Adult Irritable Bowel Syndrome (IBS) IBS Prevalence – 10-20%.Symptoms often noticeable 20-30yrs.
Make a positiv e diagnosis based on symptoms rather than exhaustive investigations
History Absolute Red Flags - Refer Urgently: Consider in anyone with a history of: Abdominal, pelvic or rectal masses Abdominal pain/discomfort eased by defecation or associated with altered stool form or frequency and at least 2 of:- Ascites Unexplained increased urinary urgency Bloating, distension, tension or hardness >40 years jaundice or unexplained weight loss Change in stool passage – straining, urgency, incomplete evacuation Bristol Sto ol Ch art (can be useful) and abdominal pain >50 years with unexplained rectal bleeding Symptoms worse with eating >60 years with iron deficiency anaemia or Passage of mucus change in bowel habit or weight loss and one Other features such as lethargy, nausea, backache and bladder symptoms are of: change in bowel habit/back pain/ abdominal pain/nausea/vomiting/new- onset common in people with IBS and may be used to support the diagnosis. Use Rom e Self-fill Q uestion naire diabetes Consider Urgent Referral Inv estigations Examination – Abdominal + rectal +/- pelvic examination Sy stemically unwell
Consider arranging the following inv estigations to exclude an alternative diagnosis - Nocturnal symptoms
Full blood count (FBC), Erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), Strong f amily history of bowel or ovarian or breast or stool Microscopy, culture and sensitivity (MC&S), thyroid function (TFT) prostate cancer Coeliac screen – Tissue Transglutaminase (TTG) and Immunoglobulins Persistent abdominal distension (NB Consider IgA deficiency with negative TTG) Pelv ic or abdominal pain Consider Cancer antigen 125 (Ca125) in female patients Early satiety/loss of appetite Raised platelet count Faecal Calprotectin (FC): see FC pathway for full details Hav e a low threshold for thinking about rarer Consider faecal calprotectin in patients in whom there is diagnostic uncertainty but no cancers: pancreatic (multidisciplinary diagnostic red flags and in whom specialist assessment or input is being considered. centre) and ov arian (simultaneous CA125 and urgent pelvic ultrasound scan)
< 50 50-200* >200* Refer to Gastroenterology Urgent referral *See overleaf re Repeat in 2 to 4 weeks and consider IBS Result remains indeterminate Whittington advice. If negative manage as above for or >200 If faecal calprotectin >200* as Reference Ranges IBS. If still indeterminate or positive and suggests active bowel symptoms persist then refer to consultant inflammation. Routine referral <5 0 If indeterminate level and: Diagnosis and management of IBS If persistent diarrhoea or clinical If meet IBS diagnosis criteria no need for scoping, imaging, faecal occult blood etc concern or Identify subtype: Constipation predominant = IBS -C Diarrhoea predominant = IBS-D If resistant to treatment Or mixed = IBS-M
Dietary adv ice – give BDA Patient Leaflet Psychological therapies –
not Pharmacological treatments Yoghurt – consider 4 week trial probiotic ( consider if relevant to the prescribable) yoghurt twice a day. Pain relief individual or if symptoms st refractory to treatment Trial of a low FODMAP diet (fermentable 1 line antispasmodics oligosaccharides, disaccharides, Hyoscine butylbromide - 20mg four times a monosaccharides and polyols) diet has been Refer to iCOPE for Cognitive Behavioral shown to achieve relief of overall gastro intestinal day or Therapy (CBT) (GI) symptoms in 86% of patients particularly Mebeverine hydrochloride - 135mg or where there are symptoms of bloating, flatus and Hypnotherapy endorsed by NICE, abdominal pain three times a day 20min before meals however needs PoLCE approval Peppermint oil (if hyoscine butylbromide or
IBS- Constipation: add up to a maximum of 1 mebeverine not suitable or ineffective) - There is currently limited evidence for tablespoon/day of linseeds whole or ground to food Biofeedback/relaxation therapies and 1-2 capsules herbal medicines. These are therefore and take with small glass water Three times a day 20 min before meals not recommended locally.
Fibre – discourage eating insoluble fibre e.g. bran. If nd need fibre eat soluble fibre e.g. ispaghula/oats 2 line – Tricyclics (unlicensed) amitriptyline See fibre sheet – 5-10mg at night, max 30mg
Please refer to the Summary of Fluids >8 cups (2 litres) a day water and non- rd carbonated non-caffeinated drinks 3 line SSRI (unlicensed) if above Product Characteristics (SPC) of any ineffective/not tolerated – citalopram 20mg drug considered. This pathway has Lactose intolerance – can cause similar symptoms daily, sertraline 50mg daily, fluoxetine 20mg been developed from published to IBS- D. Consider trial of lactose free diet 2-4 daily guidance in collaboration with local
weeks to see if symptoms improve. gastroenterologists. This guidance is Constipation – Ispaghula husk (see BNF for dose)+/-macrogol oral powder 1-2 to assist GPs in decision making and is NICE DG11 Oct 13, NICE 2008 CG61, http://www.bda.uk.com/foodfacts/IBSfoodfacts.pdf, BMJ 2012;345:e5836 sachets/daily . Drink with pleanty of fluid not intended to replace clinical Refer to current BNF or SPC for full medicines information Clinical Contact for this pathway for queries: camden.pathways@nhs. net judgement Pathway Created 2014. Updated May 2018 Diarrhoea - loperamide (see BNF for dose). Approved by: Clinical Cabinet 07/2018, Medicines Management and Commissioning committees - 08/18 Review due 08/2021
Faecal calprotectin (FC) Pathway Please refer to the Summary of Product Characteristics (SPC) of any drug considered. This pathway has been developed from published Consider faecal calprotectin in patients in whom there is diagnostic uncertainty but no red guidance in collaboration with local flags and in whom specialist assessment/input is being considered. gastroenterologists. This guidance is to assist GPs in decision making and is not intended to replace clinical judgement
Investigations: Faecal Calprotectin (FC) - request and send stool sample to lab Probable IBS. Low probability of organic pathology. Lifestyle advice and dietary advice sheet. Increase
Note: Stop NSAIDs 4 weeks prior to FC testing and physical activity. exclude conditions as with other causes FC Consider: Dietetic referral Antispasmotic medication (Hyoscine butylbromide mebeverine, peppermint oil)
Age 16-40 years Treat as IBS. Refer to secondary care FC negative - <50μg/g if suspicious symptoms even if FC negative Whittington Hospital ranges Age >40 years Treat as IBS. Consider investigating only- >50mg /kg* change in bow el habits. Be alert for ovarian cancer in females >50years
FC indeterminate 50-200μg /g* Whittington Hospital ranges only 50-150mg /kg* Consider other causes of inflammation .Repeat test after 4 weeks. If negative manage as above FC positive - >200μg /g* Routine general GI for IBS. If still indeterminate or clinic referral Whittington Hospital ranges positive and symptoms persist then
only- >150mg /kg* refer to consultant
Other causes of a positive FC – Moderate probability of organic Gastro Intestinal Infections- Giardia, bacillary dysentery, viral pathology. gastroenteritis, helicobacter gastritis Malignancy, - colorectal cancer, gastric carcinoma, intestinal Urgent IBD clinic referral lymphoma Drugs Miscellaneous- NSAID, proton pump inhibitor, gastro- oesophageal reflux disease (GORD), coeliac disease, diverticular disease, protein losing/autoimmune enteropathy, microscopic colitis, liver cirrhoisis
Faecal Calprotectin (FC)
Calprotectin is a stable protein that is released into faeces when neutrophils gather at the site of any G.I tract inflammation. Calprotectin can provide a non -invasive, inexpensive and objective method for assessing patients who may require referral for additional procedures e.g. Colonoscopy or imaging studies.
The faecal calprotectin test has a relatively high specificity and sensitivity (approximately 90%) for distinguishing between non-inflammatory bowel disorders (e.g. irritable bowel syndrome) and inflammatory bowel disease (e.g. ulcerative colitis and Crohn's disease). Calprotectin will also be elevated in some cases of GI tract malignancy (e.g. colorectal cancer). Calprotectin concentrations relate well to disease activity in the inflammatory bowel diseases and can therefore be used to monitor therapy. The test is non-invasive and can be used on adults and children (not neonates); the same reference range appears to apply to both.
Sample Requirements. Random faecal sample (any time of day, no dietary restrictions required) in a plain universal container and approximately 1 gram in weight. Should not be exposed to temperatures >30°C
NOTE: Samples grossly contaminated with blood are unsuitable for FCALP analysis.
*Whittington Hospital (WH) sends all FC samples to Rotherham Hospital who use the Immundiagnostik IDK Calprotectin ELISA kit and the interpretative thresholds for adults are as follows: >50mg/kg regarded as positive 100 to 150 mg/kg indicative of bowel inflammation >150 mg/kg consistent with active IBD