
contact your local community dietitian to discuss dietary
modifications for the various sub-classifications of IBS. List
the most important or significant dietary modifications for
each sub-classification of IBS; you may wish to capture this
information in a table to enable ease of reference during
patient consultations. How might you support patients to
make changes to, or modify their, diet?
TIME OUT 5
Research the difference between soluble and insoluble
fibres found in food and the effect each may have on the
symptoms of IBS. Discuss with a dietician any dietary
modifications that may improve the symptoms of IBS and
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how you could incorporate this information into patient KEY POINT
education.
Treatment of IBS should
Diet focus on symptom
Individuals with IBS are often advised to management using lifestyle
increase their intake of dietary fibre, for and dietary modifications,
example wholegrain cereals, fruit and because there is no known
vegetables that are high in insoluble fibre cure for the condition.
(Spiller et al 2007). However, the healthcare Regular exercise and stress
professional should consider the patients or anxiety management
dietary intake and base their advice on the can be useful in reducing
information gained during the assessment. symptoms of IBS. A study
For example, a patient who has a high intake of 666 patients with IBS
of insoluble fibre, might be advised to try a demonstrated that dietary
low fibre diet. The BSG (2014) and NICE modifications, exercise
(2015) recommended a trial period excluding and patient education
insoluble fibre, while monitoring the patients were the most frequently
response. Food diaries can enable the patient used interventions,
and healthcare professional to record and with satisfactory relief
monitor any response to diet modification. achieved in 57% of patients
Patients with IBS-C, IBS-D and IBS-M (Whitehead et al 2004)
often state that certain food types aggravate
their symptoms, for example caffeine,
dairy products and cereals, and artificial
sweeteners, such as sorbitol and xylitol
(Spiller et al 2007). It is common for
symptoms to become worse when the
patient consumes gluten, even when coeliac
disease has been excluded (Biesiekierski et al
2011); bloating, lethargy, abdominal pains,
diarrhoea, constipation, joint pains and
headaches may be reported by patients. This
is known as gluten sensitivity (Catassi et al
2013, Czaja-Bulsa 2015). Some patients find
that removing gluten from their diet can
eliminate many of the symptoms associated
with this food type. Patients can also be
sensitive or intolerant to fat or lactose,
presenting with similar symptoms to those
of gluten sensitivity (Spiller et al 2007).
Excluding these food types one at a time,
and systematically reintroducing them
one at a time, can help to identify whether
an intolerance or sensitivity is a probable
aggravating factor for IBS in individual
patients (Catassi et al 2013).
NICE (2015) provides recommendations
on dietary modifications for patients with
IBS as follows:
Have regular meals and take your time
when eating.
Avoid long intervals between eating and
avoid skipping meals.
Drink at least eight glasses of fluid per
volume 31 number 26 / 22 February 2017 / 57
evidence & practice / CPD / long-term conditions
KEY POINT day, especially water and non-caffeinated
Many patients identify a link drinks, such as herbal tea.
between stress or anxiety Reduce tea and coffee intake to three
and their gut symptoms. cups per day.
The healthcare professional Limit your intake of alcohol and fizzy
should establish if the drinks.
patient is experiencing For some, it may be helpful to limit your
any psychological co- intake of high-fibre foods.
morbidities in the initial Limit your intake of fresh fruit to three
assessment to determine if portions per day.
referral to a psychological Individuals with diarrhoea should avoid
therapist is required. artificial sweeteners and sugars found in
Research has shown that sugar-free sweets, chewing gum and drinks.
there are several types Individuals with wind and bloating may
of psychotherapy that find oats and linseed helpful.
have proved beneficial There is evidence to show that a diet that
to individuals with IBS, is low in fermentable oligosaccharides,
with short and long-term disaccharides, monosaccharides and polyols
effects, including cognitive (FODMAP) can improve IBS symptoms
behavioural therapy, (stgaard et al 2012, Bhn et al 2015).
mindfulness-based stress Foods that contain FODMAP include beans
reduction, gut-directed and pulses, onions, garlic, certain fruits
hypnotherapy and and vegetables, wheat and artificial sugars.
relaxation (Kennedy et al Healthcare professionals are advised to refer
2005, Mykletun et al 2010, patients to a dietitian to provide education
Zernicke et al 2013, Laird et about the low-FODMAP diet and support
al 2016). All psychotherapy patients to make the necessary changes.
treatments should be Patients who require more than basic dietary
provided by trained and advice should also be referred to a dietitian.
experienced therapists
Physical activity
Sport and exercise can help to improve
bowel function, especially for patents
with IBS-C. A sedentary lifestyle can
result in reduced colonic stimulation and
worsening constipation. Song et al (2012)
demonstrated that moderate-to-high levels
of physical activity in females resulted in
an improvement in colonic transit time.
Physical activity has also been shown
to reduce abdominal bloating and clear
flatus; reduce levels of stress, anxiety and
depression; and improve sleep, energy levels,
physical functioning and quality of life (El-
Salhy et al 2010, Johannesson et al 2011).
However, caution is necessary when making
recommendations regarding exercise to
patients with co-morbidities; a doctor should
be consulted and referral to a physiotherapist
should be made, if necessary.
Psychological factors
Psychological symptoms are common
58 / 22 February 2017 / volume 31 number 26
in patients with IBS; approximately half
of patients with IBS (46/91) present
with anxiety, depression and paranoia
(Mykletun et al 2010). The brain-gut
axis theory explains the link between the
gut and psychological health (Burnett and
Drossman 2004). It suggests that cognitive
information and external factors can affect
gastrointestinal function, and that stress
and emotions may trigger neuroimmune or
neuroendocrine reactions affecting the gut,
via the brain-gut axis (Mayer et al 2001,
Mulak and Bonaz 2004). Koloski et al
(2012) conducted a 12-year longitudinal,
prospective, population-based study
on the brain-gut axis and concluded
that the central nervous system and gut
interact bidirectionally in functional
gastrointestinal disorders.
Many patients identify a link between
stress or anxiety and their gut symptoms.
The healthcare professional should
establish if the patient is experiencing any
psychological co-morbidities in the initial
assessment to determine if referral to a
psychological therapist is required. Research
has shown that there are several types of
psychotherapy that have proved beneficial
to individuals with IBS, with short and long-
term effects, including cognitive behavioural
therapy, mindfulness-based stress reduction,
gut-directed hypnotherapy and relaxation
(Kennedy et al 2005, Mykletun et al 2010,
Zernicke et al 2013, Laird et al 2016). All
psychotherapy treatments should be provided
by trained and experienced therapists.
Pharmacological management
Pharmacological intervention should be
based on the nature and severity of the
patients predominant symptoms. Laxatives
may be considered for patients with IBS-C
(NICE 2015), alongside dietary and lifestyle
advice, but the healthcare professional should
be certain that the patient is constipated.
Individuals who state they are constipated
should be informed that bowel habits may
show considerable variation in frequency,
without resulting in harm. Some individuals
may consider themselves to be constipated
if they do not have a bowel movement every
day. Misconceptions about normal bowel
habits can lead to excessive or inappropriate
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laxative use, with negative consequences.
Inappropriate laxative use, including use of
natural products such as senna, may lead
to hypokalaemia (Gennari and Weise 2008).
In the authors practice, normal bowel
frequency is considered to range from three
times per day to three times per week. The
Bristol Stool Form Scale (Lewis and Heaton
1997) can be used to enable the patient and
healthcare professional to determine whether
the use of laxatives is required.
TIME OUT 6
Explain the differences between stimulant, bulk-forming
and osmotic laxatives. Discuss with a colleague and
provide the rationale for the type of laxative you would
consider to manage the following:
A patient presenting with hard stools.
A patient presenting soft stools that are difficult to pass.
Laxatives
Laxatives have been shown to relieve
symptoms of constipation but have
not been shown to relieve abdominal
pain (Bijkerk et al 2004); side effects of
laxatives include abdominal bloating and
an increase in flatulence (British National
Formulary (BNF) 2016). Healthcare
professionals should advise the patient to
drink plenty of water after taking laxatives.
Laxatives include bulk-forming, osmotic
and stimulant laxatives. A bulk-forming
laxative, such as ispaghula husk, adds bulk
to the stool (NICE 2015) and works in a
similar way to psyllium husk, the dietary
supplement. If stools remain hard, osmotic
laxatives, such as macrogols, should be
introduced. Healthcare professionals
should be aware that the use of lactulose
is not recommended in treating patients
diagnosed with IBS, because it is likely
to precipitate or worsen bloating (NICE
2015).
When stools are softer, but are
incomplete or remain difficult to pass,
healthcare professionals are advised to
prescribe a stimulant laxative, such as
bisacodyl or senna to improve peristalsis
(NICE 2015). Stimulant laxatives are
generally recommended for occasional
use only, because they are associated with
tachyphylaxis and dependency (Spiller et al
2007). An accurate assessment of the
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patient enables the healthcare professional KEY POINT
to identify whether the incomplete Antispasmodic or
evacuation of stools is caused by the stool anticholinergic medications,
type or a functional problem, such as pelvic such as mebeverine
floor dysfunction or anismus, which should hydrochloride, hyoscine
be treated with pelvic floor training, rather butylbromide and
than laxatives. peppermint oil can be
Linaclotide is indicated for use beneficial to the patient,
in moderate to severe IBS-C (NICE because they alleviate
2015). It is a minimally absorbed symptoms of abdominal
guanylate cyclase-C receptor agonist pain and discomfort by
(Chey et al 2012) that decreases visceral relaxing the smooth muscle
pain, increases intestinal fluid secretion and in the stomach and intestine
improves intestinal transit (NICE 2013). (Anastasi et al 2013). These
medications are best taken
Antispasmodics 20-30 minutes before meals,
Antispasmodic or anticholinergic three times per day
medications, such as mebeverine (BNF 2016)
hydrochloride, hyoscine butylbromide and
peppermint oil can be beneficial to the
patient, because they alleviate symptoms
of abdominal pain and discomfort by
relaxing the smooth muscle in the stomach
and intestine (Anastasi et al 2013). These
medications are best taken 20-30 minutes
before meals, three times per day (BNF
2016).
Antidiarrhoeals
Individuals with IBS-D have an increased
colonic transit time compared to healthy
individuals and benefit from medication
to delay transit time. Antidiarrhoeal
medications, such as loperamide
hydrochloride, slow intestinal transit time
by inhibiting peristalsis (Anastasi et al
2013). This reduces stool frequency and
urgency (Gunn et al 2003) and improves
stool consistency. NICE (2015) guidelines
recommend these medications for use in
patients with IBS-D. As with antispasmodic
medications, the BNF (2016) recommends
that they are taken 20-30 minutes before
meals. The optimal dosage depends on the
patients response and the change in stool
consistency. Loperamide hydrochloride is
available in capsule or liquid form. The use
of liquid loperamide can help to titrate the
dosage up or down by small increments,
reducing the risk of patients becoming
constipated.
A few patients with IBS-D may have bile
salt malabsorption. This can be diagnosed
volume 31 number 26 / 22 February 2017 / 59
evidence & practice / CPD / long-term conditions
KEY POINT
There is limited evidence
in relation to adults using
rectal irrigation to treat
constipation and faecal
incontinence or increased
bowel frequency. Most
of the evidence available
relates to neurogenic bowel
conditions, but there are
robust reviews to support its
use (Christensen and Krogh
2010, Emmanuel et al 2013,
Emmett et al 2015). There are
several types of irrigation
systems available and
patients should be assessed
on an individual basis
for the most appropriate
system according to their
symptoms
60 / 22 February 2017 / volume 31 number 26
via a tauroselcholic [selenium-75] acid
(SeHCAT) scan (NICE 2012) and patients
may respond well to colestyramine
(Gunn et al 2003); however, this drug
may not be well tolerated because of its
side effects, which include constipation,
diarrhoea, nausea, vomiting and abdominal
pain (BNF 2016).
Probiotics
Probiotics are dietary supplements that
contain live bacteria. They can be beneficial
to patients with IBS when taken on a regular
basis, because they alter the gastrointestinal
flora (Ford and Tally 2012). Probiotics
can improve symptoms such as bloating,
pain and flatus, and improve bowel
frequency (Wall et al 2014). Lactobacilli and
bifidobacteria are the most commonly used
strains of bacteria in the treatment of IBS
(Wall et al 2014). Probiotics are found in
food types that contain live active cultures,
such as some yoghurts, and in fermented
foods, such as kefir and sauerkraut. They
are also available as a dietary supplement.
Healthcare professionals should be
careful when evaluating research into the
effectiveness of probiotics versus a placebo,
because of the varying methodologies in
researching probiotic species, preparations
and dosage (Whelan and Quigley 2013,
Wall et al 2014).
Rectal irrigation
Rectal or transanal irrigation can be used to
assist rectal emptying, when patients with IBS
do not respond adequately to conservative
methods of treatment, such as those
discussed earlier in the article. This treatment
is used in patients with IBS-C, IBS-D and
IBS-M. For patients with IBS-C, rectal
irrigation shortens colonic transit time and
ensures regular emptying, thus improving
overall bowel frequency and routine. The
introduction of water into the lower bowel
softens stool in the rectosigmoid region,
making it easier for patients to defecate any
remaining hard stools.
For patients with IBS-D, rectal irrigation
is used to prevent new faeces from reaching
the rectum by efficiently emptying the distal
colon and rectum. This can mean that
the patients need to empty their bowels
is reduced, by an average of two days
(Emmanuel et al 2013). There are several
rectal irrigation systems available for patients
to trial; each system should be selected
based on the individuals needs, following
a thorough assessment that includes an
anorectal assessment. The patients mobility,
dexterity and other additional factors
determine the appropriate system for use
(Collins and OBrien 2015).
There is limited evidence in relation
to adults using rectal irrigation to treat
constipation and faecal incontinence or
increased bowel frequency. Most of the
evidence available relates to neurogenic
bowel conditions, but there are robust
reviews to support its use (Christensen
and Krogh 2010, Emmanuel et al 2013,
Emmett et al 2015). There are several types
of irrigation systems available and patients
should be assessed on an individual basis
for the most appropriate system according
to their symptoms.
TIME OUT 7
Identify and learn about three different types of irrigation
system, with particular reference to the use of each in the
management of the sub-classifications of IBS. Identify the
irrigation systems used in your area of practice and list
the reasons for their use.
Biofeedback therapy
In the authors practice, biofeedback
therapy is a complex package of care that
includes symptom assessment, education on
bowel anatomy and physiology, bowel and
muscle re-training, behaviour and dietary
modification, and psychological support
(Collins and OBrien 2015). Biofeedback
therapy is provided in an outpatient setting,
with patients attending an average of four to
five times, at intervals of four to six weeks.
The initial assessment lasts 60 minutes and
involves the specialist physiotherapist or
nurse obtaining a comprehensive patient
history. At follow-up appointments, which
last 30-40 minutes, the patients symptoms
and progress are reassessed and management
plans are adapted accordingly.
The aim of biofeedback therapy is to
enable patients to regain control of their
bowels. It has been shown to be superior to
standard therapy in patients with disordered
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defaecation and pelvic floor dysfunction
(Rao et al 2010), and involves an instrument-
based learning process to reinforce normal
evacuation, and regular feedback to reinforce
correct function. The patient should adopt
a squatting position, raise the feet on a
footstool, breathe normally, avoid holding
their breath and use their abdominal muscles
to achieve a brace and bulge or brace-
pump technique (Collins and OBrien 2015),
while pushing downwards and backwards
into the rectum. This reduces the patients
need to strain and results in more effective
and complete defaecation.
Sometimes patients can develop a chaotic
bowel pattern in which gaining control might
seem impossible. However, bowels respond
well to routine, so it is important for the
healthcare professional to support patients
to establish a daily toileting routine at an
optimum time for them. This is generally first
thing in the morning on getting out of bed, or
after a meal (Collins and OBrien 2015).
Patients with IBS-C should be discouraged
from resisting the urge to defecate, because
this can cause further slowing of colonic
transit time. In contrast, patients with
IBS-D, who are likely to experience urgency
because of loose stools and an increased risk
of incontinence, should undertake urge-
resistance training. This educates the patient
on how to resist the urge to open their
bowels in response to urgency, by actively
contracting the external sphincter muscle
and using a distraction technique (Haslam
and Laycock 2008), for example reciting
the alphabet backwards or counting down
from 100 in sevens. Applying pressure on
the perineum can also help to switch off the
pelvic floor. Continuing this on an ongoing
basis reduces the feeling of urgency.
Strengthening the sphincter complex
allows patients to regain control of their
bowels. Strengthening the pelvic floor
complex also enables improvements in
pelvic floor strength, co-ordination and
overall function. Pelvic floor muscle
re-training should follow a thorough
rectal or vaginal internal assessment in
females, or rectal internal assessment in
males, and exercise programmes should be
individually tailored to the ability of the
patient (Haslam and Laycock 2008).
Conclusion
Assessment and management of IBS can be
challenging. Patients should be treated on an
individual basis according to their presenting
symptoms, which can be numerous and
complex. Diet, lifestyle, stress and anxiety
are common aggravating factors in IBS;
changes in these factors may result in
worsening symptoms. Management of these
factors is essential for patients with IBS.
The provision of reassurance and support
by healthcare professionals can minimise
patient anxiety and distress. Healthcare
professionals assessing and treating patients
with IBS should have a broad knowledge
of the range of treatments available, so
that they can advise and inform patients,
offer individualised care and management
plans, and monitor the effectiveness of
interventions.
TIME OUT 8
Nurses are encouraged to applythe four themes of
The Code (NMC 2015) to their professional practice.
Consider how knowledge of the symptoms, treatment and
management of IBS relates to the themes of The Code.
TIME OUT 9
Now that you have completed the article, you might like
to write a reflective account as part of your revalidation.

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