Management of irritable bowel syndrome can be successfully achieved by patients themselves, provided they are sufficiently informed about potential triggers and empowered to take control of their condition.
Irritable Bowel Syndrome (IBS) affects about 15% of people in the UK, and about two and half million people seek advice from their GP for their IBS every year. While IBS is not a life threatening condition, it is a major cause of ill health and disability, disrupting social activity and work.1,2 The large number of patients affected, the screening for other diseases in secondary care, hospital admissions (planned or unplanned), absenteeism and impairment in the workplace all constitute a major cost to the health service and society at large.3
What is IBS?
IBS is a common, medically unexplained disturbance of bowel function, comprising symptoms of abdominal discomfort and disturbance in bowel habit (either diarrhoea or constipation or an alternating pattern).4,5 There is no basis in pathology and no definitive cause, although in many patients the condition appears to be brought on by stress, and in some it is instigated by an attack of gastroenteritis. Physiological tests have shown evidence of increased rectal sensitivity and reactivity, and in some cases a mild inflammation. There is no uniformly effective treatment.
Getting the right Diagnosis
The characteristic symptoms of IBS are those of bowel irritability and are therefore found in other conditions affecting the bowel, yet there is no diagnostic marker. It is essential that common conditions that may generate the same symptoms are effectively screened out.
These include coeliac disease, inflammatory bowel disease and bowel cancer, all of which can present with symptoms of IBS. Although only 4 in every hundred people with IBS have coeliac disease, this is about five times as common as in the general population. The National Institute for Health and Clinical Excellence (NICE) has therefore recommended that all patients with symptoms of IBS should be screened for coeliac disease with blood tests for tissue transglutaminase and also antigliadin or endomysial antibodies. A positive blood test is considered diagnostic even when there is no structural change to the intestine on mucosal biopsy. False negative results may occur in patients already on a gluten free diet.6
IBS may also be confused with inflammatory bowel disease, but fortunately there is also a sensitive screening test for that too. It is called faecal calprotectin, and is a protein which is released into the bowel from white cells shed from inflamed mucosa.7 A new immunological test for faecal occult blood constitutes a sensitive screening test for bowel cancer.
Patients with IBS also exhibit many other symptoms that are not directly referable to the bowel, such as indigestion, heartburn, tiredness, frequency of micturition, backache and headache. The illness also tends to come and go, and change its presentation according to the changes and tensions that occur in the patient’s life. In fact, the presentation and natural history of the disorder vary so much that it might well be considered the individual expression of a state of sensitivity or dysphoria that affects many different parts of the body as well as the mind. Patients with IBS show a stronger association with psychological distress and psychiatric illness than those with organic disease of the bowel, and exacerbations of illness are often triggered by life changes and life events.
Some people develop chronic symptoms of IBS and mild inflammation of the bowel after an attack of gastroenteritis though this is more likely if they have been anxious, depressed and experiencing life stress at the time of their original illness. It’s as if the symptoms of gastroenteritis have been recruited to express the ongoing emotional distress.
Although food often induces symptoms in the sensitive intestines of IBS, immunological evidence of food allergy is rare as are specific food intolerances.
Guided self-care: the key to successful management?
The variability of IBS does not allow specific treatment. Although there is no definitive cure, the intensity of the condition may be reduced by symptomatic treatments, alterations of diet and lifestyle and containment of stress. Such an individual expression of illness often requires individual management. In IBS, it is often more important to understand the patient than the illness and to help them cope with their own condition.
Self-management8 implies a therapeutic partnership with an informed patient to help them understand what their illness represents in order to help them resolve it or live better with it.
Proposed changes to care pathways
Currently, too many patients with chronic IBS are referred to secondary care in order that pathological diseases can be ruled out and advice regarding management sought. Substantial savings could be made and services improved if patients were screened and self-care facilitated in primary care using an approved IBS self care plan, such as that soon to be published on line9 by The IBS Network.
This model of practice might work as follows: once other common conditions had been excluded, patients would be interviewed in-depth, enquiring about diet, lifestyle and life events in order to help them understand what is making them ill. Symptomatic treatment would then be prescribed and patients would be invited to attend a self-help group for 7 weekly sessions, monitoring their own progress with a diary of symptoms and lifestyle (diet and events) and developing their own self-care plan. Practice nurses, counsellors or dietitians could be trained to screen patients and deliver self-care for IBS. All Patients would be followed up at 6 months. If they continued to suffer from disabling symptoms, then they would be referred up to secondary care; or if there were significant emotional issues underlying their condition, referred for counselling or psychotherapy or prescribed antidepressants and followed up. Any patient who had developed symptoms indicative of organic disease would be referred to secondary care.
1. Akehurst RL, Brazier JE, Mathers N et al. Health-related quality of life and cost impact of irritable bowel syndrome in a UK primary care setting. Pharmacoeconomics. 2002;20(7):455-62.
2. Hakanson C, Sahlberg-Blom E, Ternestedt BM. Being in the patient position: experiences of health care among people with irritable bowel syndrome. Qual Health Res. 2010;20(8):1116-27.
3. Maxion-Bergemann S, Thielecke F, Abel F, Bergemann R. Costs of irritable bowel syndrome in the UK and US. Pharmacoeconomics. 2006;24(1):21-37.
4. Spiller R, Aziz Q, Creed F, Emmanuel A, Houghton L, Hungin P, et al. Guidelines on the irritable bowel syndrome: mechanisms and practical management. Gut. 2007;56(12):1770-98.
5. NICE. Irritable bowel syndrome in adults: Diagnosis and management of irritable bowel syndrome in primary care. London: National Institute of Health and Clinical Excellence, London; 2008.
6. Shahbazkhani B, Forootan M, Merat S, et al. Coeliac Disease presenting with symptoms of irritable bowel syndrome. Alimentary Pharmacology & Therapeutics. 2003;18(2):231-5.
7. Otten, CMT Kok L Witten BJM, et al. Diagnostic performance of rapid tests for faecal calprotectin and lactoferrin and their ability to discriminate inflammatory from irritable bowel syndrome. Clin. Chem. Lab. Med. 2008;46:1275-1280.
8. Robinson A, Lee V, Kennedy A, et al. A randomised controlled trial of self-help interventions in patients with a primary care diagnosis of irritable bowel syndrome. Gut. 2006;55(5):643-8.
9. Coulson NS. Receiving social support online: an analysis of a computer-mediated support group for individuals living with irritable bowel syndrome. Cyberpsychol Behav. 2005;8(6):580-4.
The IBS Network www.theibsnetwork.org
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