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UPDATE Clinical chemistanddruggist.co.uk/update-plus
Module 1810
Irritable bowel syndrome From this module you will learn:
●●What irritable bowel syndrome (IBS) is ●●The typical symptoms and prevalence of IBS ●●How the condition is diagnosed and managed ●●How to distinguish IBS from similar conditions
November Clinical: Irritable bowel syndrome
5 November
Constipation
12 November
Drugs in the young: part 1
19 November
Drugs in the young: part 2
26 November*
*Online-only for Update Plus subscribers
Asha Fowells Pharmacist and freelance health writer
Of all the gastrointestinal (GI) disorders, the one that most lives up to its name is irritable bowel syndrome (IBS). Its symptoms are irritating, not only because they are often changeable, unpredictable and lifelong, but because the condition appears to have no discernible cause, and is therefore a source of intense annoyance to patients and healthcare professionals alike.
Prevalence A significant number of people are thought to be affected by IBS – with estimates suggesting 10-20% of the UK’s population (between 6.5 and 13 million people). The actual number may well be higher, as many people do not seek medical advice for this condition. In some cases, this is because sufferers put their symptoms down to having a “dodgy tummy” or a “delicate system” rather than considering their symptoms as part of a syndrome. For others, embarrassment prevents them from seeking advice.
Symptoms The symptoms of IBS can be as uncertain as its cause or prevalence. This is because they vary between individuals in their nature, severity, duration and frequency. Sufferers typically experience changes in bowel habits, which may include constipation (covered in C+D’s next Update module on November 12), diarrhoea or a mixture of the two, often with abdominal distension and discomfort that is eased after defecation. There are several accompanying symptoms to IBS: ●●faecal urgency ●●feeling that bowels have not been emptied fully after going to the toilet ●●flatulence ●●passing mucus with stools. Other less common symptoms include incontinence, pain during sexual intercourse, urinary urgency and frequency, backache, nausea and fatigue. IBS can have a profound impact on everyday life, with some sufferers developing mental health issues, such as depression and anxiety. 14 Chemist+Druggist 05.11.2016
IBS is difficult to diagnose, due to its similarity to a variety of other gastrointestinal conditions
Aetiology
Diagnosis
The cause of IBS has been investigated and debated for years. Several theories have been put forward, for example: ●●abnormal GI motility ●●gut hypersensitivity ●●abnormal central nervous system activity in the GI tract ●●atypical immune functioning ●●GI inflammation or infection ●●diet ●●antibiotic use ●●psychological upset ●●surgery ●●genetic causes. However, it seems likely that rather than there being one definite cause, the syndrome is due to a number of interconnected factors.
Establishing that an individual has IBS is not straightforward, as one of the cornerstones of diagnosis is the exclusion of other conditions. However, IBS should be considered a possibility if the patient says they have experienced recurrent abdominal discomfort, bloating or altered bowel habits for at least six months. A diagnosis of IBS is likely if the discomfort is relieved by defecation or is associated with a change in bowel frequency or stool form (see panel on opposite page), and the patient reports at least two of the following: ●●straining, urgency or a feeling of incomplete evacuation when passing stools ●●abdominal bloating ●●mucus in the stools ●●symptoms worsen upon eating.
IBS versus IBD While irritable bowel syndrome (IBS) may have initials in common with inflammatory bowel disease (IBD), they are very different. IBD is the umbrella term that covers the chronic conditions ulcerative colitis (UC) and Crohn’s disease, which differ only in the amount of the GI tract they affect. UC is confined to the colon, whereas Crohn’s can affect all of the GI system. Like IBS, people with IBD generally experience relapses and remissions, but the
symptoms themselves are different, usually featuring abdominal pain, recurrent or bloody diarrhoea, weight loss and fatigue. IBD is much rarer than IBS, and the two conditions are poles apart in terms of management, with IBD often needing aminosalicylates, corticosteroids or immunosuppressants for it to be controlled. In addition, some patients suffer so severely from IBD that they need part of their gut surgically removed.
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Nonspecific symptoms such as nausea, backache, lethargy and bladder problems may be used to support the diagnosis. Conditions to discount include: ●●constipation that has arisen for another reason, such as medication use ●●inflammatory bowel disease (IBD) ●●diarrhoea due to another cause, such as coeliac disease, IBD, infection or medication ●●underlying malignancies ●●other GI conditions, for example: gallstones, ulcers, gastro-oesophageal reflux disease, pancreatitis and diverticular disease ●●endometriosis ●●premenstrual syndrome ●●some mental health conditions, such as anxiety and depression. While there is no definitive test for IBS, investigations may be carried out to help exclude some of the above. The most commonly used tests look at full blood count, erythrocyte sedimentation rate, C-reactive protein and coeliac disease antibodies. Invasive procedures, such as a colonoscopy, will usually only be conducted if another condition is suspected. IBS most often presents in people aged between 20 and 30 years old, and women are twice as likely as men to be affected. However, trend analysis over recent years has shown an increase in the prevalence of IBS in older people, proving that the condition cannot be discounted due to age alone.
Non-medical management There are several self-help measures that individuals with IBS can take to try and improve their symptoms.
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The following management methods have been suggested by the National Institute for Health and Care Excellence (Nice) in its 2008 guidelines on IBS: Diet – A patient’s meals should be regular and not rushed, and fluid intake must be adequate. If the patient requires more fibre, soluble fibre should be introduced, as a supplement (eg ispaghula) or in dietary form (eg oats). The following foods should be avoided: ●●Insoluble fibre – eg wholemeal flour, highbran cereals and whole grains, such as brown rice ●●Resistant starches – found in processed and reheated foods, raw and cooled potatoes, raw oats and legumes ●●Alcoholic and fizzy drinks ●●Fatty and rich foods ●●The artificial sweetener sorbitol (also known as glucitol) Portions of fresh fruit and caffeinated drinks should be limited to three a day. Studies have shown that around 10% of people with IBS are lactose intolerant, so this should also be taken into account. Nice advises that food exclusion diets should only be undertaken under the supervision of a dietician, due to the risk of inadequate nutrient intake. Stress – Managing stress levels, by identifying sources of anxiety and building in regular relaxation time, can relieve symptoms. Data suggests that around half of IBS patients consider their symptoms to be triggered by stressful events. Triggers – A patient can try to identify triggers by keeping a food and mood diary
1.
It is estimated that around 10-20% of the general population are affected by IBS. True or false?
3. IBS patients should follow a diet that is high in insoluble fibre. True or false?
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Describing stools can be an embarrassing experience for all concerned, which increases the risk of the conversation being cut short. One way of making sure that both healthcare professional and patient are on the same wavelength is to use a visual aid. Probably the best known of these is the chart developed at the University of Bristol and published in the Scandinavian Journal of Gastroenterology nearly 20 years ago. It is not perfect, in that it really only prompts the patient to classify the consistency of their stools and not the quantity, but is nonetheless useful as a starting point for discussions. A copy of the Bristol Stool Scale chart is available at tinyurl.com/updateibs2
for a few weeks. If a certain food is found to be triggering symptoms, then you should recommend that the patient avoids this whenever possible. Activity – Increasing activity levels, either by lifestyle (eg walking or climbing stairs) or structured exercise, aiming for 30 minutes at a moderate intensity on at least five days a week, can relieve some of the effects of IBS. Wider studies have pointed towards a link between regular exercise and improved gastric emptying and colonic transit time, with a reduction both in straining during defecation and the proportion of hard or incomplete stools. Probiotics – A patient should consider trying probiotics for four weeks, sticking to the same brand. There is evidence that such
Take the 5-minute test
2. IBS most often presents in people aged between 30 and 40 years old. True or false?
CPD Podcast
Bristol Stool Scale
4. Studies have shown that around 10% of people with IBS are lactose intolerant. True or false? 5. Nice does not recommend the use of probiotics for IBS, as there is little evidence of their efficacy. True or false?
7. Lactulose is the laxative of choice for patients with IBS. True or false? 8. IBS patients with diarrhoea should be managed using an antimotility agent such as loperamide. True or false? 9. Low dose tricyclic antidepressants have been shown to improve IBS symptoms, including abdominal pain. True or false? 10. Over-the-counter products for IBS should not be sold to patients who have not been diagnosed by a doctor. True or false?
6. Spasmodic pain in IBS can be treated with mebeverine, alverine or peppermint oil. True or false? 05.11.2016 Chemist+Druggist 15
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food supplements can improve IBS symptoms, without causing any harm.
Medical management The many different symptoms of IBS each require different treatments. These include: Spasmodic pain – this takes the form of an abdominal pain which can be described as crampy, achy, dull, intermittent or sharp. If spasmodic pain is an issue, an antispasmodic such as mebeverine, alverine or peppermint oil can prove helpful, alongside lifestyle measures. Constipation – for IBS sufferers with constipation, bulk-forming laxatives (such as isphagula, macrogol or sterculia) are often effective. The dose should be tweaked according to the response, with the aim being a soft, but well-formed stool – such as that seen in type three and four of the Bristol stool chart (tinyurl.com/updateibs2). Lactulose is not recommended as it can cause flatulence and bloating. Those requiring a laxative, but cannot tolerate the bulk-forming types, can try a stimulant agent for short-term use, such as senna. Diarrhoea – IBS patients with diarrhoea should be managed using an antimotility agent, such as loperamide. The dose can be adjusted as needed by the patient. Treatments for diarrhoea will be covered in an upcoming Update module. For those for whom the symptomatic relief described above is insufficient, a low dose tricyclic antidepressant (TCA) can be trialled. This should be reviewed after four weeks and increased gradually if needed from the starting dose of 5-10mg amitriptyline (or equivalent) to a maximum of 30mg at night. A selective serotonin reuptake inhibitor (SSRI), such as citalopram, can be used in individuals who cannot take a TCA or for whom the drug class seems ineffective. Both classes of antidepressant have been shown to improve symptoms, including reducing abdominal pain. The mechanism of action of antidepressants in IBS is not completely understood. Individuals with symptoms that persist despite trying pharmacological treatments for a year may be referred for psychological interventions such as cognitive behavioural therapy or hypnotherapy, with the aim of resolving the underlying issues leading to IBS.
What can pharmacists do? Pharmacy has a vital role to play in supporting patients with IBS, and not just in terms of dispensing prescriptions. There is a need to be sensitive when dealing with patients with IBS or who you suspect may have the condition. They may find their symptoms embarrassing and will only disclose details if they feel comfortable with the person they are talking to, so this is an ideal opportunity to usher them to the consultation room for a private discussion. 16 Chemist+Druggist 05.11.2016
Be alert to symptoms in patients who believe they have, or have been diagnosed with, IBS that could indicate a more serious condition. These red flags include: ●●unintentional or unexplained weight loss ●●rectal bleeding (for more information see bit.ly/unexpectedbleeding) ●●a recent but persistent change in bowel habits in a person aged over 60 years ●●an abdominal or rectal mass ●●signs of anaemia, including general fatigue, weakness, pale skin or dizziness ●●a family history of ovarian or bowel cancer. In all cases, the patient should be referred to their GP for further investigation. Do not sell IBS products to someone who has not had the condition diagnosed by a doctor. While this is not outside the licensing restrictions, it is listed under the special warnings and ‘precautions for use’ section of the summary of product characteristics for all IBS over-the-counter products, and therefore should be adhered to. Ensure you ask appropriate questions in order to separate IBS from other conditions that cause similar symptoms, even if the patient has had a prior diagnosis. For example, ask a patient if they have taken any new medicines recently or consult their patient medication record if they get their prescriptions dispensed at your pharmacy. This can yield very relevant and useful information. Similarly, asking a female customer if there is any pattern to the symptoms they are experiencing can help rule out a link to the menstrual cycle. If you believe this is the cause, you should refer the patient to their GP as they may benefit from further consultation.
You can support lifestyle changes your patients are trying to make to improve their IBS symptoms, by providing information and advice on measures such as diet and exercise (see previous page). Anyone wishing to make more sweeping changes should be referred to a dietician. If a patient asks about complementary and alternative therapies such as acupuncture, reflexology and aloe vera, you should explain there is insufficient evidence to support them. Ensure patients have access to education, advice and information about their condition and its management. Check regularly if they have any questions or concerns, as these are likely to evolve over time.
For more information Clinical Knowledge Summaries tinyurl.com/nice-cks-ibs NHS Choices tinyurl.com/nhsibs1 The Bristol Stool Scale tinyurl.com/updateibs2 The Association of UK Dietitians tinyurl.com/CDIBSFF The IBS Network theibsnetwork.org Core corecharity.org.uk The Irritable Bowel Syndrome Self Help and Support Group ibsgroup.org Steps for Stress stepsforstress.org
Irritable bowel syndrome CPD Reflect What are the symptoms of irritable bowel syndrome (IBS)? How do IBS and inflammatory bowel disease (IBD) differ? What dietary changes can help improve IBS symptoms? Plan This article contains information about the typical symptoms and prevalence of IBS and how the condition is diagnosed and managed. The differences between IBS and other conditions that have similar presentations, and the role of the pharmacist in supporting IBS patients, are also discussed.
Read the MUR tips for patients with IBS on the C+D website at tinyurl.com/updateibs3 Find out more about the IBS Network’s Can’t Wait Card, which can be used to request permission to use toilets in offices and stores which are otherwise inaccessible, and the Radar key, which can be used to access locked public toilets, both of which are useful for people who may need to use a toilet urgently when outside the home, at tinyurl.com/updateibs4
Act Read more about IBS on the Patient website at tinyurl.com/updateibs1
Read more about methods to reduce stress, which can help with IBS symptoms, on the Scottish Government website at tinyurl.com/updateibs5
Revise your knowledge of the Bristol Stool Chart on the bladder and bowel community website at tinyurl.com/ updateibs2
Evaluate Are you now confident in your knowledge of IBS and its symptoms and diagnosis? Could you give advice to patients about the management of IBS?
