New Guidelines for Treatment of Irritable Bowel Syndrome in Adults

May 11, 2007 — The British Society of Gastroenterology has issued guidelines for diagnosing and treating irritable bowel syndrome (IBS), including dietary and psychological treatments, in primary care and other settings. The new recommendations for IBS, a chronic, relapsing gastrointestinal problem characterized by abdominal pain, bloating, and changes in bowel habit, are published in the May 8 Online First issue of Gut.

"While the precise prevalence and incidence depends on the criteria used, all studies agree that it is a common disorder, affecting a substantial proportion of individuals in the general population, and presenting frequently to general practitioners and to specialists," write Robin Spiller, MD, from the University Hospital in Nottingham, United Kingdom, and colleagues. "IBS is troublesome, with a significant negative impact on quality of life and social functioning in many patients, but is not known to be associated with the development of serious disease or with excess mortality. IBS generates significant healthcare costs both direct, due to IBS symptoms and associated disorders as well as indirect, due to time off work."

In most countries, IBS affects 5% to 11% of the population, with prevalence peaking from age 20 to 45 years with a female predominance (female:male ratio approximately 2:1). The disorder may account for approximately 3% of all consultations referred from primary care.

The current recommendations were issued at the request of the Chairman of the Clinical Services Committee of The British Society of Gastroenterology to provide guidelines for the evaluation and treatment of adult patients with IBS. Members of the committee were assigned specific areas to review. Literature search of PubMed, EMBASE, MEDLINE, Web of Science, and Cochrane databases and search of extensive personal reference databases focused on high-quality studies that used established methodology and substantial patient numbers with clearly defined entry criteria. Criteria for inclusion of treatment trials were randomization and placebo control.

The predominant bowel habit (diarrhea or constipation) is a useful classification scheme. When diarrhea is a prominent feature, few investigations are needed, although alarm features may warrant further investigations.

Careful attention to history is of vital importance to the diagnosis. Abdominal pain or discomfort is typically relieved by defecation and associated with change in stool form (usually looser) and change in stool frequency.

Associated features that may be helpful in making the diagnosis include frequent consultation for medically unexplained symptoms, somatization, and past history of anxiety or depression. Psychological assessment to evaluate current anxiety and depressive symptoms is also important.

The presence of alarm symptoms, though nonspecific, should mandate further investigations. These include age older than 50 years, symptom duration less than 6 months, weight loss, nocturnal symptoms, family history of colon cancer, rectal bleeding, anemia, and recent antibiotic usage.

When these alarm symptoms are present, further investigations may be useful in primary care settings. Before these are undertaken, however, patients should be told that IBS is the most likely diagnosis and that these tests are designed to rule out celiac and inflammatory bowel disease. Useful tests may include full blood count and erythrocyte sedimentation rate, as well as testing for endomysial antibodies.

Many patients fear that their symptoms may reflect serious disease. These fears should be elicited and specifically addressed in an adequate consultation including exploration of patient anxieties and concerns.

Because of accompanying adverse psychological features and somatization, IBS is often best managed by evaluating the patients' concerns and explaining symptoms in simple terms the patient can understand. Giving the patient a positive diagnosis and reassuring them of the benign nature of IBS without denying the significance of their symptoms tends to improve outcomes. Treatment of associated anxiety and depression often improves bowel and other symptoms.

Irritable bowel syndrome is a heterogeneous condition with a wide spectrum of treatments, each benefiting a small proportion of patients. Dietary management should begin with a thorough dietary history and moderation of excessive consumption of any 1 component. If intake of lactose, wheat, and/or insoluble fiber appears to be above average for the population, trial exclusion of these foods may be helpful.

Psychological therapies should be first-line treatment when anxiety, panic attacks, and depression are prominent features. Based on evidence from randomized placebo-controlled trials, cognitive behavioral therapy and psychodynamic interpersonal therapy improve coping, and hypnotherapy benefits global symptoms in otherwise refractory patients. Relaxation therapy may also be beneficial.

In terms of drug therapies, antispasmodic drugs are safe, but offer only a small improvement relative to placebo. Soluble fiber supplements may benefit those with constipation, whereas bran and other insoluble fiber may aggravate symptoms.

Loperamide is helpful for symptoms of urgency and frequency but may exacerbate abdominal pain and discomfort. Antispasmodic and tricyclic antidepressant drugs improve pain, whereas ispaghula improves pain and bowel habit.

Although 5HT₃ antagonists improve global symptoms, diarrhea, and pain, they may rarely cause unexplained colitis. 5HT₄ Agonists improve global symptoms, constipation, and bloating, whereas selective serotonin reuptake inhibitors improve global symptoms.

"Patients [with IBS] comprise such a large proportion of gastroenterology outpatients that their streamlined and effective management would impact favourably on any gastroenterology department's overall performance and hence improve the management of all GI [gastrointestinal] diseases," the authors write. "Better ways of identifying which patients will respond to specific treatments are urgently needed."

Warning signs indicating that the primary care clinician should refer the patient with suspected IBS to a specialist are as follows:

• Rectal bleeding requires rectal examination and usually referral for a flexible sigmoidoscopic examination
  
  


• Presence of several alarm features
  
  


• Uncertainty concerning the diagnosis
  
  


• Failure to respond to initial management strategies
  
  


• Disabling health-related anxiety
  
  


• Long-standing symptoms with impaired quality of life

The authors have disclosed various financial relationships with Novartis, Mundi Pharma, GlaxoSmithKline, Pfizer Pharmaceuticals, Eli Lilley & Co, Solvay, Clasado, AstraZeneca, Tillots Pharma, Ferring, Rotta Research, Proctor & Gamble, and/or Astellas.

Gut. Published online May 8, 2007.

Learning Objectives for This Educational Activity

Upon completion of this activity, participants will be able to:

• Identify alarm features of patients presenting with suspected irritable bowel syndrome that should trigger referral to a specialist by a primary care clinician.


• Describe treatment strategies for irritable bowel syndrome.

Clinical Context

IBS is a chronic, relapsing gastrointestinal syndrome, with key features of abdominal pain, bloating, and changes in bowel movements. IBS has a high prevalence in the general population and is seen commonly in clinical practice both by general practitioners and by specialists.

Although IBS is not known to lead to serious disease or excess mortality, it has a significant negative impact on quality of life and social functioning and generates significant direct and indirect healthcare costs. The Chairman of the Clinical Services Committee of The British Society of Gastroenterology convened an expert panel to provide guidelines for the evaluation and treatment of adult patients with IBS.

Study Highlights

• When diarrhea is a prominent feature of IBS, few investigations are needed unless alarm features are present.


• Diagnosis is made by history of abdominal pain or discomfort typically relieved by defecation and associated with change in stool form (usually looser) and in stool frequency.


• Associated features that may aid in diagnosis include frequent consultation for medically unexplained symptoms, somatization, and past history of anxiety or depression. Psychological assessment should evaluate current anxiety and depressive symptoms.


• Alarm features mandating further investigations include age older than 50 years, symptom duration less than 6 months, weight loss, nocturnal symptoms, family history of colon cancer, rectal bleeding, anemia, and recent antibiotic usage.


• Warning signs indicating that the primary care clinician should refer the patient with suspected IBS to a specialist include rectal bleeding (warrants referral for flexible sigmoidoscopy), presence of several alarm features, uncertainty concerning the diagnosis, failure to respond to initial management strategies, disabling health-related anxiety, and longstanding symptoms with impaired quality of life.


• Before additional testing (eg, for full blood count, erythrocyte sedimentation rate, and endomysial antibodies), patients should be told that IBS is the most likely diagnosis. Patients' fears that their symptoms may reflect serious disease should be elicited and specifically addressed. Without denying the significance of their symptoms, giving the patient a positive diagnosis and reassuring them that IBS has a benign course tends to improve outcomes.


• Treatment of associated anxiety and depression often improves bowel and other symptoms.


• IBS is a heterogeneous condition with a wide spectrum of treatments including dietary modifications and psychological and pharmacologic therapies. Each of these therapeutic approaches benefits a small proportion of patients.


• Dietary management should begin with moderation of excessive consumption of any 1 component, especially lactose, wheat, and/or insoluble fiber.


• When anxiety, panic attacks, and depression are key symptoms, psychological therapies should be first-line treatment, including cognitive behavioral therapy and psychodynamic interpersonal therapy to improve coping, hypnotherapy to reduce global symptoms in otherwise refractory patients, and relaxation therapy.


• Antispasmodic drugs are safe but only slightly more effective than placebo. Soluble fiber supplements may improve constipation, but bran and other insoluble fiber may aggravate symptoms.


• Loperamide may reduce urgency and frequency but increase abdominal pain and discomfort. Antispasmodic and tricyclic antidepressant drugs improve pain, and ispaghula improves pain and bowel habit.


• 5HT₃ Antagonists improve global symptoms, diarrhea, and pain but may rarely cause unexplained colitis. 5HT₄ Agonists improve global symptoms, constipation, and bloating, while selective serotonin reuptake inhibitors improve global symptoms.

Pearls for Practice

• The primary care clinician should refer the patient with suspected IBS to a specialist for rectal bleeding (for flexible sigmoidoscopy), presence of several alarm features, uncertainty concerning the diagnosis, failure to respond to initial management strategies, disabling health-related anxiety, and longstanding symptoms with impaired quality of life.


• Treatments of IBS may be dietary (moderation of lactose, wheat, and/or insoluble fiber), psychological (first-line therapy when psychiatric symptoms present), or pharmacologic (may be effective but aggravate some symptoms), each benefiting a small proportion of patients.

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