Irritable Bowel Syndrome – Irritable but Manageable? Dr Akeel Alisa explains

Irritable Bowel Syndrome (IBS) is considered one of the functional gastrointestinal disorders with major focus on the gut brain access and classified by gastrointestinal symptoms relating to motility disturbances, visceral hypersensitivity, altered mucosal and immune function, altered gut microbiota and altered central nervous system processing.

Scale of Challenge

  • Majority of patients affected are under the age of 35 and often uncommon in the over 50s.
  • Over 75% of the patients may remain symptomatic after 5 years of diagnosis.
  • One of the most common gastrointestinal presentation in general practice.
  • Very prevalent with greater occurrence in women than in men.
  • Have an average of three days of work missed per month with various degree of severity of presentation mainly from mild to severe symptoms.

Diagnosis & Management
In general, it refers to recurrent abdominal pain at least one day a week in the last three months associated with more than two of the following:
1. Defecation.
2. A change in frequency of stools.
3. Change in the form of stools.

  • Often a sensation of incomplete emptying of the bowels, occasionally passing mucus per rectal and with abdominal bloating and swelling.
  • Need a full history and to ensure no red flag symptoms for sinister pathology.
  • To assess the impact of the symptoms on daily life as well as any other psychological comorbidity or other comorbidities, which may be related to the presentation, such as gynaecological or urological.
  • Trigger factors such as stress or diet needs to be also explored.
  • 30 – 40% of patients may have anxiety or depression with other atypical symptoms ranging from backache, lethargy, nausea, bladder symptoms or even having a stressful life event.
  • It is prudent to refer patients, once red flag symptoms are excluded, for symptoms such as; constant abdominal pain, constant diarrhoea and distension with a change in bowel habit to loose or more frequent stools or both, persisting for more than six weeks, especially in patients over the age of 60. Any rectal bleeding, unexpected weight loss or any concerning family history of bowel or ovarian cancer needs to be also considered. The presence of anaemia, abdominal masses, rectal masses or any uncertainty in diagnosis, or failure to control symptoms in primary care, would necessitate a referral as well as having an elevated CRP or ESR or raised faecal calprotectin.
  • Often positive diagnosis and could be further subdivided into diarrhoea pre-dominant, constipation pre-dominant, pain pre-dominant or pain pre-dominant. It is important to consider such classification as the treatment strategy for management differs accordingly.
  • Treatment strategies directed towards the main symptoms or a combination of symptoms.
  • It is also important to explore the pathophysiology of Irritable Bowel Syndrome to patients.

IBS – Diarrhoea pre-dominant

  • Exclude bile acid malabsorption.
  • Consider treatment such as Loperamide or a low dose tricyclic antidepressant in a low dose.
  • Change of diet following a review by a dietician to consider exclusion diet or low FODMAP diet may be of help.

IBS – Constipation pre-dominant

  • Consider Osmotic laxatives may be helpful such as Movicol or Laxido.
  • Newer agents to consider include Resolor (Prucalopride) or Constella (Linaclotide).
  • Stimulant laxatives may make symptoms worse.
  • Lactulose may exacerbate distention and flatulence.

IBS – Pain pre-dominant

  • One may consider antispasmodics, peppermint capsule.

IBS – alternative management to explore

  • Assessing for small intestinal bacterial overgrowth, lactose intolerance and fructose intolerance.
  • Use of antibiotics such as Rifaximin or alternative antibiotics may be of value in controlling the symptoms of IBS especially with a positive SIBO test or diarrhoea.
  • When SIBO is positive, giving a course of probiotic after completing the antibiotics course may be of help, using probiotics such as Alflorex, Vivomixx, VSL#3, Symprove.
  • Other areas to be considered include CBT, hypnotherapy and acupuncture.
  • To use the assistance of an experienced gastroenterology dietician and to set some goals in regards to achieving symptom control.
  • To establish good rapport with patients and to offer clear explanation about the level of evidence used in the management of IBS and likely outcomes following treatment.