IBS – NICE guidelines

There’s a summary of these in the latest BMJ, much of which I already know, but here are a few notes on the bits I need some aide-memoires for:

Diagnostic criteria

Abdominal pain or discomfort which is:

  1. Relieved by defaecation or associated wtih altered stool form or frequency, and
  2. associated with at least two of the following:
  • altered stool passage (straining, urgency, incomplete evacuation)
  • abdominal bloating, distension, tension or hardness
  • symptoms worsened by eating
  • passage of mucus

Associated features

Lethargy, nausea, backache and bladder symptoms are common.

Investigations

Pretty much what I’d have thought:

  • FBC
  • Inflammatory markers
  • Coeliac screen
  • Consider Ca-125 if appropriate

Lifestyle advice

I remember about FODMAPs, obviously, but here are the rest:

  • Regular meals – avoid missing meals or taking long gaps between them – take time to eat.
  • Drink at least 8 cups of fluid a day, but restrict tea and coffee to no more than three of those cups
  • Limit alcohol
  • Limit fizzy drink intake
  • Possibly limit high fibre food (wholemeal, wholegrains). If fibre is needed, make it soluble, such as oats or ispaghula husk.
  • Limit fresh fruit to three portions a day.
  • Reduce intake of resistant starch – this is startch that doesn’t get digested in the small intestine & hence reaches the colon intact. This is often found in processed or re-cooked foods.
  • In cases of diarrhoea, avoid sorbitol.
  • In cases of wind or bloating, oats and linseeds (up to one tablespoon of linseed a day)
  • If probiotics are tried, give them at least four weeks at whatever dose is recommended by the manufacturer.
  • Alternative medicine does not seem to have a lot to offer. (Details: Acupuncture does not seem to be helpful. Aloe vera is discouraged, though that seems to be more an ‘absence of evidence’ thing. Reflexology was found unhelpful in one small study of dubious quality, so that’s an ‘absence of very much evidence’, I suppose. Chinese herbal medicine was not helpful. Non-Chinese herbs may in some circumstances be helpful but results were very variable, so currently not sufficient evidence to recommend them, especially given the potential for harm.)
  • Exclusion diets should be advised only by a dietician.

Linaclotide

This is a new addition to the treatment – a laxative for particularly severe and refractory cases of constipation. It’s only meant to be tried in situations where:

  1. Multiple laxatives have failed to work at maximal doses, and
  2. The patient has had constipation for >12 months. (This last strikes me as an awkward one – if a patient has severe and refractory constipation, I don’t much like the idea of sending them away for another several months until they’ve had it long enough to qualify for linaclotide.)

If linaclotide is used, the effectiveness should be reviewed after three months. I wonder if a month would do? It’s bound to be expensive and so I won’t be prescribing more than a month at a time initially.

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About Dr Sarah

I'm a GP with a husband and two young children.
This entry was posted in Credits 2015, Gastroenterology. Bookmark the permalink.

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